Eighth Edition of the AJCC Staging Manual Offers a More Personalized Approach to Patient Classification

A Conversation With Frederick L. Greene, MD, FACS

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This year marks the 60th anniversary of the creation of the American Joint Committee on Cancer (AJCC), whose founding mission was to standardize the anatomic staging of cancer based on the size of a tumor and any spread to nearby tissue (T); the spread of the cancer to nearby lymph nodes (N); and the spread of cancer to other parts of the body (M). The intent was to better understand the clinical behavior of specific cancers, determine prognosis, and help physicians compare outcomes of similar groups of patients.

Developed in the 1940s and 1950s by Pierre Denoix, MD, a surgical oncologist at the Institut Gustav-Roussy in Paris, the TNM staging system was primarily used for the clinical classification of breast cancer. In 1987, it became accepted worldwide as the anatomic staging system for most solid tumors.1

The AJCC was launched on January 9, 1959, to provide cancer classification that not only incorporated the international TNM staging system, but that was also relevant—and acceptable—to American oncologists. Initially composed of a coalition of 6 medical organizations, including the ACS, ACR, American Cancer Society, College of American Pathologists, American College of Physicians, and National Cancer Institute, today there are 22 sponsoring organizations of the AJCC, including the National Comprehensive Cancer Network® and ASCO.

Staying Relevant

Over the past 6 decades, the AJCC has published eight editions of its staging system based on the TNM concept. The latest, AJCC Cancer Staging Manual, Eighth Edition,2 which became effective on January 1, 2018, is the most ambitious one yet. It signifies a dramatic departure from previous staging classifications to keep pace with the rapid advances in knowledge regarding the biologic and molecular factors that determine the clinical course of cancer.

Although previous editions of the AJCC Cancer Staging Manual have focused on anatomic methods of staging alone, the new edition incorporates prognostic biomarkers to more accurately estimate clinical outcomes and treatment response; it does not rely solely on the anatomic extent of disease to determine prognosis. Factors such as tumor grade, hormone receptor, and oncogene expression, as well as multigene panel recurrence scores are now integrated with anatomic definitions.

For example, the chapter on breast cancer includes estrogen receptor and progesterone receptor expression; HER2 expression; and/or amplification and histologic grade to the anatomic assessment of tumor size, regional lymph node involvement, and distant metastases. In addition to breast cancer, the new edition includes risk-assessment models for several pilot sites, including the lungs, head/neck, esophagus, prostate, skin (melanoma), and colon/rectum.

“Staging has become so complex that we are hoping to make it easier through the use of mobile devices physicians can use to ‘punch in’ prognostic factors and quickly retrieve the information they need to make a staging decision.”
— Frederick L. Greene, MD, FACS

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“It was our feeling, even with the fifth edition of the AJCC Cancer Staging Manual, that if we kept the anatomic staging system alone, TNM would become irrelevant in the next few years. You have to include biomarkers to provide patients with more precise individual prognostication,” said Frederick L. Greene, MD, FACS, Medical Director of Cancer Data Services at the Levine Cancer Institute, and co-editor of the seventh and eighth editions of the manual. “In the latest edition, in addition to including prognostic biologic and molecular factors for breast cancer, we have included that information for gastrointestinal cancer, melanoma, and other tumor types as well.”

Using Technology to Stay Current

To ensure that the staging manuals stay user-friendly, Dr. Greene said the AJCC is developing technology tools to help oncologists simplify the staging process. “Staging has become so complex that we are hoping to make it easier through the use of mobile devices physicians can use to punch in prognostic factors and quickly retrieve the information they need to make a staging decision,” explained Dr. Greene. An effort is also underway to incorporate new cancer staging rules into patients’ electronic health records and into cancer registry software to accurately collect data for surveillance and research. In addition, to ensure that the information contained in the manual is always current, AJCC is planning to make periodic updates to the manual available on its website,

“What has enabled the AJCC and its staging manuals to remain clinically relevant over the past 6 decades is the commitment of our sponsoring members, including ASCO, to work with us to ensure we provide oncologists with the latest concepts in cancer staging and prognostication. It is this collaboration that has made the AJCC stronger and our staging manuals crucial in the personalized care of patients with cancer,” said Dr. Greene. ■

DISCLOSURE: Dr. Greene reported no conflicts of interest.


1. Hutter RV: Arch Surg 122:1235-1239, 1987.

2. Amin MB, et al: AJCC Cancer Staging Manual, Eighth Edition. New York; Springer International Publishing; 2017.