AJCC Staging

The American College of Surgeons (ACoS) Commission on Cancer has required that all approved programs must TNM stage all sites contained in the AJCC Manual for Staging of Cancer since January 1, 1991. Effective with 1995 cases, all cancers must be coded for the AJCC staging elements both clinically and pathologically.

Clinical staging is based on information accumulated before cancer-directed treatment. It is based on the physical examination, imaging, endoscopy, biopsy, surgical exploration, and other relevant findings. Clinical classification is appropriate for sites accessible for clinical examination. Use clinical classification when an organ does not have a pathologic evaluation.

Pathologic extent of disease is based on information gathered before cancer-directed treatment, as well as evidence gathered from surgery and pathological examination of the resected specimen. Pathologic extent of disease is a combination of all findings through first course of surgery, or 4 months, whichever is longer, in the absence of disease progression.

Post-therapy or post-neoadjuvant therapy staging determines how much cancer remains after a patient is treated with systemic therapy (chemotherapy or hormones) and/or radiation therapy prior to surgery or where no surgery is performed. This can be assessed by clinical staging guidelines after the therapy. It may also be assessed by pathological staging guidelines after surgery following the therapy.

In 2016, other national standard setters began to require AJCC staging as well. These include the CDC's National Program of Cancer Registries and the NCI's Surveillance, Epidemiology, and End Results (SEER) Program.

AJCC Editions and Effective Dates for Cancer Diagnosis:

  • 9th edition [Version 9]
    • Jan 1, 2024 – current:
      • Neuroendocrine Tumors (NET) of the Appendix
      • Neuroendocrine Tumors (NET) of the Colon & Rectum
      • Neuroendocrine Tumors (NET) of the Duodenum & Ampulla of Vater
      • Neuroendocrine Tumors (NET) of the Jejunum & Ileum
      • Neuroendocrine Tumors (NET) of the Pancreas
      • Neuroendocrine Tumors (NET) of the Stomach
      • Vulva
    • Jan 1, 2023 – current:
      • Anus
      • Appendix
      • Brain & Spinal Cord
    • Jan 1, 2021 – current:
      • Cervix Uteri
    • 8th edition: Jan 1, 2018-present (for most sites, except 9th edition versions)
    • 7th edition: Jan 1, 2010 – Dec 31, 2017
    • 6th edition: Jan 1, 2003 – Dec 31, 2009
    • 5th edition: Jan 1, 1998 – Dec 31, 2002
    • 4th edition: Jan 1, 1993 – Dec 31,1997
    • 3rd edition: Jan 1, 1989 – Dec 31, 1992
    • 2nd edition: Jan 1, 1984 – Dec 31, 1988
    • 1st edition: Jan 1, 1978 – Dec 31, 1983

 EOD (Extent of Disease) 2018

Beginning in January 1, 2018, Extent of Disease (EOD) and Summary Stage data items are being incorporated into cancer staging. It is a set of three data items (EOD Primary Tumor, EOD Regional Nodes and EOD Mets) that describe how far a cancer has spread at the time of diagnosis. Extent of Disease should include all information available through completion of surgery(ies) in first course treatment or within four months of diagnosis in the absence of disease progression, whichever is longer.

SEER Summary Stage 2018

The Commission on Cancer also requires Summary Staging for any and all sites not included or not appropriate for AJCC TNM staging. The Kentucky Cancer Registry required Summary Staging 1977 on all cases diagnosed prior to January 1, 2001. On January 1, 2001, the SEER Summary Stage 2000 coding scheme was implemented. This field will be calculated from the data values entered in the SEER Extent of Disease and Collaborative Stage fields, so it does not have to be manually coded.  Summary Stage 2018 is new for 2018 and stores the directly assigned Summary Stage 2018. This data item is effective for cases diagnosed January 1, 2018 and later.

Extent of disease is limited to all information available through completion of first course surgery(ies) or within four months of diagnosis in the absence of disease progression, whichever is longer.

