The influence of lung cancer mass screening on surgical results

Changes in the demographics and prognoses of patients with resected non-small cell lung cancer: a 20-year experience at a single institution in Korea

The demographics and prognosis of non-small cell lung cancer patients have changed during the last few decades. We conducted this study to assess the change in demographics and prognosis in resected non-small cell lung cancer patients during a 20-yr single-institution study in Korea. We retrospectively reviewed the medical records of 2,076 non-small cell lung cancer patients who underwent pulmonary resection between 1990 and 2009. Their clinical characteristics and survival were analyzed over a five-year period. With time, the proportions of female, adenocarcinoma, stage IA, and lobectomy patients increased, whereas the proportions of male, squamous cell carcinoma, stage IIIA, and pneumonectomy patients decreased. These demographic changes caused improved prognosis. The five-year survival rate of all patients was 53.9%. The five-year survival rate increased from 31.9% in 1990-1994, to 43.6% in 1995-1999, 51.3% in 2000-2004, and 69.7% in 2005-2009 (P < 0.001). In conclusion, among patients with resected non-small cell lung cancer, the proportions of female, adenocarcinoma, stage IA, and lobectomy patients have increased, and the five-year survival rate has gradually improved during the last 20 yr in Korea.

Prognostic Factors in 3315 Completely Resected Cases of Clinical Stage I Non-small Cell Lung Cancer in Japan

BACKGROUND

The objective of this retrospective study was to identify prognostic factors in completely resected clinical (c-) stage I non-small cell lung cancer cases.

METHODS

In 2001, the Japanese Joint Committee of Lung Cancer Registry collected data on the outcome and clinicopathological profiles of 7408 patients who had undergone resection for primary lung cancer in 1994. They included 3315 c-stage I patients who underwent complete resection, and in this study attempted to identify prognostic factors in the c-stage IA and c-stage IB cases.

RESULTS

The overall 5-year survival rate was 66.5%: 74.7% in the 2085 c-stage IA cases and 52.5% in the 1230 c-stage IB cases. The survival curve of the c-stage IA cases was higher than that of the c-stage IB cases. Multivariate analysis of the c-stage IA cases revealed six factors that predicted a significantly better outcome: age, gender, pathological (p-) T status, p-N status, nodal dissection, and tumor diameter (< or =2 cm), and the same analysis of the c-stage IB cases revealed six factors: age, gender, p-T status, p-N status, operative procedure, and tumor diameter (<5 cm). The c-stage IA patients whose tumor diameter was 2 cm or less had a higher survival rate than the patients whose tumor diameter was more than 2 cm, and the c-stage IB patients whose tumor diameter was less than 5 cm had a higher survival rate than the patients whose tumor diameter was 5 cm or more.

CONCLUSION

Tumor size is an independent prognostic factor for postoperative survival in c-stage I patients.

Registration of resected lung cancer in Niigata Prefecture

OBJECTIVES

Our registration of surgically treated lung cancer patients in Niigata Prefecture began in 2001. The purpose of this study was to identify the characteristics of patients and surgical treatment of lung cancer.

METHODS

All patients who underwent resection for lung cancer in Niigata Prefecture from January 2001 to December 2002 were eligible for registration. A total of 31 medical data for each patient were registered.

RESULTS

During the 2-year period, 1,211 patients were registered. A total of 605 cases (50%) were detected by mass screening, and 874 cases (72%) were diagnosed preoperatively. There were 718 (59%) c-stage IA cases and 317 (26%) c-stage IB cases. The most common operative procedure was lobectomy; 850 patients underwent single lobectomy. Limited resection was performed in 301 patients (25%), and video-assisted thoracoscopic surgery in 193 (16%). The most common histological type was adenocarcinoma in 860 cases (71%), followed by squamous cell carcinoma in 273 (23%). Pathologic staging yielded stage IA in 635 cases (52%) and stage IB in 262 (22%).

CONCLUSIONS

The results of our registration demonstrate a very high ratio of surgically treated stage IA cases in Niigata Prefecture and that limited resection was performed in many patients. Accumulation of these data will reveal the characteristics of lung cancer surgically treated in Niigata Prefecture and will provide a basis for determining the future course of surgical treatment for lung cancer. Registration is continuing, and it will provide new and useful information about lung cancer, eventually including 5-year survival data.

Does the lobectomy plus lymph node dissection still remain a standard surgical procedure for patients with cT1N0M0 adenocarcinoma of the lung?

OBJECTIVES

Controversies still exists regarding treatment for cT1N0M0 adenocarcinoma of the lung. The following topics need to be answered: 1) Should all patients undergo lobectomy plus lymph node dissection? and 2) Is there poor-prognostic subgroup that may need adjuvant therapy?

