Abstract
Cancer survival may be inversely related to the speed at which a primary tumour grows
and disseminates. Assessment of prognosis using surgical and/or radiological definition
of disease extent, i.e. staging, has thus become a standard intervention in newly
diagnosed patients, with the most popular framework being the tumour-node-metastasis
(TNM) system. However, increasing use of biomarkers – non-TNM factors that predict
therapeutic benefit, rather than adverse disease outcome – has weakened the decision-making
dominance of TNM. This shift from risk-led to benefit-led practice is now starting
to blur the time-honoured qualitative distinction between curable (M0, early stage, adjuvant) and incurable (M1, early metastatic, palliative) disease treatment strategies; the same biologic drug
strategy may improve average survival outcomes by similar increments for two patients,
one of whom is ‘adjuvant’ and the other ‘metastatic’. Plausibly, then, biomarker-positive
patients presenting with high-TNM (M1) disease may enjoy the same, if not more, disease-free and/or overall survival benefit
as conventional low-TNM (M0) patients when treated with standard adjuvant interventions. Conversely, M0 patients concerned by quality-of-life issues such as alopecia may in future be able
to choose better-tolerated personalised drug regimens similar to those now used with
survival benefit in palliative settings, even if such adjuvant regimens have not yet
been validated by level 1 data. To these ends, a modernised decision-oriented disease
staging system called METS (molecular/extra-primary/tumour/symptoms) is presented
here.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to European Journal of CancerAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Rethinking TNM: breast cancer TNM classification for treatment decision-making and research.Breast. 2006; 15: 3-8
- TNM: evolution and relation to other prognostic factors.Semin Surg Oncol. 2003; 21: 3-7
- New TNM melanoma staging system: linking biology and natural history to clinical outcomes.Semin Surg Oncol. 2003; 21: 43-52
- T4 breast cancer under closer inspection: a case for revision of the TNM classification.Breast. 2007; 16: 625-636
- The future of the TNM staging system in colorectal cancer: time for a debate?.Lancet Oncol. 2007; 8: 651-657
- Using extracellular biomarkers for monitoring efficacy of therapeutics in cancer patients: an update.Cancer Immunol Immunother. 2008; 57: 759-775
- Cytogenetic biomarkers for human cancer.Front Biosci. 2008; 13: 5928-5949
- Commercialized multigene predictors of clinical outcome for breast cancer.Oncologist. 2008; 13: 477-493
- A personalized approach to cancer treatment: how biomarkers can help.Clin Chem. 2008; 54: 1770-1779
- Emerging biomarkers and new understanding of traditional markers in personalized therapy for breast cancer.Clin Cancer Res. 2008; 14: 8019-8026
- The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience.Cancer. 2001; 91: 1231-1237
- Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board.Cancer. 2006; 107: 2346-2351
- Conflict between guideline methodologic quality and recommendation validity: a potential problem for practitioners.Clin Chem. 2006; 52: 65-72
- Improved prediction of prostate cancer recurrence through systems pathology.J Clin Invest. 2007; 117: 1876-1883
- Swing of the surgical pendulum: a return to surgery for treatment of head and neck cancer in the 21st century?.Int J Radiat Oncol Biol Phys. 2007; 69: S129-S131
- A multidisciplinary approach to the management of breast cancer, part 2: therapeutic considerations.Mayo Clin Proc. 2007; 82: 1131-1140
- Time without symptoms and toxicity (TWiST): a quality-of-life-oriented endpoint to evaluate adjuvant therapy.in: Salmon S. Adjuvant therapy of cancer. Grune and Stratton, Orlando1987: 455-465
- Sentinel lymph nodes in gynaecological malignancies: frontline between TNM and clinical staging systems?.Eur J Nucl Med Mol Imaging. 2003; 30: 1684-1688
- Review article: current management of metastatic colorectal cancer – the evolving impact of targeted drug therapies.Aliment Pharmacol Ther. 2008; 27: 997-1005
- Failure of chemotherapy to prolong survival in a group of patients with metastatic breast cancer.Lancet. 1980; i: 580-582
- Polychemotherapy for early breast cancer: an overview of the randomised clinical trials with quality-adjusted survival analysis.Lancet. 2001; 358: 277-286
- Moderate neutropenia with adjuvant CMF confers improved survival in early breast cancer.Br J Cancer. 2003; 89: 1837-1842
- The CXCL12-CXCR4 chemotactic pathway as a target of adjuvant breast cancer therapies.Nat Rev Cancer. 2004; 4: 901-909
- Cancer: an attack on cytologism.Lancet. 1962; i: 493-499
- The contribution of NSABP trials of primary breast cancer therapy to an understanding of tumor biology: an overview of findings.Cancer. 1980; 46: 1009-1025
- Complete remission following endocrine or combined cytotoxic and hormonal treatment in advanced breast cancer.Oncology. 1987; 44: 51-59
- Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2.N Engl J Med. 2001; 344: 783-792
- Adjuvant systemic therapy for early breast cancer.Cancer. 1994; 74: 401-409
Article info
Publication history
Published online: March 31, 2009
Accepted:
February 23,
2009
Received in revised form:
January 26,
2009
Received:
January 13,
2009
Identification
Copyright
© 2009 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.
