The TNM classification of breast cancer: need for change

Abstract

The need for a unified and internationally accepted cancer staging system was recognized in the first half of the twentieth century and led to the publication of the first International Union Against Cancer (UICC) [1] staging system in the 1950s. This was followed by the International Federation of Gynecology and Obstetrics (FIGO) classification of women’s cancers [2] and the American Joint Committee for Cancer (AJCC) classification, the first edition of which was published in 1977 [3]. These manuals are based on clinical and pathological data and make it possible to assign a stage to a malignancy that indicates the extent of the disease, and also provides indications for treatment and prognosis. The UICC TNM classification (TNMUICC) considers the size of the primary (T), regional lymph node status (N), and presence of distant metastases (M) as the fundamental disease characteristics. Although the TNM classification has been regularly updated since its first edition in 1977 (new 7th edition published in December 2009), the TNMUICC classification of breast cancer is, in our opinion, obsolete and requires radical overhaul, with the introduction of new information to produce a more modern and useful characterization of breast tumours. Based on the experience of an interdisciplinary work group, which over the last 10 years examined over 30,000 breast cancer patients, the European Institute of Oncology has produced proposals for a revision of the TNM classification of breast cancers. One of motives that inspired the new classification was the language of the existing TNMUICC which often has a negative psychological impact on the patient receiving the diagnosis. Words like ‘‘malignancy’’, ‘‘carcinoma’’, and ‘‘infiltrating’’ are particularly at fault here. Psychological problems are present in around 20–40% of persons diagnosed with cancer [4] and the emotive terminology used by the physician or in the diagnostic report—which conjures up images of pain, suffering, and death—are likely to exacerbate these problems. The fear and uncertainty that a cancer diagnosis generates may motivate the person to put her faith in the treating physician, ask questions about the illness, and find out more on the Internet. But the opposite reaction of This article is an extended and modified version of the one published previously in J Clin Oncol 2009; 27(15):2427–2428. Permission has been granted by Prof. Umberto Veronesi, Scientific Director of European Institute of Oncology to reuse the information again for this article.