Summary Stage for all sites is based on pathological, operative, and clinical assessments. The priority for using these reports is:

-Pathologic

-Operative (Particularly important when the surgical procedure does not remove all malignant tissue)

-Clinical

Summary Stage is available at https://seer.cancer.gov/tools/ssm/

Derived Coded Summary Stage 2018

Derived Summary Grade [1975] has been defined. This field will be calculated at the central registries for all cases diagnosed in 2018 and later. The more severe value from Grade Clinical [3843] and Grade Pathological [3844] will be used. Breast is a special case because behavior affects the priority. If this field is required for your registry, logic is provided in section 14.1. The current expectation is that this logic will be added to NAACCR*Prep. Central registries may choose to calculate this value via NAACCR*Prep and not store it in their database.

SEER Extent of Disease (EOD)

For cases diagnosed from January 1, 2000 to December 31, 2003, the Kentucky Cancer Registry requires SEER Extent of Disease coding. Extent of Disease should include all information available through completion of surgery(ies) in first course treatment or within four months of diagnosis in the absence of disease progression, whichever is longer.

For all sites, extent of disease is based on a combined clinical and operative/pathological assessment. Use the SEER Extent of Disease Coding Manual, Third Edition (1998) to determine the code values for these fields.

Collaborative Staging

Collaborative Staging (CS) is to be used for cases diagnosed on or after January 1, 2004 through December 31, 2017. It is not to be used for cases diagnosed prior to that date. Its introduction does not affect CoC requirements for physicians to assign AJCC staging or the requirement that the physician-assigned staging values be recorded in the registry.

With Collaborative Staging, registrars code discrete pieces of information once and the CS computer algorithm derives the values for AJCC T, N, M and Stage Group, Summary Stage 1977, and Summary Stage 2000. The derived stage codes are ideally suited for data analysis because of the consistency that can be obtained with objectively-recorded, identically-processed data items.

The timing rule for CS coding was designed to make use of the most complete information possible to yield the "best stage" information for the tumor at the time of diagnosis- "use all information gathered through completion of surgery(ies) in first course of treatment or all information available within four months of the date of diagnosis in the absence of disease progression, whichever is longer.” Disease progression is defined as further direct extension or distant metastasis known to have developed after the diagnosis was established. Information about tumor extension, lymph node involvement, or distant metastasis obtained after disease progression is documented, should be excluded from the CS coding.

CS data items are coded by the registrar. The CS algorithm produces the output items listed as derived fields. The derived AJCC items are separate from the physician-coded items; and the derived Summary Stage items are separate from the manually-coded items collected by the CoC in the past. The derived items cannot be manually altered.

Like the AJCC and Summary Stage codes that are derived from it, CS is a site-specific staging system. The CS algorithm uses tumor site and histology to determine which CS schema to apply. Depending on the schema, the coding instructions and code definitions will vary. Collaborative Staging codes are defined for every site and histology combination. The AJCC Cancer Staging Manual does not cover all sites, and some histologies are excluded from sites with an AJCC coding scheme. When the CS algorithm processes a site-histology combination that does not have an applicable AJCC code, it assigns the display string "NA” for "Not applicable.” A blank display string for a derived item means the CS algorithm was not run for the case.

The complete instructions and site-histology defined codes are available in the Collaborative Staging Manual and Coding Instructions. Part I provides general instructions and the instructions and codes for generic (non site-specific) items. Part II contains the site-specific instructions and codes. The CS Manual and related information is available electronically on the AJCC Web site at https://staging.seer.cancer.gov/cs/home/02.05.50/

In 2016, The Commission on Cancer (CoC) and the National Program of Cancer Registries (NPCR) both discontinued the collection of collaborative stage and implemented AJCC staging. However, at the request of The SEER Program, KCR will continue to collect CS data elements as well as AJCC Staging.