METHODS

Between 1990 and 1999, 141 patients with cT1N0M0 adenocarcinoma of the lung underwent lobectomy plus lymph node dissection. Fifteen clinicopathological characteristics of the entire population were investigated with regard to survival. Forty-seven samples, which were possible to reexamine among 68 patients with small adenocarcinoma 2 cm or less in greatest dimension, were assessed according to Noguchi's classification.

RESULTS

Nine of fifteen clinicopathological variables were significant in indicating poor prognostic factors in univariate analysis: gender, differentiation, p-T status, p-N status, pm, lymphatic invasion, vascular invasion, pleural invasion, and serum carcinoembryonic antigen (CEA) level. The p-N status and high serum CEA level were independent predictive variables in multivariate analysis. A five-year survival rate for patients with Noguchi's type A and B was 100%. However, six (8.8%) of 68 patients with small adenocarcinoma had lymph node involvement and four patients (5.9%) had pulmonary metastasis.

CONCLUSIONS

It is inappropriate and inadequate to omit lobectomy or lymph node dissection only on the basis of tumor size. Therefore, it seems reasonable to conclude that lobectomy plus lymph node dissection still remains as a standard surgical procedure to treat cT1N0M0 adenocarcinoma of the lung. We must continue to search for new deciding factors in order to choose candidates for limited operation among patients with cT1N0M0 adenocarcinoma of the lung.

Clinical trials of peripheral stage I (T1N0M0) non-small cell lung cancer

Debate continues regarding the choice of resection for peripheral stage I (T1N0M0) non-small cell lung cancer (NSCLC). Anatomic lobectomy has been considered the standard of care for resectable NSCLC; however, intriguing results of clinical trials have been reported with the use of sublobar resection as primary therapy of selected small peripheral lung cancers. Most modern clinical studies comparing lobectomy to sublobar resection of stage I NSCLC demonstrate equivalent survival, but local recurrence following sublobar resection appears to be greater. Low energy computed tomography screening programs for lung cancer have increasingly identified small peripheral lesions potentially amenable to effective therapeutic management with sublobar resection. We discuss the possible management scenarios for stage I NSCLC in this age of early computed tomography detection of lung cancer, more precise molecular biologic staging of the disease, optimized peri-operative management of the marginally resectable patient, and improved adjunctive treatment measures for local control following lung cancer resection.

Strategies in lung cancer detection. Achieving early identification in patients at high risk

Screening can be crucial for timely identification of lung cancer and thus for early treatment and a favorable prognosis. This conclusion is true particularly for persons at high risk for lung cancer, including those exposed to asbestos or silicon dust. In this article, Drs Bechtel and Petty discuss the types of screening procedures available, their cost, and the approaches and timing that are most beneficial to the public as a whole.

Outcome in patients with lung cancer found on lung cancer mass screening roentgenograms, but who did not subsequently consult a doctor

GOALS OF THE STUDY

To evaluate the outcome in patients with lung cancer found on lung cancer mass screening roentgenograms, but who did not subsequently consult a doctor.

PATIENTS AND METHODS

This study enrolled 198 asymptomatic patients with lung cancer found by lung cancer mass screening during the 9-year period. Five-year survival rates in patients who did not consult a doctor or who stopped consulting a doctor in spite of abnormal shadows detected on last mass screening chest roentgenograms (n=45, delayed consultation group) and in patients who subsequently consulted a doctor when abnormal shadows were detected (n=153, control group) were evaluated by the method of Kaplan and Meier and clinical variables were examined as possible predictors of survival time by the Cox proportional-hazards model.

RESULTS

There was a significant difference between the 5-year survival rates in the delayed consultation group and in the control group (21 vs. 51%, log rank: P=0.0003, Wilcoxon: P=0.0009). The risk of death increased 115.0% for the 1-year delay in consultation (hazard ratio: 2.150, 95% CI: 1.203-3.842, P=0.0097). With regard to the reason why they did not consult a doctor, many of them answered that they did not have any respiratory symptoms.

CONCLUSION

The 1-year delay in consultation had a great significance in that these patients did not receive any treatment for lung cancer for 1 year, and the 1-year delay in treatment itself affected the outcome.

Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer

OBJECTIVE

The present study was undertaken to demonstrate that limited pulmonary resection for peripheral small-sized lung cancer yields outcomes not inferior to those of lobectomy.

