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Journal of the National Cancer Institute, Vol. 96, No. 19, October 6, 2004
Background: The recently revised American Joint Committee on Cancer (AJCC) sixth edition cancer staging system
increased the stratification within colon cancer stages II and
III defined by the AJCC fifth edition system. Using nationally representative Surveillance, Epidemiology, and End Results (SEER) data, we compared survival rates associated
with colon cancer stages defined according to both AJCC
systems. Methods: Using SEER data (from January 1, 1991,
through December 31, 2000), we identified 119 363 patients
with colon adenocarcinoma and included all patients in two
analyses by stages defined by AJCC fifth and sixth edition
systems. Tumors were stratified by SEERs extent of disease and number of positive [lymph] nodes coding
schemes. KaplanMeier analyses were used to compare
overall and stage-specific 5-year survival. All statistical tests
were two-sided. Results: Overall 5-year survival was 65.2%.
According to stages defined by the AJCC fifth edition system, 5-year stage-specific survivals were 93.2% for stage I,
82.5% for stage II, 59.5% for stage III, and 8.1% for stage
IV. According to stages defined by the AJCC sixth edition
system, 5-year stage-specific survivals were 93.2% for stage
I, 84.7% for stage IIa, 72.2% for stage IIb, 83.4% for stage
IIIa, 64.1% for stage IIIb, 44.3% for stage IIIc, and 8.1% for
stage IV. Under the sixth edition system, 5-year survival was
statistically significantly better for patients with stage IIIa
colon cancer (83.4%) than for patients with stage IIb disease
(72.2%) (P<.001). Conclusions: The AJCC sixth edition system for colon cancer stratifies survival more distinctly than
the fifth edition system by providing more substages. The
association of stage IIIa colon cancer with statistically significantly better survival than stage IIb in the new system
may reflect current clinical practice, in which stage III patients receive chemotherapy but stage II patients generally
do not. [J Natl Cancer Inst 2004;96:1420 5]
T stage
N stage
M stage
T1 or
T3 or
Any
Any
T2
T4
T
T
N0
N0
N1
Any N
M0
M0
M0
M1
T1 or T2
T3
T4
T1 or T2
T3 or T4
Any T
Any T
N0
N0
N0
N1
N1
N2
Any N
M0
M0
M0
M0
M0
M0
M1
RESULTS
Demographics
Data from a total of 119 363 patients with colon adenocarcinoma were evaluated. Mean age ( standard deviation) for the
cohort was 71.1 12.6 years. Females represented 51.6% of the
group, and 54.4% of patients were married at the time of
diagnosis. The overall racial and/or ethnic distribution was
77.0% whites, 9.7% blacks, 5.4% Hispanics, 5.9% Asians, and
2.0% other.
Survival by AJCC Fifth and Sixth Edition Staging
Overall 5-year colon cancerspecific survival for the entire
cohort was 65.2%. By use of stages defined by the AJCC fifth
Table 2. Proposed staging system
Stage
I
IIa
IIb
IIIa
IIIb
IIIc
IIId
IIIc
IV
T stage
N stage
M stage
T1 or T2
T3
T4
T1 or T2
T3 or T4
Any T
Any T
Any T
Any T
N0
N0
N0
N1
N1
N2
N3
N4
Any N
M0
M0
M0
M0
M0
M0
M0
M0
M1
Stages I, IIa, IIb, IIIa, and IIIb are the same as in the American Joint
Committee on Cancer sixth edition system. T1 tumor invades submucosa; T2
tumor invades muscularis propria; T3 tumor invades through the muscularis
propria into the subscrosa or into nonperitonealized pericolic tissues; T4
tumor directly invades other organs or structures and/or perforates visceral
peritoneum; N0 no positive lymph nodes; N1 one to three positive lymph
nodes; N2 four or five positive lymph nodes; N3 six to eight positive lymph
nodes; N4 nine or more positive lymph nodes; M0 no distant metastasis;
M1 distant metastasis.
Journal of the National Cancer Institute, Vol. 96, No. 19, October 6, 2004
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Patient Demographics
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Fig. 3. Five-year survival for American Joint Committee on Cancer fifth edition
by grade. Solid bars, low-grade tumors; shaded bars, high-grade tumors. Star,
P.001, log-rank test. All statistical tests were two-sided.
Journal of the National Cancer Institute, Vol. 96, No. 19, October 6, 2004
Fig. 4. Five-year survival for American Joint Committee on Cancer fifth edition
by histologic subtype. Solid bars, adeno; open bars, mucinous; shaded bars,
signet cell. Star, P.001, log-rank test, compared with signet cell carcinoma.
All statistical tests were two-sided.
5-year survival was 83.6% and 83.7%, respectively, for rightand transverse-colon lesions, 81.5% for the left colon, and
80.7% for sigmoid lesions.
Number of Positive Lymph Nodes and Proposed
Staging System
DISCUSSION
The TNM system for staging cancer was developed in the
1940s (4) and since then has become an important and dynamic
part of our cancer language. Many physicians also still continue
to use other staging systems with long-standing histories, the
Dukes staging system (5) and the AstlerColler (6) and Kirklin
(7) modifications of the Dukes staging system. For the evalua-
Fig. 5. Five-year survival for American Joint Committee on Cancer fifth edition
by tumor location. Open bars, left; diagonal-hatched bars, right; solid bars,
transverse; vertical-hatched bars, sigmoid. Star, P.001, log-rank test, compared with sigmoid colon. All statistical tests were two-sided.
Journal of the National Cancer Institute, Vol. 96, No. 19, October 6, 2004
ARTICLES 1423
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NOTES
1
Manuscript received April 23, 2004; revised June 16, 2004; accepted August
6, 2004.
Journal of the National Cancer Institute, Vol. 96, No. 19, October 6, 2004
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