Thomas P. Baker, MD
Kay Washington, MD, PhD
April 2021—In the continuum of cancer care, diagnostic specialties such as ours play critical roles. We touch virtually all aspects of cancer care through cancer diagnostics, the use of molecular studies in treatment and as predictive markers, and our key role in anatomic pathologic staging. The widespread use of the CAP cancer protocols has improved cancer reporting by standardizing format and terminology while also incorporating the concept of human factors engineering and standards for developing high-quality clinical practice guidelines.
Our partnerships and involvement with standard-setting organizations have helped us to improve our efforts as well. The World Health Organization Classification of Tumours publications (“blue books”) are produced by the WHO Classification of Tumours Group at the International Agency for Research on Cancer. Pathologists are involved extensively in the development and editorial process for the new editions, and a CAP liaison was added recently to the editorial board. Our efforts to harmonize cancer terminology align with their efforts to do the same.
The American College of Surgeons (ACS) Cancer Programs, including the American Joint Committee on Cancer (AJCC), Commission on Cancer (CoC), and others, have embraced our efforts and helped improve our ability to provide high-quality care. The ACS, for example, is in the process of implementing “synoptic operative reports” largely based on the extensive experience and lessons learned from our efforts with the cancer protocols. Recognizing the significant role that standardized pathology reporting has played in improving cancer care, the CoC recently expanded the use of our cancer protocols as a part of its accreditation process.
The pathologist has a pivotal role in tumor staging, and as a member organization of the AJCC and key stakeholder, the CAP is involved at all levels in these efforts. The AJCC recently published its first disease site (referred to as chapters in previous editions) for cervical cancer and has several others in the development pipeline. This is the first step to publishing Version 9 of the Cancer Staging System that will ultimately replace the eighth edition of the Cancer Staging Manual.
As the AJCC rolls out its newest version of its Cancer Staging System, it is important to understand its current efforts and future direction:
- The AJCC is the standard setter for cancer staging. Its publications and other offerings serve as the authoritative guide for cancer staging and serve thousands of medical professionals across the continuum of cancer care. While anatomic staging (TNM staging) is at the core of its staging system and is critical to cancer treatment, rapid advancements in cancer care are providing opportunities to better define prognosis and treatment at the individual level (personalized medicine). As a result, the AJCC’s role as the preeminent source for cancer staging has never been more crucial to the cancer care, surveillance, research, and patient advocacy communities than it is today.
- The Cancer Staging Manual has been rebranded as the Cancer Staging System and Version 9 will be released on a rolling basis. Unlike previous versions, which were hardcopy editions released at six- to seven-year intervals, Version 9 will be released on a chapter-by-chapter or disease-site-by-disease-site basis based on the needs of the cancer care community. The goal in this effort is to ensure that cancer staging is current and evidenced-based and meets the needs of the clinical care and surveillance communities.
- Unlike the previous edition of the Cancer Staging Manual, the Cancer Staging System has gone digital. As new disease sites (chapters) become available, they will be released initially on Amazon through the Kindle platform. Additionally, library services vendors and content aggregators will add Version 9 to the existing AJCC offerings in Kindle format. The AJCC has developed and deployed Application Programming Interfaces, or APIs, for the clinical and registry environments to allow for the rapid integration of updated staging information into electronic health records and cancer registry databases and the use of such information. The AJCC is working on additional tools and applications that will improve the ability to use the Cancer Staging System in cancer care.
- New and updated disease sites within Version 9 of the Cancer Staging System will be more streamlined and user-friendly with significant stakeholder input and involvement. The AJCC has revamped the previous editorial board structure and formalized it as the AJCC editorial committee. This change allows for increased stakeholder involvement and input regarding editorial content and text structure. The new disease sites are being written with more stringent levels of evidence and incorporate standardized terminology that aligns with efforts of stakeholders and other standard-setting organizations. New disease sites will include easy-to-use staging tables tailored for use by a broad set of end users in addition to the traditional sections on risk-assessment models, registry data collection variables, prognostic factors, and others.
- The eighth edition of the Cancer Staging Manual will continue to be used for staging and cancer surveillance until new disease sites are available with Version 9. As the AJCC releases disease sites of Version 9 over the next several years, these will replace the existing chapters in the eighth edition of the Cancer Staging Manual for staging and cancer surveillance. Until the process of replacing all chapters is completed, the relevant chapters in the eighth edition will continue to be used for cancer staging. The chapter on “Principles of Cancer Staging” in the eighth edition is an important resource, and select sections will be included in the Version 9 content. The AJCC will work with its stakeholder organizations to communicate this ongoing effort widely to ensure a seamless transition for end users of the Cancer Staging System.
Dr. Baker is chief medical officer, Joint Pathology Center, Silver Spring, Md., and CAP liaison to the AJCC executive committee. He serves as vice chair of the AJCC education and promotions committee and is a past chair of the CAP Cancer Committee. Dr. Washington is professor of pathology, Vanderbilt University, and chair of the AJCC editorial committee and an executive committee member. She is a past chair of the CAP Cancer Committee and is currently a member of both the Cancer Committee and CAP Center Guideline Committee.
The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The identification of specific products, scientific instrumentation, or organizations is considered an integral part of the scientific endeavor and does not constitute endorsement or implied endorsement on the part of the author, DoD, or any component agency.