Survival analysis of untreated patients with non-small-cell lung cancer

Rural-Urban Disparities in Receipt of Surgery for Potentially Resectable Non-Small Cell Lung Cancer

INTRODUCTION

Access to cancer care, especially surgery, is limited in rural areas. However, the specific reasons rural patient populations do not receive surgery for non-small cell lung cancer (NSCLC) is unknown. We investigated geographic disparities in reasons for failure to receive guideline-indicated surgical treatment for patients with potentially resectable NSCLC.

METHODS

The National Cancer Database was used to identify patients with clinical stage I-IIIA (N0-N1) NSCLC between 2004 and 2018. Patients from rural areas were compared to urban areas, and the reason for nonreceipt of surgery was evaluated. Adjusted odds of (1) primary nonsurgical management, (2) surgery being deemed contraindicated due to risk, (3) surgery being recommended but not performed, and (4) overall failure to receive surgery were determined.

RESULTS

The study included 324,785 patients with NSCLC with 42,361 (13.0%) from rural areas. Overall, 62.4% of patients from urban areas and 58.8% of patients from rural areas underwent surgery (P < 0.001). Patients from rural areas had increased odds of (1) being recommended primary nonsurgical management (adjusted odds ratio [aOR]: 1.14, 95% confidence interval [CI]: 1.05-1.23), (2) surgery being deemed contraindicated due to risk (aOR: 1.19, 95% CI: 1.07-1.33), (3) surgery being recommended but not performed (aOR: 1.13, 95% CI: 1.01-1.26), and (4) overall failure to receive surgery (aOR: 1.21, 95% CI: 1.13-1.29; all P < 0.001).

CONCLUSIONS

There are geographic disparities in the management of NSCLC. Rural patient populations are more likely to fail to undergo surgery for potentially resectable disease for every reason examined.

Impact of waiting times on tumour growth and pathologic upstaging in patients with non-small cell lung cancer having lung resection

OBJECTIVE

There are limited data on tumour growth or pathologic upstaging in patients with early-stage lung cancer awaiting lung resection. We aimed to evaluate whether waiting times on the current lung cancer treatment pathway were associated with significant tumour growth or pathologic upstaging.

METHODS

This is a retrospective observational study of a consecutive series of patients with early-stage, non-small cell lung cancer who underwent resection for lung cancer. The difference between tumour size at diagnostic and preoperative computed tomography (CT) scans was calculated. Significant tumour growth was defined as a diameter increase of ⩾5 mm or ⩾20%. The time intervals between baseline and repeat CT (CT-int) and between baseline CT and date of surgery (Surg-int), as well as other potential clinical and pathologic prognostic factors, were compared between upstaged and nonupstaged patients.

RESULTS

There were 121 patients identified. Fifty-four patients (44.6%) had tumour growth ⩾5 mm and 27 patients (22%) had tumour growth ⩾20%. Median CT-int and Surg-int were 2.4 and 2.6 months, respectively. Forty-four patients (36%) were upstaged at surgery due to new lymph node involvement (n = 19), pleural invasion (n = 12), satellite nodules (n = 4), or increase in tumour diameter (n = 9). There was a marginal, but statistically insignificant, difference in median CT intervals in patients who had tumour growth <20% vs ⩾20% at 2.4 vs 2.6 months (p = 0.06).

CONCLUSION

Current cancer pathway waiting times are not associated with significant tumour growth or pathologic upstaging in this cohort.

Survival of localized NSCLC patients without active treatment or treated with SBRT

BACKGROUND

Little information on the natural history of patients with localized NSCLC is available since many of the studies covering the subject lack information on pathological confirmation, staging procedures and comorbidity. No randomized studies have compared SBRT with no treatment for patients with localized NSCLC. The purpose of this study was to evaluate whether SBRT has influence on overall survival for patients with localized NSCLC and investigate the effect of baseline ventilatory lung function on overall survival.

MATERIAL AND METHODS

From 2007 to 2013, 136 patients treated with SBRT at Odense University Hospital were prospectively recorded. The thoracic SBRT consisted of three fractions of 15-22 Gy delivered in 9 days. For comparison, a national group of 73 untreated patients in the same time period was extracted from the Danish Lung Cancer Registry. All patients had histologically/cytologically proven NSCLC T1-2N0M0 with a tumour diameter ≤5 cm.

