The AJCC: 60 years of cancer staging leadership

This year, 2019, marks the 60th anniversary of the founding of what is now known as the American Joint Committee on Cancer, commonly referred to as the AJCC. The AJCC was organized in 1959 as the American Joint Committee for Cancer Staging and End-Results Reporting (AJC). It is appropriate to commemorate and acknowledge the founding of this multidisciplinary organization in the Bulletin because the founding of the AJC can be traced directly to leaders of the American College of Surgeons (ACS) who had the foresight, the influence, and the will to develop an organization whose primary purpose was the staging of patients with cancer.

Initial cancer staging efforts

In the 1940s and ’50s, Prof. Pierre Denoix, MD, a French surgeon and later director of the Institut Gustave Roussy, Villejuif, France, developed a simple anatomic staging system for breast cancer dependent on the size of the tumor, nodal status, and metastatic (TNM) findings.¹ This clinical classification of cancer was pioneered before the founding of the AJC for the purpose of developing a common international language to facilitate the staging of neoplastic disease and to compare the results of therapy. The World Health Organization (WHO) played an important role in the early days of cancer staging development, as did the International College of Radiology and the International Committee for Stage-Grouping in Cancer and for Presentation of the Results of Treatment of Cancer (ICPR).² These organizations were instrumental in promulgating the TNM system, which had as its primary objectives the provision of comparability of stage grouping and of end results reporting that were aligned with WHO rules.

Once the TNM system was adopted at the 1953 International Congress of Radiology, the International Union Against Cancer, later known as the Union for International Cancer Control (UICC), assumed a leadership role after a joint meeting of the ICPR and the UICC Committee on Tumor Nomenclature and Statistics (CTNS). The Committee on Clinical Stage Classification and Applied Statistics ultimately replaced the CTNS, and in 1956 the name was changed to the TNM Committee of the UICC.

AJCC is established

Three years later, on January 9, 1959, the AJC—the forerunner of the modern AJCC—was organized as a result of a recommendation from Earle E. Barth, MD, chairman of the American College of Radiology (ACR) Board of Chancellors, to I. S. Ravdin, MD, FACS, then-Chairman of the ACS Board of Regents and later ACS President (1960–1961).² Dr. Barth, inspired by the cancer committee of the ACR, proposed the establishment of a U.S. committee to develop a system of staging and reporting cancer end results that would be acceptable to U.S. and Canadian physicians and would continue the TNM format that Professor Denoix proposed. The founding leadership believed that cancer classification, while embracing the TNM concepts, should also embrace the needs of U.S. physicians and hospitals that were working in ACS-approved cancer clinics. This proposal represented the beginning of the accreditation process that the future ACS Commission on Cancer (CoC) would use.³ It seemed wise, therefore, to develop an official body that could evaluate the recommendations of the UICC TNM committee so as to suggest or offer alternate classifications based on the TNM system that were more suitable for use by North American physicians.

From its beginning, the AJCC has been administratively housed at the ACS headquarters in Chicago, IL. Noted surgical oncologist Murray M. Copeland, MD, FACS, was the first Chair of the AJC (1959–1969); followed by acclaimed pathologist W.A.D. Anderson, MD (1969–1973); and subsequently by Oliver H. Beahrs, MD, FACS, a future President of the College (1988–1989). Under Dr. Beahrs’ direction, the AJC produced its first staging manual after a 1976 meeting of the cancer site task forces in Atlanta, GA, in 1976.

In keeping with the concept that the fledgling AJC should be a coalition of organizations that have cancer management as their primary goals, the initial sponsoring organizations of this seminal organization were the ACS, the ACR, the College of American Pathologists, the American College of Physicians, the American Cancer Society, and the National Cancer Institute.

As Dr. Beahrs wrote in that first edition of the manual, Classification and Staging of Cancer by Site, “Proper classification and staging of cancer will allow the physician to determine treatment for the patient more appropriately, to evaluate results of management more reliably, and to compare statistics reported from various institutions more confidently.”⁴ The AJC developed a concept in which multidisciplinary task forces for each cancer site were created. These task forces or expert panels were assigned to review available outcomes data culled from existing rudimentary hospital registries and literature reports. AJCC expert panels and editorial boards continue to use this nascent approach today. The National Cancer Database (NCDB), created in the late 1980s, is a proven resource for more modern approaches to updating the TNM system and inclusion of newer biological and molecular markers in cancer staging.⁵

Throughout the ensuing decades, both the UICC and the AJCC have been partners in promoting and educating the international cancer health care community regarding the taxonomy of cancer staging and the importance of using both clinical and pathological staging to assess cancer outcomes.⁶ Through vigorous discussion and the work of many clinicians dedicated to cancer care in both organizations, promulgation of a worldwide TNM system was finally realized in 1987.^7,8 Since 1997, when the fifth editions of both the UICC and AJCC print monographs were introduced, the two organizations have worked diligently to ensure that each iteration of the TNM system is published in a synchronous fashion worldwide.

