Setting the “stage” for Surgical Oncology fellows: Pierre Denoix and TNM staging

Surgeons have been and continue to remain essential partners in the multidisciplinary care of cancer patients. A seminal contribution to cancer care is the TNM staging system pioneered by the surgeon Pierre Denoix, who led the first cancer center in Europe, the Institut Gustave Roussy from 1956 to 1982. Together with his collaborators, he introduced the TNM staging system in 1952. Criticized at the time for being overly simplistic, advocates pointed out its practicality and universality, observations that have remained true to present day. Despite limitations such as the lack of significant differentiation in prognosis between and within groups for some disease sites and the difficulty with incorporation of nonanatomic factors, TNM staging remains critical to the care of the cancer patient. It serves as the cornerstone of treatment and surveillance strategies, as well as eligibility, stratification, and analysis of clinical trials for disease sites including melanoma, colorectal and breast cancer, among others. On January 1st, 2018, the 8th Edition of the American Joint Committee on Cancer (AJCC)/International Union against Cancer (UICC) TNM Cancer Staging Manual was formally implemented. This final product was the culmination of several years of intense collaboration among experts in multiple disease sites from around the world. For the first time, a funded position was created coincident with the development of the 8th edition for a clinical scholar‐in‐residence at the AJCC to learn, engage and participate in efforts to revise and refine the staging system. Inviting the “future generation” of surgeons to be immersed in the cancer staging arena is important because: (i) it facilitates the preservation of the knowledge of the core principles of staging, (ii) engenders interest in staging, (iii) creates a strong awareness about the limitations of existing data and approaches, and (iv) opens the door for novel and creative strategies to further optimize and refine current and future staging systems. Additionally, as surgeons, participating and promoting TNM staging is not only important to render good clinical care, but also pays homage to the surgical heritage of cancer staging. To help achieve the goal of assigning a documented stage for every “stageable” cancer patient, it is imperative to engage surgical trainees. Educating surgical oncology fellows to understand and champion cancer staging will ensure that the future generation of surgeons carry forth the torch, preserve where necessary, and innovate to adapt to these exciting and rapidly evolving times. In our Complex General Surgical Oncology fellowship training program at The University of Texas MD Anderson Cancer Center, we have launched a quality initiative (QI) project that seeks to increase the percentage of documented stage for patients with “stageable” cancer treated in our Department of Surgical Oncology. With the aid of a staging tool that is embedded in the electronic medical record, fellows document AJCC/TNM stage and pertinent prognostic factors based on disease site and patient presentation. The staged document is then electronically reviewed and cosigned by the faculty of record. Obvious benefits to this QI project include: (i) educational value as fellows and faculty review College of American Pathologists protocols for each patient including identification of areas in which the current system requires further optimization and (ii) a decrease in “missing data. ” It is hoped that incorporating the documentation of cancer stage into our educational objectives will set the “stage” for our trainees to carry on the legacy of Pierre Denoix and the passion to continue to innovate within the field of oncology.