RESULTS

The 5-year relative survival was 44% versus 7% for the SBRT and untreated groups, respectively. In a propensity score matched comparison the median overall survival was 47 months versus 11 months for the SBRT and untreated groups, respectively (p < .05). On multivariate analysis, SBRT was significantly associated with improved prognosis while ECOG performance status 2+ and tumour diameter ≥3 cm significantly predicted poorer prognosis. Severe to very severe reduction of forced expiratory volume in one second (FEV1) did not predict poorer survival for the SBRT treated patients with localized NSCLC.

CONCLUSIONS

SBRT offers more favourable survival than no treatment for patients with localized NSCLC. Performance status of 0-1, tumour diameter less than 3 cm and SBRT predicted improved survival. SBRT should not be withheld for patients with localized NSCLC based on poor ventilatory lung function.

Comparison of the Effectiveness of Radiofrequency Ablation With Stereotactic Body Radiation Therapy in Inoperable Stage I Non-Small Cell Lung Cancer: A Systemic Review and Pooled Analysis

PURPOSE

To performed a systematic review and pooled analysis to compare clinical outcomes of stereotactic body radiation therapy (SBRT) and radiofrequency ablation (RFA) for the treatment of medically inoperable stage I non-small cell lung cancer.

METHODS AND MATERIALS

A comprehensive literature search for published trials from 2001 to 2012 was undertaken. Pooled analyses were performed to obtain overall survival (OS) and local tumor control rates (LCRs) and adverse events. Regression analysis was conducted considering each study's proportions of stage IA and age.

RESULTS

Thirty-one studies on SBRT (2767 patients) and 13 studies on RFA (328 patients) were eligible. The LCR (95% confidence interval) at 1, 2, 3, and 5 years for RFA was 77% (70%-85%), 48% (37%-58%), 55% (47%-62%), and 42% (30%-54%) respectively, which was significantly lower than that for SBRT: 97% (96%-98%), 92% (91%-94%), 88% (86%-90%), and 86% (85%-88%) (P<.001). These differences remained significant after correcting for stage IA and age (P<.001 at 1 year, 2 years, and 3 years; P=.04 at 5 years). The effect of RFA was not different from that of SBRT on OS (P>.05). The most frequent complication of RFA was pneumothorax, occurring in 31% of patients, whereas that for SBRT (grade ≥3) was radiation pneumonitis, occurring in 2% of patients.

CONCLUSIONS

Compared with RFA, SBRT seems to have a higher LCR but similar OS. More studies with larger sample sizes are warranted to validate such findings.

Challenges in the treatment of early non-small cell lung cancer: what is the standard, what are the challenges and what is the future for radiotherapy?

In the last 15 years, the use of Stereotactic Ablative Radiation Therapy (SABRT) in the management of small peripheral lung tumours has developed considerably, so that it currently represents a standard of care for inoperable stage I non-small cell lung cancer (NSCLC), offering a survival advantage over traditional radiotherapy, local control rates at 3 years around 90%, with a low risk of toxicity. Indications have extended to larger tumours up to 5 cm and centrally located tumours. In this review we will explore the role of SABRT in early stage NSCLC, the state of the art, the challenges and the future for this technique. There are ongoing studies to optimize such approaches within a multicentric setting. Trials comparing surgery to SABRT in operable or marginally operable have failed because of poor accrual. Several questions remain that need to be addressed in prospective studies.

WITHDRAWN: Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable)

The authors are unable to update this review. A new team is being sought to update it.

The editorial group responsible for this previously published document have withdrawn it from publication.

Radiofrequency ablation for early-stage nonsmall cell lung cancer

This review examines studies of radiofrequency ablation (RFA) of nonsmall cell lung cancer (NSCLC) and discusses the role of RFA in treatment of early-stage NSCLC. RFA is usually performed under local anesthesia with computed tomography guidance. RFA-associated mortality, while being rare, can result from pulmonary events. RFA causes pneumothorax in up to 63% of cases, although pneumothorax requiring chest drainage occurs in less than 15% of procedures. Other severe complications are rare. After RFA of stage I NSCLC, 31–42% of patients show local progression. The 1-, 2-, 3-, and 5-year overall survival rates after RFA of stage I NSCLC were 78% to 100%, 53% to 86%, 36% to 88%, and 25% to 61%, respectively. The median survival time ranged from 29 to 67 months. The 1-, 2-, and 3-year cancer-specific survival rates after RFA of stage I NSCLC were 89% to 100%, 92% to 93%, and 59% to 88%, respectively. RFA has a higher local failure rate than sublobar resection and stereotactic body radiation therapy (SBRT). Therefore, RFA may currently be reserved for early-stage NSCLC patients who are unfit for sublobar resection or SBRT. Various technologies are being developed to improve clinical outcomes of RFA for early-stage NSCLC.

