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Assessment of the American Joint Committee on Cancer (6th and 7th editions) for clinically localized prostate cancer and comparison to the National Comprehensive Cancer Network risk stratification method.

23 Background: The purpose was to compare the prognostic value of the AJCC staging version 6 (v6), version 7 (v7), and the risk-stratification model of the NCCN.


METHODS
2,469 men (1989-2006) with clinical T1-4, N0/X-N1, M0 prostate cancer received definitive RT +/- ADT (median follow-up: 70 months). The NCCN grouping was: low-risk included T1-T2a, GS < 7, and PSA < 10 ng/mL; intermediate-risk included T2b-2c, GS = 7, and PSA 10 - 20 ng/mL; high-risk included T3, GS 8, and PSA > 20 ng/mL. The Benjamini and Hochberg adjustment was used to compute the false discovery rates in order to adjust for multiple comparisons.


RESULTS
There was a migration of stage II patients to stage I with version 7 (Stage I increased from 1% to 38%, while Stage II decreased from 91% to 55%). Pair-wise comparisons of Kaplan-Meier estimates of BF, DM, PCSS, and OS between stages were not statistically significant for AJCC v6 with one exception (PCSS: II vs III). On the other hand, 16/24 (67%) of comparisons were significant with AJCC v7. For NCCN, 9/12 (75%) of comparisons were significant, including all comparisons for OS. Concordance probability estimate (CPE) and standard error (SE) analysis showed uniform and significant improvement in the predictive power of AJCC v7 versus AJCC v6 for all outcomes. CPE±SE values for AJCC v6 versus AJCC v7 was .51±.009 vs .59±.02 for BF, .54±.02 vs. .70±.05 for DM, .57±.009 vs. .76±.007 for PCSS, and .52±.006 vs. .57±.01 for OS. There was further, albeit modest improvement with the NCCN method. CPE±SE values for AJCC v7 versus NCCN was .59±.02 vs. .59±.02 for BF, 0.70±.05 vs. 0.72±.05 for DM, .76±.007 vs. .80±.01 for PCSS, and .57±.01 vs. .57±.01 for OS.


CONCLUSIONS
AJCC v7 is a major improvement over AJCC v6 because it better distributes patients among the stages and is more prognostic. Further improvements are needed as the majority of men (55%) are Stage II and the sub-stratification into IIA and IIB was not prognostic. The NCCN model is superior to the AJCC v7 and remains the preferred method for risk-based clinical management of prostate cancer with RT +/- ADT.