Changes to the standards for staging of prostate cancer

The most recent, 8th edition, of the American Joint Committee on Cancer (AJCC) Staging Manual has introduced some relatively minor modifications to the standards for staging of prostate cancer. Awareness of the changes to these standards will not seriously impact the management of the majority of individual patients, but it is important for prostate cancer support group leaders and other prostate cancer educators to be aware of them.

A complete and excellent summary of the changes as gthey relate to prostate cancer can be found in this full text article by Buyyounouski et al. in CA: A Cancer Journal for Physicians. However, the following provides a bullet-point summary of the absolute basics:

  • Pathological staging of prostate cancer after surgery will no longer contain the subcategories pT2a, PT2b, and pT2c. All pathologically localized prostate cancer that is confined to the prostate will simply be categorized as pT2. Why? Because there is no evidence that using the subcategories in the pathological setting makes any difference to projection of long-term outcomes. (Note, however, that the subcategories cT2a, cT2b, and cT2c will still be used in clinical as opposed to pathological staging based on rectal examination and imaging tests prior to biopsy.)
  • Pathologic stage (post-biopsy and post-surgery) should now be reported using both the Gleason score (AJCC 7th edition criteria) and the newer grade groups (AJCC 8th edition criteria) developed by the International Society for Urologic Pathology.
  • The AJCC prognostic Stage III category will now include patients with select, organ-confined disease based on the patients’ PSA level and Gleason/grade group status (see Table 4 in the paper by Buyyounouski et al.).
  • Two prognostic nomograms that provide prjection of overall survival in men with metastatic, castration-resistant prostate cancer (the so-called Halabi nomograms) are recommended for projection of overall survival-specific outcomes (see Table 2 in the paper by Buyyounouski et al.). The reason for not including more commonly used prognostic models such as the Kattan nonograms and the Partin tables is that the outcomes projected by these models are not overall survival.

We strongly suggest that all support group leaders and other prostate cancer educators ensure that information they are distributing are updated to conform with the recommendations of the revised 8th edition of the AJCC staging manual.

2 Responses

  1. This paper will help us master the revisions in terminology.

    It is also an interesting snapshot of the state of thinking among some leaders in prostate cancer that is already slipping into the rear view mirror in our rapidly advancing field. The paper has some interesting omissions, perhaps a result of this rapid change, including basic paradigm change for something as fundamental as staging, where genetics may soon move to prominence.

    For example, the widely used Halabi nomograms for prognosis for patients with metastatic, castrate-resistant disease and for second-line chemo for such disease, for which the paper provides convenient links, are based on inputs including, for the first nomogram, ECOG performance status, site of metastases, PSA, hemoglobin, albumin, alkaline phosphatase, LDH > 1 ULN, opioid analgesic use, and for the second nomogram, ECOG performance status, visceral disease, progression on docetaxel, duration on hormone, measurable disease, pain, PSA, hemoglobin, alkaline phosphatase. We could probably make some money by betting that various key genetic indicators — all associated with improved therapy decision making — will soon be added. Specific genetic aspects that got attention at the 2016 conference on prostate cancer included at least the following: BRCA1/2 gene status; RB1, TP53, and PTEN cancer suppressor gene status; TMPRSS2 and ERG gene fusion status; and ARV7 status, as well as others — all representing key forks in the road for treatment decision making. These seem to be important features for superior staging of patients with well advanced disease or disease that appears potentially life-threatening at presentation. (At the conference Drs. Charles “Snuffy” Myers, Nick Vogelzang, Mark Scholz, and Mark Moyad were excited about this genetic technology that they are now putting to use in their clinics, achieving some stunning successes.)

    In the important and rapidly improving field of imaging, it was interesting that the paper, while mentioning some scans that are now proving useful, omitted any mention of C11 (carbon 11) acetate scanning (Phoenix, Arizona) and C11 choline PET-CT scanning (Mayo Clinic in Minnesota, and recently elsewhere) that are proving so valuable for patients with advanced disease. I suspect that too will soon change in the near future for staging guidance.

  2. Jim,

    Keep in mind that AJCC is a staging system, and not mainly a risk stratification system (except for the AJCC Stage Groups, which I have never seen used by clinicians). The genetic components do not come into play for staging.

    They did note that the PSMA-based PET scans are a lot better than any of the others. However, until they are widely available and in common use (DCFPyL is in a large national clinical trial for recurrent prostate cancer), they could not include any of them for staging. This is a rapidly evolving field, and the C-11 PET scans are already pretty much yesterday’s news.

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