In the Clinic

On Cancer: More-Accurate Colorectal Cancer Staging Helps Doctors Personalize Treatment

By Jim Stallard, MA, Writer/Editor  |  Thursday, November 8, 2012
Pictured: Martin Weiser Surgical oncologist Martin R. Weiser has led the effort to build colorectal cancer prediction tools.

Memorial Sloan Kettering researchers have pioneered prediction tools to assess disease risk and survival rates following surgery to remove colorectal cancer. These mathematical models, which are available online, are proving to be more accurate than traditional colorectal cancer staging methods.

Patients and physicians can use these prediction tools, known as nomograms, to help make treatment decisions, and researchers can use them to help plan clinical trials. A new nomogram, now available on Memorial Sloan Kettering’s website, predicts a patient’s chance of survival – given in a percentage – five years after surgical removal of all cancerous tissue.

“As our therapeutic options have expanded, we need more-accurate predictions of disease survival and recurrence in order to make better decisions about treatment and long-term follow-up,” says Memorial Sloan Kettering surgical oncologist Martin R. Weiser, who has led the effort to build colorectal cancer prediction tools. “Creating these new models enables us to address the distinct needs of every patient.”

Limitations of Traditional Colorectal Cancer Staging

The traditional approach to evaluating colorectal cancer risk, developed by the American Joint Committee on Cancer (AJCC), stages colorectal cancer based on minimal information about the tumor — specifically, three anatomical details regarding how much the cancer has grown and spread. The staging system is called TNM because it uses information about the tumor, lymph nodes, and metastasis (if the cancer has spread).

The TNM model categorizes cancer into one of four main stages, each of which is associated with a range of likely survival five years after surgery. In 2009, the AJCC divided TNM’s four stages into substages by incorporating more tumor characteristics.

The TNM model has shortcomings, Dr. Weiser explains. The outlook for different patients within the same overall stage can vary significantly. And although the addition of the substages improved the accuracy of prognosis within each stage, the clear order of the stages was lost — for example, some TNM stage III patients now have better survival rates than certain stage II patients.

“The AJCC’s increased number of categories has become confusing and often counterintuitive,” Dr. Weiser says. “We decided what was needed are predictive models that do away with all the groupings and instead produce for each patient an absolute number — a percentage showing the likelihood of remaining disease-free or surviving a certain number of years.”

More Data and Better Results

Memorial Sloan Kettering’s nomograms build on the TNM system, supplementing it with routinely available data such as the patient’s sex and age, how much the tumor resembles its tissue of origin – known as tumor differentiation – and whether tumor cells were found in or around surrounding lymph nodes, blood vessels, and nerves. 

“The additional information gives our models a great deal of predictive power,” Dr. Weiser says. “And people easily grasp percentages, which makes it easier for patients and physicians to discuss treatment options.”

An earlier nomogram, which is also available online, predicts the probability of being disease-free five to ten years after surgery. The newer nomogram predicts a person’s chances of survival five years after surgery.

The researchers validated the newer nomogram’s accuracy by applying it to more than 125,000 colorectal cancer cases recorded in a government database. In December 2011, the researchers reported in the Journal of Clinical Oncology that the nomogram’s predictive power surpassed the TNM model when applied to the same database.

“I think this nomogram will more likely be seen as a valuable add-on that we offer here, rather than a complete replacement for traditional staging,” Dr. Weiser says. He explains that the nomogram will probably have the greatest impact on whether to use chemotherapy following surgery.

But the nomogram also could enable researchers to conduct clinical trials with fewer people, since more precisely defined risk groups make it possible to test a treatment’s effectiveness in a smaller population.

Dr. Weiser says the next step will be to incorporate molecular and genetic information into the prediction tools — much of it uncovered through research at Memorial Sloan Kettering. “The biology of this cancer is much more complex than we imagined, so adding these new variables will be essential to refining these tools to make them as accurate as possible,” he explains. 

Comments

My wife was diagnosed recently with Adenocarcinoma of unknown primary source, staged as T14-M1b, and she is being treated for an assumed colon adenocarcinoma. I had heard great things for MSKCC, but I am disappointed that they are not able to identify the primary source. Where is the team work in diagnosing and planning the treatment. The other thing I am frustrated of is the disregard of the staff of every level to give the service on time. How can you as healthcare professional let a suffereing patient to wait for 2.5 hours to deal with them only 5 minutes? I have more on MSKCC, but I am not sure if anybody takes care of complaints from patients and their families. I haven't seen such things happening in any other hospital or clinic. Obviously,MSKCC has a very poor work culture. Is there any administration dep. in it investigating the complaints? Is there ant e-mail contact to submit a complaint? I don't see such things in their website. The MSKCC is like a castle guarded fanatically.

