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On January 1, 2018, the world will wake up to the eighth edition of the TNM classification for lung cancer. This will mark the first day that everyone around the globe will be using this new edition, the day when we will all resume speaking the same language. As Detterbeck
points out in this Invited Expert Opinion in this issue of the Journal, it is nearly impossible to imagine that we can deliver adequate lung cancer care without this staging system. The TNM staging system allows us to standardize diagnostic investigations, treatments, and prognostication when we communicate among each other and with our patients. In addition to serving as a universal communication platform, this particular eighth edition ushers us into a new era of lung cancer treatment.
“What is my stage, doctor?” a patient will invariably ask at some point during a lung cancer encounter. Stage IA (T1aN0) is usually met with a sigh of relief, and is even regarded as somewhat good news. With the advent of the eighth edition, the same T1aN0 will be classified as stage IA1—something that you would almost say with two thumbs up! This small difference in nomenclature is the result of colossal research that has allowed us to gain strides in the early detection and treatment of lung cancer. After the advent of low-dose computed tomographic screening, and the subsequent rise of targeted surgery for subcentimeter and partially solid nodules, we are now able to achieve cure rates approaching 100% for T1a preinvasive non–small cell lung cancer. By breaking down T1 into 1-cm size increments, the eighth edition ushers us into the “era of the nodule” and reinforces the need for thoracic surgeons to become adept at early-detection techniques, targeted surgery, and minimally invasive sublobar resections.
Contrarily, the news of having stage IV disease is usually met with a sigh of despair and perhaps tears. Stage IVA sounds slightly more hopeful than stage IVB, however, and serves to highlight the fact that we are now pushing the limits of what can be offered to patients whom we think have incurable disease. With the advent of targeted therapy, immune therapy, and metastasectomy, we are now able to measure survival of patients with stage IV disease in years rather than months. We also find ourselves, as thoracic surgeons, becoming active in an area where our role was previously limited to draining malignant pleural effusions. The eighth edition ushers us into the “era of hope,” in which it becomes conceivable that maybe one day, a few editions after this one, stage IV disease may prove to be not as incurable as we thought.
The introduction of new TNM editions should be more than just a new way to classify disease stages into boxes. It should be an opportunity for us to take an introspective look at our practice to ensure that we remain current with the evolution of the field of lung cancer. More importantly, it should be an opportunity for us to project to the future, to adapt our surgical science to it, and to remain leaders in innovation and delivery of “cutting edge” lung cancer care.
The eighth edition TNM stage classification for lung cancer: what does it mean on main street?.
Feature Editor's Note—The eighth edition of the American Joint Commission on Cancer TNM staging system for non–small cell lung cancer was introduced in January 2017 and will be implemented in the United States in January 2018. The eighth edition has been bolstered with a number of data-driven updates that will substantially affect the staging of early non–small cell lung cancer and are critical for the thoracic surgical oncologist to embrace in daily practice. New entities such as T1mi, T1c, M1c, and stage IA1 tumors, among others, will become regular in the language that we use to care for patients with lung cancer, and this staging framework is critical for advancing the field of thoracic oncology.