When the Okies left Oklahoma.

When we first saw this analysis of stage migration in anal cancer, something wasn’t quite right. Without substantial changes in tumor stage, rates of node positivity have increased ~7% over each recent decade--with incidence more than doubling from the RTOG 8704 (17%) published in 1996 to ACT II (35%) in 2013. Because of better staging, right? Sure enough, survival has significantly increased for both node negative and positive patients over time...but not so much for both groups combined. Oh, hey Will Rogers. But wait. The hazard ratio for survival of node negative versus positive patients has actually decreased over time. And here’s where things get newsworthy: In cancers where there have been big advances in diagnostic imaging, we now run the risk of over-staging to the point that we start to lose, rather than gain, the ability to detect differences in outcome--and thus over-treat good actors rather than amend under-treatment of bad actors. They call this phenomenon reduced prognostic discrimination, and it could have broad implications on future trials and treatment over-intensification. Especially in an era when increased prognostic capabilities should be doing just the opposite.