Safety and efficacy of thoracoscopic wedge resection for elderly high-risk patients with stage I peripheral non-small-cell lung cancer

Background

Elderly patients with severe cardiopulmonary and other system dysfunctions are unable to tolerate pulmonary lobectomy. This study aimed to evaluate the risk and efficacy of wedge resection under video-assisted thoracoscopic surgery (VATS) on elderly high-risk patients with stage I peripheral non-small-cell lung cancer (PNSCLC).

Methods

Elderly patients (≥70 years) with suspected PNSCLC were divided into high-risk group and conventional risk group. The high-risk patients confirmed in stage I by the examination of positron emission tomography computed tomography (PET-CT) and the postoperative patients in stage I PNSCLC with negative incisal margin were treated with VATS wedge resection. The conventional risk patients were treated with VATS radical resection and systematic lymphadenectomy. The clinical and pathological data were recorded. The total survival, tumor-free survival, recurrence time and style of patients were followed up.

Results

The operative time and blood loss of the VATS wedge resection group (69.4 ± 15.5 min, 52.1 ± 11.2 ml) were significantly less than those of the VATS radical resection group (128 ± 35.5 min, 217.9 ± 87.1 ml). Neither groups had postoperative death. The overall and tumor-free survival rate of the VATS wedge resection group within three years were 66.7% and 60.0%, and those of the VATS radical resection group were 93.8% and 94.1%, without significant difference (P > 0.05). The recurrence rates of the VATS wedge resection group and VATS radical resection group were 14.3% and 3.0%, without significant difference (P > 0.05).

Conclusion

It is safe, minimally invasive and meaningful to perform VATS wedge resection on the elderly high-risk patients with stage I PNSCLC.

American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer

BACKGROUND

The standard treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not candidates for lobectomy because of severe medical comorbidity.

METHODS

A panel of experts was convened through the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. Following a literature review, the panel developed 13 suggestions for evaluation and treatment through iterative discussion and debate until unanimous agreement was achieved.

RESULTS

Pretreatment evaluation should focus primarily on measures of cardiopulmonary physiology, as respiratory failure represents the greatest interventional risk. Alternative treatment options to lobectomy for high-risk patients include sublobar resection with or without brachytherapy, stereotactic body radiation therapy, and radiofrequency ablation. Each is associated with decreased procedural morbidity and mortality but increased risk for involved lobe and regional recurrence compared with lobectomy, but direct comparisons between modalities are lacking.

CONCLUSIONS

Therapeutic options for the treatment of high-risk patients are evolving quickly. Improved radiographic staging and the diagnosis of smaller and more indolent tumors push the risk-benefit decision toward parenchymal-sparing or nonoperative therapies in high-risk patients. Unbiased assessment of treatment options requires uniform reporting of treatment populations and outcomes in clinical series, which has been lacking to date.

Survival of patients with non-small cell lung cancer without treatment: a systematic review and meta-analysis

BACKGROUND

Lung cancer is considered a terminal illness with a five-year survival rate of about 16%. Informed decision-making related to the management of a disease requires accurate prognosis of the disease with or without treatment. Despite the significance of disease prognosis in clinical decision-making, systematic assessment of prognosis in patients with lung cancer without treatment has not been performed. We conducted a systematic review and meta-analysis of the natural history of patients with confirmed diagnosis of lung cancer without active treatment, to provide evidence-based recommendations for practitioners on management decisions related to the disease. Specifically, we estimated overall survival when no anticancer therapy is provided.

METHODS

Relevant studies were identified by search of electronic databases and abstract proceedings, review of bibliographies of included articles, and contacting experts in the field. All prospective or retrospective studies assessing prognosis of lung cancer patients without treatment were eligible for inclusion. Data on mortality was extracted from all included studies. Pooled proportion of mortality was calculated as a back-transform of the weighted mean of the transformed proportions using the random-effects model. To perform meta-analysis of median survival, published methods were used to pool the estimates as mean and standard error under the random-effects model. Methodological quality of the studies was examined.