METHODS

During the 9-year period from 1992 to 2000, patients with cT1 N0 M0 peripheral non-small cell lung cancer whose maximum tumor diameter was 2 cm or less on diagnostic imaging and in whom lobectomy was determined to be feasible were treated with limited resection if the patient consented to the procedure and with lobectomy if consent to limited resection was not obtained. The survival and clinical outcome of the patients whose tumors were postoperatively staged as pT1 N0 M0 were compared between the limited resection group (n = 74) and the lobectomy group (n = 159).

RESULTS

The limited resection group consisted of 60 patients treated with segmentectomy and 14 patients treated with wedge resection. Among patients followed up for a mean period of 52 months after the operation, neither the 3-year nor 5-year survivals differed significantly between the limited resection group (3-year survival, 94.0%; 5-year survival, 89.1%) and the lobectomy group (3-year survival, 97.0%; 5-year survival, 90.1%). Postoperative tumor recurrence was noted in 5 patients after limited resection and in 9 patients after lobectomy, and the difference in the incidence of postoperative recurrence between the 2 groups was not significant.

CONCLUSIONS

The results of this study indicate that in patients with peripheral T1 N0 M0 non-small cell lung cancer whose maximum tumor diameter was 2 cm or less, the outcome of limited pulmonary resection is comparable with that of pulmonary lobectomy.

Prognosis of non-surgically treated, clinical stage I lung cancer patients in Japan

OBJECTIVE

The optimal management of stage I lung cancer is surgical resection. However, some of these patients are not candidates for surgery because of several medical problems. We analyzed prognosis of non-surgically treated, clinical stage I lung cancer patients.

METHODS AND RESULTS

There were 21211 lung cancer patients registered from 1982 to 1991 in the data-base of the Japanese National Chest Hospital Study Group for Lung Cancer, and the number of non-surgically treated, clinical stage I lung cancer patients during the 10 years was 802. The 5- and 10-year survival rates of the 799 patients, exclusive of two carcinoid tumors and one adenid cystic carcinoma which have good prognosis, were 16.6 and 7.4%. We analyzed the 799 patients according to several prognostic factors. Sex, T factor of the tumor, histology, performance status and the method in which lung cancer was detected were prognostic factors, but age and treatment method were not associated with prognosis. Forty-nine patients survived for 5 years or more without surgical resection, but the survival rate continued to decrease even after 5 years, and the 7- and 10- year survival rates were 34.4 and 18.1% in the 49 patients.

CONCLUSIONS

It is a fact that there are long-term survivors in non-surgically treated, stage I lung cancer patients. However, the rate is low, and the survival curve continues to decrease even after 5 years. Long-term survivors might suggest the presence of a lung cancer in which the tumor growth is slow.

Outcome in patients with lung cancer found retrospectively to have had evidence of disease on past lung cancer mass screening roentgenograms

This study enrolled 143 asymptomatic patients with lung cancer detected by mass screening during an 8-year period (January 1, 1993 to December 31, 2000) and who had received a lung cancer mass screening roentgenogram one year before the disease was found. There was no difference between the 5-year survival rates in patients with one-year delayed detection of lung cancer (n=62) and in patients without (n=81) (46 vs. 58%, log rank: P=0.1330, Wilcoxon: P=0.1008). However, according to the tumor size on the overlooked chest roentgenogram, the outcome in stage I+II patients with missed tumors >20 mm in dimension (n=20) was worse than those with missed tumors <10 mm (n=24) or those with missed tumors 10-20 mm (n=18) (40 vs. 82 or 81%, log rank: P=0.0047, Wilcoxon: P=0.0010). All missed tumors in the lung field that did not overlap thoracic components were <10 mm in dimension and appeared as patchy ground-glass opacities, and they could not have been recognized if there was no other information that the tumor developed in that location. This might also be related to the lack of mortality effectiveness of previous lung cancer mass screening problem. Although it may be difficult to find the tumors <10 mm on a chest roentgenogram on mass screening, one-year delayed detection of lung cancer < or = 20 mm will not affect the prognosis.

Fluorescence bronchoscopy for early detection of lung cancer: a clinical perspective

The conventional method of bronchoscopy has only a 30% sensitivity to detect early stage cancer in the central airways. For patients with positive sputum cytology who clearly harbor early cancers, repeat and lengthy sessions of bronchoscopies are required for accurate localization of these lesions. This leads to a significant delay in obtaining the diagnosis, postponing an appropriate treatment and reduces the chance for cure. There are valid reasons for improving the detection rate of early stage lung cancers. The number of individuals at risk forms a large population, the outcome of patients treated with early stage cancer has been shown to be better and bronchoscopic treatments, e.g. photodynamic therapy and electrocautery, are currently alternatives for surgical resection. Finding more early stage cancers by screening the population at risk and accurate staging to enable treatment at the earliest stage feasible, may improve the dismal prognosis of many patients. This article deals with the clinical background and current problems in early detection of lung cancer and discusses our expectations regarding new developments in bronchoscopy for early detection, accurate staging and treatment of lung cancer.

