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Evaluating TNM stage prognostic ability in a population-based cohort of gastric adenocarcinoma patients in a low-incidence country

  • Special Section on Epidemiology and Biostatistics: Quantitative Research
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Abstract

Objectives

TNM stage is the preeminent cancer staging system and a fundamental determinant of disease prognosis. Our goal was to evaluate the predictive power of TNM stage for gastric adenocarcinoma (GAC), in a low-incidence country.

Methods

A province-wide chart review of GAC patients diagnosed from April 1, 2005 to March 31, 2008 was conducted in Ontario and linked to routinely collected vital status data with a follow-up on March 31, 2012. TNM staging was classified using the sixth and seventh Union International for Cancer Control/American Joint Committee on Cancer editions. Kaplan-Meier and log-rank tests compared stage-stratified survival estimates. Discrimination was evaluated using Harrell’s C statistic.

Results

The cohort included 2366 patients. One- and 5-year survival was 43% and 17%. Using the sixth edition, 9% of patients had stage I disease, 5.4% stage II, 7.3% stage III, and 64% stage IV; 15% were not staged. Using the seventh edition, 9% were stage I, 7.7% stage II, 16% stage III, and 54% stage IV; 14% were not staged. Stage-stratified 5-year survival ranged from 68% to 7% with the sixth edition and from 70% to 4% with the seventh edition. Harrell’s C statistic was 0.64 (0.63–0.65) for the broad sixth edition staging categories and 0.68 (0.67–0.69) for the broad seventh edition. Discriminative power was similar for the refined stage categories and across multiple subgroup analyses; it was best in non-metastatic patients.

Conclusion

Existing staging systems for GAC used in North America predict individualized prognosis poorly. The creation of a more complex prediction tool is necessary to provide accurate and precise prognostication information to oncologists, patients, and their families.

Résumé

Objectifs

La classification TNM est le principal système de stadification du cancer, en plus d’être un déterminant fondamental du pronostic de la maladie. Nous avons cherché à évaluer la capacité prédictive de la stadification TNM pour l’adénocarcinome gastrique (ACG) dans un pays à faible incidence.

Méthode

Un examen des dossiers médicaux des patients ayant reçu un diagnostic d’ACG entre le 1er avril 2005 et le 31 mars 2008 a été mené à l’échelle de l’Ontario et maillé aux données sur le statut vital systématiquement recueillies, avec suivi jusqu’au 31 mars 2012. Le stade TNM a été déterminé selon les 6e et 7e éditions de la classification de l’UICC/AJCC. Les estimations de survie stratifiées selon le stade ont été comparées à l’aide des tests de Kaplan-Meier et du log-rank. La discrimination a été évaluée à l’aide de l’indice C de Harrell.

Résultats

La cohorte était constituée de 2 366 patients. Le taux de survie après un et cinq ans était de 43 % et de 17 %, respectivement. Selon la 6e édition, 9 % des patients avaient un cancer de stade I, 5,4 % de stade II, 7,3 % de stade III et 64 % de stade IV; pour 15 %, le stade était indéterminé. Selon la 7e édition, 9 % des patients avaient un ACG de stade I, 7,7 % de stade II, 16 % de stade III et 54 % de stade IV; pour 14 %, le stade était indéterminé. La survie après cinq ans stratifiée selon le stade variait entre 68 % et 7 % selon la 6e édition et entre 70 % et 4 % selon la 7e édition. L’indice C de Harrell était de 0,64 (0,63-0,65) pour les catégories de stadification générales de la 6e édition et de 0,68 (0,67-0,69) pour les catégories générales de la 7e édition. La capacité de discrimination était semblable pour les catégories de stadification détaillées et selon de nombreuses analyses par sous-groupes; elle était la plus efficace pour les patients ayant un ACG non métastatique.

Conclusions

Le système de stadification existant de l’ACG utilisé en Amérique du Nord est inefficace pour offrir un pronostic individuel. Il est nécessaire de créer un outil de prédiction plus complexe pour fournir des pronostics exacts et précis aux oncologues, aux patients et aux familles.

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Authors and Affiliations

  1. Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada

    Alyson L. Mahar

  2. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

    Alyson L. Mahar & Daniela Cortinovis

  3. Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada

    Alyson L. Mahar, Daniel Kagedan, Matthew Dixon & Abraham El-Sedfy

  4. Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada

    Brandon Zagorski, Calvin Law, Lawrence Paszat & Natalie Coburn

  5. Department of Surgery, University of Toronto, Toronto, ON, Canada

    Daniel Kagedan, Matthew Dixon, Calvin Law & Natalie Coburn

  6. Hospital for Sick Children, Toronto, ON, Canada

    Jovanka Vasilevska-Ristovska

  7. St. Michael’s Hospital, Toronto, ON, Canada

    Corwyn Rowsell

  8. Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Calvin Law, Lawrence Paszat & Natalie Coburn

  9. Department of Surgery, Dalhousie University, Halifax, NS, Canada

    Lucy Helyer

Authors
  1. Alyson L. Mahar
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  2. Brandon Zagorski
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  3. Daniel Kagedan
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  4. Matthew Dixon
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  9. Calvin Law
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  10. Lucy Helyer
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  11. Lawrence Paszat
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  12. Natalie Coburn
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Correspondence to Alyson L. Mahar.

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Mahar, A.L., Zagorski, B., Kagedan, D. et al. Evaluating TNM stage prognostic ability in a population-based cohort of gastric adenocarcinoma patients in a low-incidence country. Can J Public Health 109, 480–488 (2018). https://doi.org/10.17269/s41997-018-0102-1

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  • DOI: https://doi.org/10.17269/s41997-018-0102-1

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