Should the 7th Edition of the Lung Cancer Stage Classification System Change Treatment Algorithms in Non-small Cell Lung Cancer?

Approximately 10 to 15% of non-small cell lung cancer patients will be assigned a stage classification according to the 7th edition of TNM that differs from that assigned by the 6th edition (the “stage shifters”). This apparent upstaging or downstaging of tumors may affect patient management, as many clinicians formulate stage-based management strategies. However, the staging system revision was not designed to evaluate treatment, and attempts to make parallel adjustments in treatment plans may not be justified. Lung cancer clinicians were surveyed at four lung cancer symposia. Treatment of the “stage shift” patients was evaluated in the International Association for the Study of Lung Cancer database and National Cancer Database. Overall, 77% of surveyed clinicians indicated they would alter patient management in response to a change in stage designation. The analysis of the data in the International Association for the Study of Lung Cancer database was not directed at supporting treatment changes. Despite the similar overall prognosis within each of the “stage shift” subgroups in the National Cancer Database, the treatment was decidedly heterogeneous. The perception that a stage change should lead to a change in management exists. The revision of the lung cancer staging system does not provide any direct information to indicate the superiority of one treatment approach over another. Assuming that overall prognosis of a subgroup is strongly linked to a specific treatment and that a particular outcome, therefore, warrants a change in treatment is not justified. Thus, making changes in management solely in response to upstaging or downstaging in the new stage classification system is not justified.