title: The anatomy of the TNM for colon cancer.
abstract: BACKGROUND
  To visualize the anatomy as revealed by dendrograms of the tumor, lymph node, and metastasis (TNM) staging system for colon cancer and compare it with the Dukes' system.
  
  
  METHODS
  A hierarchical clustering algorithm generated tree-structured dendrograms that stratified patients according to survival only. The dendrograms were constructed with the same prognostic variables used for the TNM. Because combinations of prognostic factors were stratified only on survival, additional factors of any number and type could be integrated into the TNM without changing the TNM categories.
  
  
  RESULTS
  The algorithm provided a step-by-step visualization of the TNM and the Dukes' system for colon cancer. Dendrograms and associated 5-year survival rates were generated for the T category only, the N category only, the T, N combination, and combinations of the T, N, and M, and the T, N, M with histological grade. Dendrograms revealed visual differences between the structure of TNM and the Dukes' system of staging. Dendrograms also revealed how variations in prognostic factors changed survival. By cutting dendrograms along their dissimilarity axis, multiple prognostic subgroups could be created for colon cancer that may reflect outcomes that are more accurate to estimate.
  
  
  CONCLUSIONS
  Dendrograms provide a new way to view cancer patient staging. They reveal a visual step-by-step hierarchical relationship between survival rates and combinations of prognostic variables. The dendrograms also revealed fundamental differences between the TNM and the Dukes system of staging. By stratifying on survival only, additional factors including molecular factors can be added to the TNM, because it classifies patients according to survival rates only and not according to pre-set rules of prognostic factors and stage groups. The clinical implications of stratifying only survival are discussed.
authors.affiliation: Division of Epidemiology and Biostatistics, Department of Preventive Medicine and Biostatistics, The Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA.
authors.forename: Donald E
authors.initials: DE
authors.lastname: Henson
authors.affiliation: Surgical Oncology, John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, Maryland 20889, USA.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Hueman
authors.affiliation: Division of Epidemiology and Biostatistics, Department of Preventive Medicine and Biostatistics, The Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA.
authors.forename: Dechang
authors.initials: D
authors.lastname: Chen
authors.affiliation: Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland 20889, USA.
authors.forename: Jigar A
authors.initials: JA
authors.lastname: Patel
authors.affiliation: Department: of Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC 20052, USA.
authors.forename: Huan
authors.initials: H
authors.lastname: Wang
authors.affiliation: Department of Pathology and Surgery, The George Washington University Medical Center, Washington, DC 20037, USA.
authors.forename: Arnold M
authors.initials: AM
authors.lastname: Schwartz
keywords: Colon cancer; dendrograms; hierarchical clustering; prognostic groups; staging