Although statistics for cancer of the larynx are reported according to the tumor, node, metastasis (TNM) morphological staging system, functional clinical distinctions can identify major prognostic differences within the same morphological stage. This study was done to improve the staging system by incorporating pertinent clinical variables. In 193 patients with cancer of the larynx first treated between 1973 and 1985, the total 5-year survival was 66% (127/193). By TNM stage it was I, 78% (60/77); II, 67% (32/48); III, 60% (27/45); and IV, 35% (8/23). In three new functional severity stages that combined symptom severity and comorbidity, the corresponding rates were alpha, 83% (89/107); beta, 58% (34/59); and gamma, 15% (4/27). The functional severity stages could be combined with TNM stages to create a powerful new clinical severity staging system, in which the survival results were A, 88% (53/60); B, 80% (24/30); C, 63% (38/60); and D, 28% (12/43). These results demonstrate that inclusion of clinical variables in a formal staging system can strikingly improve prognostic estimations and classification of patients.
WalshTE. The classfication of carcinoma of the larynx. Laryngoscope1953; 57: 414–8.
2.
LeborgneF. Classification of cancer of the larynx. Laryngoscope1953; 63: 1089–95.
3.
SmithRRCaulkRMRussellWOJacksonCL. End results in 600 laryngeal cancers using the American Joint Committee's proposed method of stage classification and end results reporting. Surg Gynecol Obstet1961; 113: 435–44.
4.
VanNostrandAWP. Classification, anatomy, growth, and spread of laryngeal cancer. Can J Otolaryngol1974; 3: 408–11.
5.
LauermaS. Classification according to anatomic site, extent and clinical stage. Acta Otolaryngol [Suppl] (Stockh) 1967(suppl 225): 26–35.
6.
KirchnerJA. One hundred laryngeal cancers studied by serial section. Ann Otol Rhinol Laryngol1969; 78: 689–709.
7.
BrodersAC. The grading of carcinoma. Minn Med1925; 8: 726–30.
8.
PillsburyHRCKirchnerJA. Clinical vs histopathologic staging in laryngeal cancer. Arch Otolaryngol1979; 105: 157–9.
9.
FerlitoA. Histological classification of larynx and hypopharynx cancers and their clinical implications. Acta Otolaryngol [Suppl] (Stockh) 1976(suppl 342).
10.
American Joint Committee on Cancer.Manual for staging of cancer. 3rd ed.Philadelphia, Pa: JB Lippincott Co, 1988.
11.
FeinsteinAR. On classifying tumors while treating patients. Arch Intern Med1985; 145: 1789–91.
12.
MacDonaldI. The individual basis of biologic variability in cancer [Editorial]. Surg Gynecol Obstet1958; 106: 227–9.
13.
HarrisonDFN. Intrinsic weakness of the TNM system for classification of laryngeal cancer. ORL1979; 41: 241–51.
14.
FeinsteinAR. Scientific defects in the staging of cancer. In: HallTC, ed. Prediction of response to cancer therapy. US Dept of Health, Education, and Welfare monograph 34. Bethesda, Md: National Cancer Institute, 1971: 268–73.
15.
BarrLCBaumM. Time to abandon TNM staging of breast cancer?. Lancet1992; 339: 915–7.
16.
JacobsJRSpitznagelELSessionsDG. Staging parameters for cancers of the head and neck: A multifactorial analysis. Laryngoscope1985; 95: 1378–81.
17.
NeelHBTaylorWF. New staging system for nasopharyngeal carcinoma. Arch Otolaryngol Head Neck Surg1989; 115: 1293–303.
18.
DenoixPFSchwartzD. Règles générales de classification des cancers et de présentation des résultats thérapeutiques. Acad Chirurgie (Paris)1959; 85: 415–24.
19.
FeinsteinAR. Symptoms as an index of the biological behavior and prognosis in human cancer. Nature1966; 209: 241–5.
20.
CharlsonMEFeinsteinAR. The auxometric dimension. A new method for using rate of growth in prognostic staging of breast cancer. JAMA1974; 228: 180–5.
21.
WellsCKStollerJKFeinsteinARHorwitzRI. Comorbid and clinical determinants of prognosis in endometrial cancer. Arch Intern Med1984; 144: 2004–9.
22.
FeinsteinAR. A new staging system for cancer and a reappraisal of “early” treatment and “cure” by radical surgery. N Engl J Med1968; 279: 747–53.
23.
FeinsteinARPritchettJASchimpffCR. The epidemiology of cancer therapy: II. The clinical course: Data, decisions, and temporal demarcations. Arch Intern Med1969; 123: 323–44.
24.
FeinsteinARPritchettJASchimpffCR. The epidemiology of cancer therapy: III. The management of imperfect data. Arch Intern Med1969; 123: 448–61.
25.
FeinsteinARPritchettJASchimpffCR. The epidemiology of cancer therapy: IV. The extraction of data from the medical records. Arch Intern Med1969; 123: 571–90.