Potential cost-effectiveness of one-time screening for lung cancer (LC) in a high risk cohort

The development of low-dose helical computed-tomography (CT) scanning to detect nodules as small as a few mm has sparked renewed interest in lung cancer (LC) screening. The objective of this study was to assess the potential health effects and cost-effectiveness of a one-time low-dose helical CT scan to screen for LC. We created a decision analysis model using baseline results from the Early Lung Cancer Action Project (ELCAP); Surveillance, Epidemiology and End Results (SEER) registry public-use database; screening program costs estimated from 1999 Medicare reimbursement rates; and annual costs of managing cancer and non-cancer patients from Riley et al. (1995) [Med Care 1995;33(8):828-841] and Taplin et al. (1995) [J Natl Cancer Inst 1995;87(6):417-26]. The main outcome measures included years of life, cost estimates of baseline diagnostic screening and follow up, and cost-effectiveness of screening. We found that in a very high-risk cohort (LC prevalence of 2.7%) of patients between 60 and 74 years of age, a one-time screen appears to be cost-effective at $5940 per life year saved. In a lower risk general population of smokers (LC prevalence of 0.7%), a one-time screen appears to be cost-effective at $23100 per life year. Even when a lead-time bias of 1 year is incorporated into the model for a low risk population, the cost-effectiveness is estimated at $58183 per life year. Based on the assumptions embedded in this model, one-time screening of elderly high-risk patients for LC appears to be cost-effective.

Photodynamic therapy, Nd-YAG laser and electrocautery for treating early-stage intraluminal cancer: which to choose?

The degree of healing and damage of the bronchial wall after photodynamic therapy, Nd-YAG laser and electrocautery for intraluminal early-stage cancer have been analysed. Review of the bronchoscopy reports and follow-up histology specimens of twenty-nine patients treated bronchoscopically with curative intent for their intraluminal tumor have been performed. Seventeen patients had been treated with bronchoscopic electrocautery (BE) only, six with photodynamic therapy (PDT) and six with Nd-YAG laser. Bronchial wall scarring seen during follow-up bronchoscopy was scored and subepithelial fibrosis were histologically evaluated using Alcian blue staining, Azan staining and polarised light. After BE, prominent airway scarring was seen in five patients (29%), with significant stenosis (>50% lumen) in one of these cases. Prominent scarring and significant stenosis were found in four (67%), after PDT. In five (83%) after Nd-YAG laser prominent scarring was found, one patient had significant stenosis. In three cases, two after BE and one after PDT, subepithelial tissue in the follow-up biopsies was insufficient for proper histologic examination. In the remaining biopsy specimen only one (7%) showed a moderate or excessive amount of fibroblasts after BE, whereas for PDT and Nd-YAG this was found in three (60%) and four patients (67%), respectively. Excessive matrix was found in none of the biopsies after BE, in two (40%) after PDT and in three (50%) after Nd-YAG laser. Compact collagen formations were seen in two (12%) biopsies after BE, in two (40 and 33%) after PDT and Nd-YAG, respectively. Compared to electrocautery, more airway scarring and more subepithelial fibrosis were seen after treatment with PDT and Nd-YAG laser. These findings, especially regarding PDT, is in contrast to the assumption that PDT is selective and may be important in the choice of treatment for patients with early stage cancer.

Surgical results for centrally-located early stage lung cancer

BACKGROUND

With the increasing use of mass screening programs for lung cancer, and especially the use of sputum cytology, the incidence of roentgenographically occult lung cancer has been increasing. These occult cancers comprise mainly histologically centrally-located early stage lung cancers. This study examined the clinicopathologic characteristics and surgical results of centrally-located early stage lung cancer.

RESULTS

From 1980 to 1998, there were 98 patients and 99 lesions of centrally-located early stage lung cancer resected. A total of 64 patients were detected by mass screening. Histologic examination revealed that 96 lesions were squamous cell carcinoma, and in these patients, there were 10 lesions of carcinoma in situ. The 5-year survival rate was 81.4% in all patients, and 88.9% in carcinoma in situ patients. In the postoperative follow-up period, a second lung cancer occurred in 13 patients.

CONCLUSIONS

The surgical results for centrally-located early lung cancer were good. However, sometimes these cancers are accompanied by a second centrally-located primary lung cancer, so it is necessary to follow-up with sputum cytology to allow early detection of additional centrally-located lung cancer.