American Joint Committee on Cancer (AJCC)

AJCC staging is the most comprehensive and common staging classification used in the United States and is based on

  • Location of the primary tumor
  • Tumor size and extent of the primary tumor
  • Regional lymph node involvement
  • Presence or absence of distant metastasis

It is essential when assigning AJCC stage, to use the appropriate Staging Manual and not just assume you know the correct value. Each site chapter must be reviewed for the applicable rules. Even with a great deal of experience it is easy to make a mistake. There are always new rules and designations in each edition.

Not all combinations of primary site and histology are eligible for AJCC staging. Certain sites include only specific cancer histologic types. Some sites require microscopic confirmation to verify the histology in order to stage the cancer.

AJCC staging is based on the evaluation of the T (Tumor), N (Nodes), and M (Metastasis) components of the primary cancer and the assignment of a stage grouping.

  • The T element designates the size and invasiveness of the primary tumor.
  • The N component designates the presence or absence of tumor in the regional nodes.
    • In some sites there is a designation based on size, fixation, or capsular invasion of the nodes.
  • The M component identifies the presence or absence of distant metastases, including lymph nodes that are not regional.

The stage group is assigned using the table listed in each chapter.

  • Stage 0 reflects carcinoma in-situ, noninvasive without tumor extension
  • Stage 1 reflects an invasive tumor confined to the primary site with no evidence of regional lymph node involvement
  • Stages 2 and 3 reflect an invasive tumor that may be due to regional extension with involvement of regional lymph nodes
  • Stage IV indicates either greatest tumor involvement or distant metastasis

Timing is the key to AJCC clinical and pathologic staging. Clinical staging is based on diagnostic workup before any treatment. Clinical staging can only be assigned when all necessary fields are available.

Clinical staging is assigned after the staging workup is completed but before any definitive treatment has begun. Evaluation is based on information from the following

  • Physical exam
  • Imaging
  • Endoscopy evaluations
  • Biopsy

Clinical staging is defined for each site in the AJCC Manual for Staging Cancer. Rules are site and/or histologically specific.

Clinical AJCC stage is based on clinical information, which is then used to determine the first course of treatment (neoadjuvant treatment, surgical resection, or no treatment).

The AJCC pathological stage is assigned after the resection of the primary cancer and analysis of the surgical specimen.

  • Most sites also require the removal and examination of regional lymph nodes to accurately assign a pathological stage
  • A tumor can be pathologically staged without a tumor resection, but pathological evaluation of a distant site is necessary
  • If the patient has surgical treatment, the managing physician assigns pathologic staging.

If the patient receives systemic or radiation therapy prior to surgery, the managing physician assigns post therapy staging which is preceded by y which indicates neoadjuvant treatment.

AJCC Staging Manuals (PDFs of these manuals may be downloaded from the AJCC website: https://cancerstaging.org/references-tools/deskreferences/Pages/default.aspxExternal Website Policy

  • AJCC 1st Edition (1978-1983)
  • AJCC 2nd Edition (1984-1988)
  • AJCC 3rd Edition (1989-1992)
  • AJCC 4th Edition (1993-1997)
  • AJCC 5th Edition (1998-2002)
  • AJCC 6th Edition (2003-2009)
  • AJCC 7th Edition (2010-2017)
  • AJCC 8th Edition (2018+)

Starting with AJCC 7th edition, there are also prognostic factors that now factor into the stage group. These prognostic factors are part of the Site Specific Data Items.

For more information on AJCC staging, see: https://cancerstaging.org/Pages/default.aspxExternal Website Policy

Updated: March 4, 2024