Higher AUCs indicated better model discrimination, and lower values of AIC indicated superior model-fitting. Akaike's information criterion (AIC) was applied to evaluate the model-fitting 17. The model discrimination abilities of the nTNM and AJCC TNM staging systems were assessed by areas under the curves (AUCs), and the AUCs were compared by Hanley & McNeil tests.

The Kaplan-Meier method with log-rank tests was applied. The prognostic performance of the nTNM was compared with that of the AJCC 8 th TNM classification. Five-year overall survival (OS) and estimations of hazard ratios (HRs) were calculated and presented with 95% confidence intervals (CI). The characteristics of the baseline clinical variables between the training and validation cohorts were compared with Student's t-test or П‡ 2 test. We aimed to exploit a novel TNM (nTNM) staging system for CRC based on the metro-ticket system, compare the prognostic performances of the nTNM and the AJCC 8 th TNM staging systems, and validate these findings in a validation cohort.Д¬ategorical and continuous variables were described as frequency (%) and median (interquartile range ), respectively. However, no studies have yet applied the metro-ticket paradigm to the TNM staging system for CRC. showed that application of the metro-ticket system to the TNM staging system for gastric cancer could accurately stratify patients and improve its prognostic performance 15. The metro-ticket paradigm was based on the concept that the longer the вЂњtripвЂќ (i.e., increased T stage and N stage), the higher the price of the вЂњticketвЂќ (i.e. for hepatocellular cancer (HCC) and later evolved into a novel predictive tool for HCC patients after liver transplantation 12. This paradigm was originally proposed by Mazzaferro et al. Several recent studies have suggested a 'metro-ticket' paradigm to evaluate survival 12 - 16. Similar results were also reported by the Japan Colon Cancer and Rectal Cancer Society and other research institutes 5 - 11. Based on the AJCC 7 th and 8 th TNM staging systems, data from the Surveillance, Epidemiology, and End Results (SEER) program indicated that the survival of patients with stage IIB/IIC CRC was worse than that of those with stage IIIA 3, 4. However, CRC may be an exception, especially with respect to stage IIB/C (T4N0) and stage IIIA (T1-2N1, T1N2a) tumors, with an apparent survival paradox between these stages. In general, the survival of patients with high-stage cancers should be lower than that of patients with low-stage cancers. The American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system is the most widely used prognostic standard for CRC 2, and has been revised several times over the past few decades to improve its prognostic performance and treatment suggestions for patients with CRC. The nTNM classification should therefore be considered in future revisions of the TNM classification.Д¬olorectal cancer (CRC) is the third most commonly diagnosed cancer among both males and females in the United States 1. Similar results were found in the validation cohort.Д¬onclusions: The nTNM classification for CRC has better predictive performances and superior accuracy for predicting prognosis compared with the TNM classification. 237,741), and clinical benefits than the TNM classification. The nTNM classification showed better discrimination (AUC, 0.678 vs. Taking the prognosis of stage I as the reference, survival decreased with increasing nTNM stage. In the training cohort, 18,476 patients (45.4%) experienced upstaging and 15,907 patients (39.0%) experienced downstaging in the nTNM classification compared with the TNM classification. Results: A total of 58,192 CRC patients (40,736 training cohort, 17,456 validation cohort) were finally included. The validation cohort was applied to validate these findings.

Clinical benefits were further estimated by decision curve analyses. The areas under the curves (AUCs), calibration curves, and Akaike's information criterion (AIC) were used to evaluate the predictive performances of the two classifications.

The nTNM was developed using distance from the origin on a Cartesian plane incorporating the pN (x-axis) and pT (y-axis) stages, and was compared with the AJCC TNM classification. Methods: We identified eligible CRC patients from the Surveillance, Epidemiology, and End Results database. We aimed to develop a novel TNM (nTNM) classification based on the metro-ticket paradigm. Background: Several revisions of the TNM classifications for colorectal cancer (CRC) have acknowledged that the oncological outcomes of stage IIB/IIC CRC are worse than those of stage IIIA.

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