The truth and dispute in TNM staging, standardized care and evidence-based medicine in cancer management

Abstract

Current clinical management of cancer is based on a three-pillar system: TNM staging, standardized care and evidence-based medicine. Together, they support the entire system of cancer management. In the system, there are more than 30 million cancer patients, more than a million medical workers taking care of these patients, and millions more research scientists looking for ways to conquer cancer, the emperor of all maladies. Everyone in this system is supposed to follow a number of principles derived from these three pillars. The net result, after decades of building and polishing, is the presence of a global system with massive infrastructure, advanced technologies, tremendous funding, monopolized discoursing platform of public opinion and talented people, all together to strengthen the few principles derived from the three pillars. It is almost impossible to doubt or challenge the correctness and usefulness of these three pillars and thus the principles derived from them, less to say to replace them with something different. Yet going back the history of these pillars, one may ask some very reasonable questions about their correctness. For example, patients with the same TNM staging do not have similar clinical outcome when treated by the same therapy. If they are same, why they respond differently to the same therapy? And if they are truly different, why are they treated by the same therapy? What makes the difference among them? What do results from clinical trials comparing groups of different patients really mean? Evidence-based medicine emphasizing “evidence”, but there is no evidence to show that putting every one with similar TNM staging to the same treatment plan is the best option for them. Medicine, like other branches of science, should emphasize reasoning, but this has not been the case in cancer management in which one only needs to pay attention to data but not why it is the way it is. On the other hand, we have findings from animal tumor models translated to clinical study in a totally unmatched way in which findings from individualized animal model are translated to a mixed group of patients. This always yielded failures. There is nothing wrong to do individualized research in human cancer patients as long as we realize its limitation and applicability to other cases. With this approach, we have accumulated some very interesting observations, developed some reliable principles from these individualized studies and have put these principles into a novel guiding system that helps to derive individualized treatment plans for any patient at any stage in their disease course. Here we present logic arguments that the three pillars of the current clinical practice in cancer management have severe shortcomings that need to be replaced with a more reasonable and individualized management system.