pTX and pNX Removed from Cancer Staging Protocols

After extensive discussion with the American Joint Committee on Cancer (AJCC) the College of American Pathologists (CAP) announced in June, 2021 that use of pTX and pNX will be removed from the cancer staging protocols and no longer listed as an option in printed or electronic cancer staging protocols.  

The group’s consensus was “…that of the AJCC as the standard-setting organization for tumor staging, assigning pathologic T and N requires an integration of multiple sources of clinical data in addition to the pathologic staging data derived from the definitive surgical resection. Since assigning pTX and/or pNX renders a tumor unstageable, they should only be used when there is an absence of information necessary to determine pT or pN. Final tumor staging is ultimately the responsibility of the managing physician who takes into consideration all the appropriate clinical information, including imaging studies, operative findings, and other clinical data, when assigning the final pathologic TNM and group stage.”

Implementing change in AJCC staging requires significant planning and forethought. The standard-setting agencies identified at least twenty-two (22) stageable cancers in the AJCC Eighth Edition of the AJCC Cancer Staging Manual that could require additional clinical information, such as imaging or operative findings, to appropriately assign the pathologic T and N categories. While the changes do not affect cases that were not surgically resected, it does impact surgically resected tumors that required pathologic assignment of the T and N categories. Cases may be rendered unstageable if assignment of the pTX and pNX is used improperly.

Despite the broad scope and application, there is precedent for changing the staging classification system. Providers and Cancer Registrars may recall when pMX was removed from the TNM staging system with release of the AJCC Sixth Edition manual as one example. While at first the announcement may be concerning, the use of pTx and pNx will continue to have a key role in clinical care and cancer surveillance if appropriately used by the managing physician and not assigned by pathology.

Both CAP and the AJCC anticipate the change will improve cancer staging, reduce staging errors and enhance the quality of staging information needed by cancer registrars and cancer surveillance community partners. Future releases of CAP protocols may include template content or language that the pathologist may use when the clinical information precludes assigning of the T or N categories.

Updated cancer staging protocols are available for download on the CAP website in PDF or MS Word format and includes current and historical protocols.   The National Comprehensive Cancer Network (NCCN) has already updated and published their treatment guidelines in response to the announcement by CAP.

Cancer Registrars should become familiar with the changes in staging policies and know to appropriate apply stage cases in the Registry for concordance. Registrars who attended the 2021 National Cancer Registrar’s Association (NCRA) virtual conference may recall a presentation by Donna Gress, RHIT, CTR titled “AJCC TNM Staging System: Past, Present and Future Staging Issues” that discussed this pending change and how Registrars could apply the new policies to their work. Conference registrants may access and download a copy of the presentation on the NCRA Center for Cancer Registry Education website. Health information technology and cancer registry software vendors have been received the technical specifications and many electronic medical record systems and cancer data management systems in the United States have or are scheduled to receive their software updates. Additional information on the AJCC Eighth Edition Cancer Staging Manual may be found on the AJCC website.

Cancer programs accredited by the Commission on Cancer (CoC), National Accreditation Program of Breast Centers (NAPBC), and National Accreditation Program for Rectal Cancer (NAPRC) can consult with their pathology department to verify the revised treatment guidelines have been implemented.  

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