The Language of Staging: Pierre Denoix, TNM and a Shared Sentence for Disease, 1943-1958
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The Language of Staging: Pierre Denoix, TNM and a Shared Sentence for Disease, 1943-1958
On Day 113 we met the scale that describes in numbers how well a patient is (Karnofsky); on Day 116, the physician who followed a drug's effect through blood counts. Today we turn to the other side of the question: how far has the disease itself spread, and how can doctors in different hospitals say so in a way that others understand? The answer to that question is neither a drug nor an operation. It is three letters.
Doctors using the same word for different things
In 1943 the French National Institute of Hygiene (the forerunner of INSERM) asked the surgeon Pierre Denoix to find out how common cancer was in the country and how advanced it was when it was diagnosed. The project was called the "Enquête permanente cancer", the Permanent Cancer Survey. Denoix is said to have been remembered later as a member of the Resistance; the dates of that service are not given in the sources.
When the first findings came in during 1944, something besides records had entered the survey: a problem. As the story is told, teams described cancer and its progression by different criteria, so centers could not be compared with one another. A disease one center called "early" could be called "advanced" by another. This was the obstacle faced by anyone who wanted to compare the results of an operation, a radiation dose or a drug: the results of two treatments given to different patients cannot be compared unless the patients' disease was at the same stage.
Three axes, first under a different abbreviation
Denoix's solution was to reduce the disease to three questions: how far has the tumor grown at its site, has it reached the regional lymph nodes, has it jumped to a distant organ? As the story is told, he first named his system with French words: TGM, for tumeur, ganglions, métastases. The T, N and M we know today carry the same three axes in English letters. In his report Six Years of the Permanent Cancer Survey, published in 1950, he is reported to have written that tumors must be described as clearly and simply as possible (conceptual summary). The system is said to have been in use inside the survey by 1947.
The idea did not appear from nothing. The sources behind this piece also name precursors. Cervical cancer is cited as one of the first places where systematic staging was applied; one source places the first attempt in 1929 under the League of Nations, another around the turn of the century. For rectal cancer, Cuthbert Dukes's classification of 1932 (A, B and C) tied the criterion to how far the cancer had spread in the bowel wall and the lymph nodes. My own reading is this: Denoix's contribution was not to invent a classification specific to one organ, but to propose a shared framework that could ask the same three questions of every organ.
From a survey to an international rule
The path described was not quick. A World Health Organization expert committee meeting in Paris in September 1951 discussed the classification; a four-stage classification of tumor spread was published in 1952. In 1953 the International Congress of Radiology recognized the approach as a common staging framework, and the Union for International Cancer Control (UICC) set up a Special Committee on Clinical Stage Classification under Denoix's chairmanship. The same year a text titled "a uniform technique for clinical classification by the TNM system" was published; in 1954 Denoix published an article in Acta Radiologica defining local, regional and distant spread as three separate fields.
In 1958 the UICC published the first international TNM proposal, for breast and larynx cancers. A series of proposals widening organ by organ followed; the first complete pocket book appeared in 1968, planting the root of today's name, "UICC TNM Classification". In 1987 the UICC and American Joint Committee on Cancer (AJCC) classifications were harmonized. The UICC announced the ninth edition in 2025. Denoix later became UICC president (1973-1978, according to the UICC list of presidents) and directed the Gustave Roussy Institute from 1956 to 1982.
How to read three letters
Numbers are added beside T, N and M. A fictional example, for illustration: the expression "T2 N1 M0" says that the tumor is at a certain step of size or depth locally, that one of the regional lymph nodes is involved, and that no spread to a distant organ has been found. The exact definition of the steps varies by organ: the same "T2" means one thing for the breast and another for the stomach. TNM is therefore not a dictionary but a grammar written separately for each organ; what is shared is the order of the sentence's three elements. An axis that cannot be assessed is marked "X"; what is unknown is not written as if it were absent.
There is one more distinction: a "c" in front of the letter shows that the measurement was made by examination and imaging (clinical), while "p" shows that it rests on pathological examination of the tissue removed at surgery. The clinical and pathological stage of the same patient can differ, and the two are not interchangeable. My own reading is this: Dukes's A, B and C build a staircase of steps with letters; TNM lays three separate pieces of information on the table before giving a step and leaves the summary for later. This means that when a new finding arrives, only the relevant letter changes.
Stage is not the only input to a treatment decision. The physician weighs the stage together with the patient's age, other illnesses and the biological features of the tumor; this piece is not a diagnostic or treatment recommendation but the history of a language.
CLASSIFICATION, STAGE AND TNM
TNM is a description: T describes the size and local spread of the tumor, N lymph node involvement, M distant metastasis. The numbers beside the three letters give the detail.
Stage is a summary derived from those descriptions: certain T, N and M combinations are gathered into a stage group (for example I-IV). So TNM is a sentence, and stage is its abbreviation. If the two are used interchangeably, what is lost is the axis along which the disease has progressed.
COST: STAGE MIGRATION
The first limit of a shared language is that the instruments measuring the language itself change. The 1985 paper by Feinstein, Sosin and Wells in the New England Journal of Medicine named this the "Will Rogers phenomenon": in lung cancer, the six-month survival of patients treated in 1977 was higher than that of patients from 1953-1964, both overall and within each TNM stage. But in the 1977 group, new imaging methods had uncovered metastases that used to go unnoticed, moving these patients from a "good" stage to a "bad" one. Survival appeared to rise within every stage, yet the fate of individual patients had not changed. When stages based on symptoms were used, the survival of the two groups was similar.
The second limit is my own inference: stage describes the anatomy of the disease; it also reflects when and from where the patient reached diagnosis. The stage distribution of the same disease can also vary with the availability of imaging at a hospital and with delay in presentation.