Hi, Gus. Our Patient Representatives are committed to ensuring that your rights are respected and that your concerns are addressed. We have sent them your concern, and you can contact them directly at 212-639-7202 to discuss this in more detail.

I really do hope that they are successful in encouraging more people to get screened for colorectal cancer this month. I found a new post in honor of Colorectal Cancer Awareness Month this month, and I wanted to share it in hopes that this can provide some more information concerning the benefits of these screening tests for anyone who may be interested. This disease remains the second-leading cause of cancer-related death in the United States, but many of these deaths can be prevented. It all starts with better education of the risks for colorectal cancer and more awareness of what you can do to protect yourself: http://www.clinicaltrialsgps.com/cancer-2/colorectal-cancer-awareness-month/

I am a colon cancer patient .I have called MSKCC several times for a second opinion .i was given the running around 10 times and even more .My primary doctor called my insurance and she was told some one from MSKCC needs to contact my insurance .What If I was really ill they partially turn me away .I still have not got a second opinion .I work with foster care kids and I haven't been able to work because am having lots of pain from my surgery.Hope some one will see this and try to help me .I am very disappointed lots of people don't care about others .I was task around and didn't get help .

Ann, if you would like to make an appointment with a Memorial Sloan-Kettering physician, please call our Physician Referral Service at 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment. They also will be able to answer questions about insurance.

I am VERY surprised to read the comments above. Presumably any persons in need of colorectal medical care will know enough to discount such anecdotal posts.

My experience was 100% the opposite of the complaints here. I live in NJ and first looked at care in my area - found that some established Docs were in network (BCrBlSh) and others were not. Laparoscopic option for surgery on my large tumor was going to be a problem.

Immediately confirmed insurance coverage at Mem Sloan Kettering, got appointment right away. Evaluation was swift. Options were immediately presented by Dr Weiser who did not leave room until assured I had no further questions.

In 12+ months of various treatments -- chemo and chemo-radiation in NJ facility; 2 surgeries in NYC; a dozen check-ups and consults with surgeon, oncologist and oncology radiation docs -- I have never had an inordinate wait. Once I think I waited over an hour because a patient before me had a crisis (heat attack?). Otherwise everything was more or less punctual. Coordination across disciplines was excellent.

As for the organization's culture, I am astounded altogether. I have never encountered an organization as thoroughly client/patient focused as MSKCC. They are a model for health care excellence. Nobody was anything less than positive in attitude - and I mean EVERY one of the several dozen persons I encountered. And, of course, it is a given that we are dealing with folks at the very top of the game in terms of professional competence. I'd think that a case study in Harvard Business Review is just as much in order as one in medical journals.

But hey, just one anecdotal impression. Check 'em out yourself. I began by asking local MDs. They knew MSKCC was special. Now I do, too.

I have been doubly blessed at Memorial Sloan Kettering ! How im connected to Sloan Kettering and on this forum - so please be patient~ In 2010 my husband took ill , at a Local hospital here in Pa they found a frontal lobe tumor, operated and went on to tell him he would have a long life , turns out a week later it biopsy diagnosed as lymphoma. my so smart daughter quickly took the reins and had the tissue sample sent back from CA to Sloan to Dr. Antonia Omura. a week later I had my husband in Sloan urgent care and was informed my husband had primary CNS brain lymphoma and without trial/treatment he was looking at 4 month life expectancy. Hes doing great and still tumor free! In 2011 right before my husbands radiation treatment onset, I found a lump in my mouth, again a mis diagnoses from a leading head n neck here- I went to Dr Dennis Kraus at Sloan he preformed a state of the art surgery on my rare peripheral nerve sheath cancer- other doctors played impotant roles as well- this being said , and why im on a color rectal posting- My mother who resides in Fl and doesn't travel well had a resection for colon cancer a year and half ago, she became hospitalized after her 3rd dose of FU-5 chemo, apparently allergic to it- 2 weeks ago she had a full hysterectomy while in surgery for a adnexal mass removal - it spread to her(L) ovary and (L) fallopian tube- her oncologist is researching a chemo she can tolerate for her Adenocarcinoma Colon Cancer any ideas????????

June, thank you for sharing your story. We are sorry to hear about your mother. We are not able to answer medical questions on our blog, so this is something you should discuss with a specialist. If your mother is not able to travel to New York and MSK, we recommend you find a National Cancer Institute-designated comprehensive cancer center that is more convenient for her. You can find a list of them here: http://www.cancer.gov/researchandfunding/extramural/cancercenters

Thank you for your comment.

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