Over the last 60 years, the original concepts recognized by the founders of the AJC have metamorphosed into the principles of the AJCC that embrace not only the importance of anatomic staging, but have highlighted the critical significance of prognostic and predictive factors into the modern concepts of cancer treatment.⁹ In addition, the AJCC has recognized and highlighted the critical role of cancer registrars. These dedicated professionals, especially registrars working in CoC-accredited institutions, have diligently collected, abstracted, and transmitted data on cancer patients to the NCDB, allowing for the information gleaned to be used in all elements of AJCC cancer staging and patient treatment. For this reason, the eighth edition of the AJCC Cancer Staging Manual has been dedicated to our cancer registrars.¹⁰

In the last six decades, working with cancer registrars, surveillance personnel, and hundreds of volunteer clinicians who serve on multiple expert panels, the AJCC has fine-tuned the cancer staging lexicon and has served as the primary promoter of education for the “language of cancer.”¹¹ In recent years, the impact of the AJCC has been elevated through productive collaborations with other staging groups, such as the International Federation of Gynecology and Obstetrics and the International Association for the Study of Lung Cancer, representing gynecologic and lung cancer staging respectively.¹²

Transformations continue

As the AJCC begins its seventh decade of work, it is strengthened by the contributions of liaison members from other cancer-related organizations (see sidebar). The opportunities to transform cancer staging from a purely anatomic basis to personalized cancer care are both daunting and exhilarating. The inclusion of artificial neural networks that lead to robust risk-assessment tools in cancer care, and technical support systems that can translate the complexities of modern staging into understandable and useful instruments for both patients and clinicians alike, are also important agenda items for the AJCC. There is little doubt that the solid foundation of collaboration championed by the founders of the AJCC—working with leadership of the ACS 60 years ago—will be instrumental in meeting the significant challenges of cancer staging and cancer care going forward.

References

1. Denoix PF. Nomenclature des cancers. Bull Inst Nat Hyg. 1944;1:52-82.
2. Copeland MM. The American Joint Committee for Cancer Staging and End-Results Reporting: Its relationship to the TNM Committee of the International Union Against Cancer. In: Classification and Staging of Cancer by Site. Chicago, IL: The Joint Committee for Cancer Staging and End-Results Reporting; 1976:3-7.
3. American College of Surgeons Committee on the Treatment of Malignant Diseases. Organization of service for the diagnosis and treatment of cancer—a minimum standard. Bull Am Coll Surg. 1931;15(2):22-25.
4. Beahrs OH (ed). Classification and Staging of Cancer by Site. Chicago, IL: The Joint Committee for Cancer Staging and End-Results Reporting; 1976.
5. Winchester DP, Stewart AK, Phillips JL, Ward EE. The National Cancer Data Base: Past, present and future. Ann Surg Oncol. 2010;17(1):4-7.
6. Greene FL. Cancer staging in outcomes assessment. J Surg Oncol. 2014;110(5):616-620.
7. Hutter RVP. At last worldwide agreement on the staging of cancer. Arch Surg. 1987;122(11):1235-1239.
8. Greene FL, Sobin LH. A worldwide approach to the TNM staging system: Collaborative efforts of the AJCC and UICC. J Surg Oncol. 2009;99(5):269-272.
9. Greene FL. Onward to the eighth edition of TNM—the blending of anatomic and molecular prognostic factors in cancer staging. J Surg Oncol. 2013;108(8):508.
10. Amin MB, Edge, SB, Greene FL, et al (eds). AJCC Cancer Staging Manual, Eighth Edition. New York, NY: Springer Publishing; 2017.
11. Greene FL, Sobin LH. The TNM system: Our language for cancer care. J Surg Oncol. 2002;80(3):119-120.
12. Goldstraw P, Crowley J, Chansky K, et al. The IASLC Lung Cancer Staging Project: Proposals for the revision of the TNM stage groupings in the forthcoming edition of the TNM classification of malignant tumours. J Thorac Oncol. 2007;2(8):706-714.