Revised AJCC staging of breast cancer: Significance of supraclavicular lymph node metastases

Abstract

Revised AJCC staging of breast cancer: Significance of supraclavicular lymph node metastasesThe Staging system for every tumour site should be reviewed from time to time due to progress in medical technology and increasing research findings. Currently, the American Joint Committee on Cancer-Tumor Node Metastasis (AJCC-TNM) staging system is, undoubtedly, the most widely practised and best staging system available. A recent revision 1 of the breast cancer staging system by AJCC is indeed worthwhile in certain aspects; however, the reclassification of supraclavicular node metastases as N3 disease is arguable The revised breast cancer staging is based on the recommendations of the Breast Task Force, an advisory body constituted by AJCC. 2 Although most of the changes recommended by the Task Force in the Staging system are evidencebased, the inclusion of supraclavicular lymph node metastases as N3 stage disease does not have firm and sufficient evidence in our opinion. The only basis for this change, as evident from the publication by Singletary et al. 2 is the study by Brito et al. 3 To make a change on the basis of one study is certainly a debatable decision because it is a non-randomised, retrospective study with a small sample size of 70 patients, and thus constitutes weak evidence. However, the previous edition of the AJCC Manual for Staging of Cancer 4 had multiple sources of evidence 5-7 to support its decision to include supraclavicular lymph node metastases as M1 disease. The study by Kiricuta et al. 5 revealed almost similar survival rates among patients with supraclavicular lymph node metastases and with distant metastases. The dismal outcome of such patients has been consistently documented in the published literature. 5-7 In our opinion, both AJCC and the Task Force have reclassified supraclavicular lymph node metastases in a hasty manner and without any convincing evidence in the literature. Various other professional organizations such as FIGO (International Federation of Gynecology and Obstetrics), and NWTSG (National Wilms' Tumor Study Group) have also modified their staging systems in the past. For instance, the subdivision of stage IB cervical cancer into IB1 and IB2 by FIGO in the revised staging 8 is based on published results of at least five studies, thus having a convincing basis. Although future revisions of Staging systems for all individual malignancies should be done as and when required, it is suggested that panellists involved should be more stringent in finding robust evidence to make such new recommendations;furthermore, every modification is likely to alter subsequent oncology practice throughout the world as the AJCC staging system is followed worldwide. REFERENCES 1.Greene FL,