What remains
- The idea of describing the disease along three axes (tumor, node, distant spread)
- A shared language that makes comparison between centers possible
- A framework, harmonized between the UICC and AJCC, that is updated with every new edition
What fell or was overcome
- Each clinic saying "early" and "advanced" by its own criteria
- The assumption that stage is a fixed fact of nature: when instruments change, stages shift
- Equating stage with the whole story of the disease
Precursors of staging, and TNM. The axis runs from 1929 to 1968; ticks mark decades. Orange boxes are precursors, green boxes are TNM steps, and the red box is a step whose date conflicts among sources. Scale approximate.
How TNM reached Turkey
I could not reach a verified source on when and at whose hands TNM was first used in Turkey, so I give no date or person. The general inference is this: a shared staging language is a precondition for making a country's cancer records comparable with those of other countries. In the part of the series devoted to Turkey, the history of registration and staging will be tested against sources.
FROM 1929 TO 2025
WHAT WAS CONFIRMED, WHAT CONFLICTS
- Where it was born: The UICC page says that between 1943 and 1952 the system was "developed at the Gustave Roussy Institute". Gustave Roussy's own news item ties the 1943 assignment to the National Institute of Hygiene and says Denoix directed the institute from 1956 to 1982. Read together, the two do not show that the 1943 work was done at that institution; this piece uses the National Institute of Hygiene.
- Starting year: The Gustave Roussy item gives 1943 for the survey, 1944 for the first findings and 1947 for use of the classification. One review says "in 1947 he proposed a unified classification", without citation. The UICC history document says "the 1940s". The piece gives the range 1943-1947.
- TGM: The French abbreviation comes from a single source (the Gustave Roussy item). I could not verify it.
- The 1953 events: The Gustave Roussy item places the Congress of Radiology's recognition and the UICC committee in 1953. The UICC's own page reports the committee as "the 1950s" without a year. The UICC history document lists a publication for 1953 (the uniform technique). The place and date of the congress were not in the sources.
- Date of the first proposal: The UICC and Gustave Roussy say 1958 for breast and larynx. One historical review dates the first UICC brochure for breast to 1960, yet the document in that same text's reference list is 1959 (Br J Surg 1959;47:330-2). I could not resolve the conflict.
- 1929 and "WHO": A SEER educational page says that in 1929 the League of Nations' "World Health Organization" staged cervical cancer. The WHO was founded in 1948, so this is an anachronism; I inferred that the body must have been the League of Nations Health Organisation. The abstract of the FIGO history review (Int J Gynaecol Obstet 2008;101:205-210) gives the first gynecological classification as "the turn of the century". The two conflict; both claims are hedged in the piece.
- Dukes: The Wellcome catalogue shows a record in J Pathol Bacteriol vol. 35 (1932) (offprint 1935). I did not verify the page range. I described the content of stages A, B and C in general terms; I did not read the paper itself.
- Presidency and edition: Denoix's 1973-1978 UICC presidency comes from the list of presidents on the UICC history page; for the ninth edition I could not find an exact publication date and relied on the UICC announcement of 2025.
- Denoix citations: Bull Inst Nat Hyg 1950;5:44-84 (Denoix and Viollet), Bull Inst Nat Hyg 1952;7:729-48 and Acta Radiol 1954;41:122-9 were taken from the reference list of a review; I did not read the originals.
- Resistance membership: From the Gustave Roussy item; no dates are given, and it is secondary.
- The Will Rogers paper: The citation gave only the date, 20 June 1985, and the journal; I did not write the volume and pages because I could not find them on the source page. I reported the abstract's results from the page; I did not read the full text.
- Out of scope: The detail of organ-specific systems such as Dukes and Astler-Coller, the Columbia classification and the edition-by-edition changes of TNM will be covered later or not at all; they were not verified here.
Avery and DNA (1944)
Today we saw how the language that describes disease was built. Tomorrow we leave tumors and go to a bacteriology laboratory: Avery and DNA in 1944. How this story ties into the history of cancer, I will test against sources before writing it, dates included.
Author's note: The history of staging fits a heroic story of discovery poorly; a shared language is an agreement that no one found alone. So in this piece I wrote Denoix's contribution as far as the sources credit it, and left the date conflicts open in the box. I also did not read Denoix's original papers; the account rests on the UICC and Gustave Roussy pages and on historical reviews.
Sources and further reading
- Denoix PF. Article, Acta Radiologica 1954;41:122-129. (Citation from a review's reference list; original text not read.)
- Denoix PF, Viollet G. Six années d'enquête permanente cancer. Bull Inst Nat Hyg 1950;5:44-84. (Citation from a review's reference list; not read.)
- Dukes CE. The classification of cancer of the rectum. J Pathol Bacteriol 1932;35. (Citation from a library catalogue; not read.)
- UICC. The page "UICC and the TNM Classification of Malignant Tumours" and the document "TNM History" (online).
- UICC. The "History of UICC" page (list of presidents) and the announcement "9th edition UICC TNM Classification of Malignant Tumours now available" (online, 2025).
- Gustave Roussy. News page "TNM classification, an invention born at Gustave Roussy" (online).
- Feinstein AR, Sosin DM, Wells CK. The Will Rogers phenomenon: stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. N Engl J Med 1985 (20 June).
- Mukherjee S. The Emperor of All Maladies: A Biography of Cancer. New York: Scribner, 2010. (The passages on staging were not separately verified for this piece.)
This piece is Day 117 of the "365 Days of Cancer History" series and tells the history of the cancer staging system. It is a historical-popular account, not a diagnostic or treatment recommendation. Consult your physician about your own health. Sources have been verified; details resting only on a secondary source are marked in the fact-check notes.
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