26.
FeinsteinAR. The pre-therapeutic classification of comorbidity in chronic disease. J Chronic Dis1970; 23: 455–69.
27.
FeinsteinAR. Taxonorics — II. Formats and coding systems for data processing. Arch Intern Med1970; 126: 1053–67.
28.
FeinsteinAR. Clinical biostatistics: XLI. Hard science, soft data, and the challenges of choosing clinical variables in research. Clin Pharmacol Ther1977; 22: 485–98.
29.
FeinsteinARWellsCK. A clinical-severity staging system for patients with lung cancer. Medicine1990; 69: 1–33.
30.
FeinsteinARSchimpffCRHullEW. A reappraisal of staging and therapy for patients with cancer of the rectum. Development of two new systems of staging — I. Arch Intern Med1975; 135: 1441–53.
31.
FeinsteinARSchimpffCRHullEW. A reappraisal of staging and therapy for patients with cancer of the rectum. Patterns of presentation and outcome of treatment — II. Arch Intern Med1975; 135: 1454–62.
32.
ClemensJDFeinsteinARHolabirdNCartwrightS. A new clinical-anatomic staging system for evaluating prognosis and treatment of prostate cancer. J Chronic Dis1986; 39: 913–28.
33.
BoydNFClemensJDFeinsteinAR. Pretherapeutic morbidity in the prognostic staging of acute leukemia. Arch Intern Med1979; 139: 324–8.
34.
TaylorWFIvinsJCUnniKKBeaboutJWGolenzerHJBlackLE. Prognostic variables in osteosarcoma: A multi-institutional study. J Natl Cancer Inst1989; 81: 21–30.
35.
NeelHBTaylorWFPearsonGR. Prognostic determinants and a new view of staging for patients with nasopharyngeal carcinoma. Ann Otol Rhinol Laryngol1985; 94: 529–37.
36.
FeinsteinARSchimpffCRAndrewsJFWellsCK. Cancer of the larynx: A new staging system and a re-appraisal of prognosis and treatment. J Chronic Dis1977; 30: 277–305.
37.
BaileyBJ. Beyond the “new” TNM classification [Editorial]. Arch Otolaryngol Head Neck Surg1991; 117: 369–70.
38.
FeinsteinAR. Clinical epidemiology. The architecture of clinical research. Philadelphia, Pa: WB Saunders, 1985.
39.
National Death Index.National Center for Health Statistics. Washington, DC: US Department of Health and Human Services, 1990.
40.
KaplanMFeinsteinAR. The importance of classifying initial co-morbidity in evaluating the outcome of diabetes mellitus. J Chronic Dis1974; 27: 387–404.
41.
FeinsteinAR. Clinical biostatistics: XIV. The purposes of prognostic stratification. Clin Pharmacol Ther1972; 13: 285–97.
42.
FeinsteinAR. Clinical biostatistics: XV. The process of prognostic stratification (part 1). Clin Pharmacol Ther1972; 13: 442–57.
43.
FeinsteinAR. Clinical biostatistics: XVI. The process of prognostic stratification (part 2). Clin Pharmacol Ther1972; 13: 609–24.
44.
FeinsteinAR. Clinical biostatistics: XVII. Synchronous partition and bivariate evaluation in predictive stratification. Clin Pharmacol Ther1972; 13: 755–68.
45.
PolissarLFeiglPLaneWGlaefkeGDahlbergS. Accuracy of basic cancer patient data: Results from an extensive recoding survey. J Natl Cancer Inst1984; 72: 1007–14.
46.
MacKinnonMD. Validity of clinical data retrieved from case notes of laryngeal and hypopharyngeal cancer: A universal method to improve accuracy. Proc R Soc Med1970; 63: 274–7.
47.
BreimanLFriedmanJHOlshenRAStoneCJ. Classification and regression trees. Belmont, Calif: Wadsworth International Group, 1984.
48.
GordonTJ. Hazards in the use of the logistic function with special reference to data from prospective cardiovascular studies. J Chronic Dis1974; 27: 97–102.
49.
VandenbrouckeJP. Should we abandon statistical modeling altogether?. Am J Epidemiol1987; 126: 10–3.
50.
LinnBSRobinsonDSKlimasNG. Effects of age and nutritional status on surgical outcomes in head and neck cancer. Ann Surg1988; 207: 267–73.
51.
KarnofskyDAAbelmanWHCraverLFBurchenalJH. The use of nitrogen mustard in the palliative treatment of carcinoma with particular reference to bronchogenic carcinoma. Cancer1948; 1: 634–69.
52.
JacksonCLNorrisCM. Cancer of the larynx. Part III — Symptomatology and diagnosis. Cancer1962; 12: 97–103.
53.
FeinsteinARSosinDMWellsCK. The Will Rogers phenomenon. Stage migration and new diagnostic technology as a source of misleading statistics for survival in cancer. N Engl J Med1985; 312: 1604–8.
