Does Size Matter Most? Reassessing Clinical Staging for Pancreatic Cancer

Abstract

Cancer staging is an ever-evolving entity. Most would agree that staging systems are generally accurate and never perfect but, nonetheless, an integral tool in treatment planning, communication, research, and education. Although current American Joint Committee on Cancer (AJCC) staging systems fulfill these missions adequately for most solid tumors, in this issue of Annals of Surgical Oncology, Morganti et al. 1 question the utility of staging for pancreatic cancer. It is certainly true that AJCC staging is rarely referred to during treatment planning for pancreatic cancer patients. Clinically, patients are generally classified as potentially resectable, unresectable because of locally advanced disease, and incurable because of the presence of metastatic disease. These clinical strata and the AJCC stages they encompass successfully segregate patients by their median survival and have formed the basis for clinical trial design. As is all too familiar to the readership, with current available therapies nearly all patients with pancreatic cancer are incurable at diagnosis because of the presence of metastatic disease, whether it is immediately visible or occult. Although we strive to cure, even for resectable patients, prolongation of survival with acceptable quality of life is what we can realistically achieve for most patients. Because of the morbidity of pancreatic surgery, numerous studies have been performed to determine whether clinical factors can identify patients who, even in the face of radiographically resectable disease, are unquestionably incurable and therefore should not be considered for operation. Although various authors have reported that CA19-9 levels of >750 or 1000 U/ml are associated with an ultimately fatal outcome, the ability to prognosticate length of life after resection is more difficult. 2 This, coupled with the lack of alternative treatments, makes it difficult for the surgeon to counsel against operation on the basis of a single clinical factor. Apart from the question of operability, then, what information should we seek from the diagnostic imaging tests we obtain in newly diagnosed pancreatic cancer patients?