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  • Radiology Experts Aid in Updating New Cancer Staging Manual

    By Stephan Benzkofer

    December 21, 2017

     Although the American Joint Committee on Cancer (AJCC) Staging Manual was first published 40 years ago, it was not until its newest edition that the manual was edited with radiologists in mind.

    For the first time, the AJCC Staging Manual, Eighth Edition, which will be published on Jan. 1, includes input from expert radiologists and was edited to bring consistency to the imaging sections, said Daniel Sullivan, MD, professor emeritus, the Department of Radiology, Duke University, Bethesda, MD.

    Dr. Sullivan, who recommended imaging experts for each cancer specialty, was recruited by AJCC and the Union for International Cancer Control, which maintains and updates the manual and its tumor, node, metastasis (TNM) staging classification. 

    “These organizations recognized that imaging is important for staging in all solid tumors,” said Dr. Sullivan, who is hopeful that the new edition will win over more radiologists who traditionally have not been rigorous in explicitly including cancer staging data in their reports (e.g., specific statements about tumor size, status of nodes and presence or absence of invasion or metastases).

    The manual serves a dual purpose. First, it helps oncologists and hospital tumor boards more quickly and accurately classify a cancer and discern the most effective course of action for treatment.

    Arguably more important is the consistency the manual provides. The updated manual now allows doctors and researchers to speak the same language and build databases of vital information about how different cancers present at different stages and how they react to treatment, which will in turn become the basis for updating future editions.

    “We can begin to better understand tumor treatment and the tumor pathophysiology,” said Christine Glastonbury, MD, a neuroradiologist at the University of California, San Francisco, who served as an expert on the head and neck chapter of the manual.

    A prime example in the Eighth Edition occurs with the human papillomavirus (HPV)-related oropharyngeal cancers. It is more likely now in the U.S. and many other parts of the world that these throat cancers are caused by the virus rather than tobacco and alcohol use, Dr. Glastonbury said.

    “These often present with large neck nodes and such tumors are frequently designated as stage 4,” Dr. Glastonbury said. “But, it turns out that HPV-related turmors respond much better to treatment than tobacco-related tumors and the patients have a much better prognosis, so in the new staging system, HPV-related oropharyngeal cancers will be lower in staging and more frequently stage 1 or 2. It reflects what we have learned in the last seven years.”

    Such a staging change would greatly benefit patients on an emotional level as well, Dr. Glastonbury said. “If somebody tells you have stage 4, can you imagine how that feels? This will be a huge mental relief.”

    Personalization Increases Complexity
    But as treatment becomes ever more personalized, cancer staging becomes even more complicated.

    According to the AJCC website, “This edition features 12 entirely new staging systems, a wide range of changed or new staging definitions, and a refined emphasis on a personalized-medicine approach.”

    That added complexity creates a challenge for physicians like Drs. Sullivan and Glastonbury, who believe passionately that medical outcomes — and the radiology field — benefit greatly when more of their peers are more closely involved.

    First, some radiologists may not understand what information is needed for staging. Second, doctors may be reticent to report an exact measurement — of a tumor mass or node, for example — when the vagaries of the modality, the machine and the image might make exactitude impossible.

    “They don’t want to report a number that sounds very accurate when they have some doubt themselves,” Dr. Sullivan said. “But for the oncologist and for the database registrar who understand that, having the radiologist’s best number is better.”

    New Manual is More Accessible
    Being familiar with the Cancer Staging Manual doesn’t mean memorizing it. “We aren’t expecting anyone to know all this minutiae, that’s unreasonable.” Glastonbury said.

    But recognizing the nuances of different cancers — for example, knowing which nodes are important in a lung CT — will aid radiologists in writing a report that is as useful as possible for the patient’s doctor.

    And new tools are available to make the manual more accessible, including an abridged version of the Eighth Edition. In addition, structured dictation templates are available for each cancer type.

    “Radiologists often feel we have to prove our value,” Dr. Glastonbury said. “That is the new catchword in radiology, actually: Value. You hear it everywhere. And it is valuable to the surgeons and oncologists we work with to provide as much information as possible from the scan that is going to affect the patient’s stage.”

    “What we as radiologists do is very important. We want to be as good at it as we can be,” Dr. Glastonbury said. “The new cancer staging manual helps with that.”



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