RESULTS

Seven cohort studies (4,418 patients) and 15 randomized controlled trials (1,031 patients) were included in the meta-analysis. All studies assessed mortality without treatment in patients with non-small cell lung cancer (NSCLC). The pooled proportion of mortality without treatment in cohort studies was 0.97 (95% CI: 0.96 to 0.99) and 0.96 in randomized controlled trials (95% CI: 0.94 to 0.98) over median study periods of eight and three years, respectively. When data from cohort and randomized controlled trials were combined, the pooled proportion of mortality was 0.97 (95% CI: 0.96 to 0.98). Test of interaction showed a statistically non-significant difference between subgroups of cohort and randomized controlled trials. The pooled mean survival for patients without anticancer treatment in cohort studies was 11.94 months (95% CI: 10.07 to 13.8) and 5.03 months (95% CI: 4.17 to 5.89) in RCTs. For the combined data (cohort studies and RCTs), the pooled mean survival was 7.15 months (95% CI: 5.87 to 8.42), with a statistically significant difference between the two designs. Overall, the studies were of moderate methodological quality.

CONCLUSION

Systematic evaluation of evidence on prognosis of NSCLC without treatment shows that mortality is very high. Untreated lung cancer patients live on average for 7.15 months. Although limited by study design, these findings provide the basis for future trials to determine optimal expected improvement in mortality with innovative treatments.

Management of early stage non-small cell lung cancer in high-risk patients

The preferred treatment of stage I non-small cell lung cancer (NSCLC) is anatomic resection with systematic mediastinal lymph node evaluation. However, 20% of patients with operable lung cancer are not candidates for this type of resection. Recent advancements in radiology-guided technologies have expanded the treatment options for high-risk patients with early-stage NSCLC. There has simultaneously been resurgence in interest and refinement of indications and techniques for sublobar resection in this population. While these treatments appear to have decreased peri-procedural morbidity and mortality, their oncologic efficacy compared to that of lobectomy remains to be determined.

Inoperable early stage non-small cell lung cancer: comorbidity, patterns of care and survival

PURPOSE

To evaluate comorbidities, patterns of care and outcomes for patients with inoperable stage I and II non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Patients diagnosed with stage I or II NSCLC in British Columbia between 1996 and 2005 who did not undergo primary surgery and were referred for oncology assessment were identified in a retrospective analysis. Baseline comorbidity and pulmonary function data for patients treated with curative radiotherapy (CurRT; biologically effective dose [BED]>58 Gy(10)) were abstracted by chart review. Kaplan-Meier and Cox regression were used to determine factors associated with overall survival (OS) and cause-specific survival (CSS) based on treatment group [no radiotherapy (NoRT), palliative radiotherapy (PallRT), or CurRT].

RESULTS

Of 1043 patients identified, approximately 1/3 received CurRT, and these patients had better performance status and lower stage disease than the other groups. There was a high prevalence of comorbid conditions in the CurRT group; 90% of CurRT patients had an age-adjusted Charlson comorbidity index (CCI) score ≥5. CurRT patients had a median survival 1-year longer than patients treated with PallRT or NoRT (p < 0.0001). In CurRT patients, CCI was predictive of OS (HR 1.1 per point CCI increase; p = 0.044), but not CSS. Patients receiving PallRT with a BED > 50 Gy(10) had significantly longer OS than those receiving PallRT of ≤50 Gy(10) (p < 0.0001).

CONCLUSIONS

Treatment of medically inoperable early stage NSCLC patients with CurRT is associated with a significantly longer survival, and for these patients CCI is a significant predictor of OS. For patients treated with PallRT, higher doses of palliative thoracic RT is associated with improved OS.

Optimal surgical management of Stage I non-small-cell lung cancer in an increasingly aging population: challenges and recent progress

Lung cancer remains the main cause of cancer deaths in the USA. The dismal prognosis for non-small-cell lung cancer (NSCLC) despite current advances in chemotherapy is disappointing. In an increasingly aging population, computed tomography screening allows the detection of very early Stage I NSCLC lesions. Although many retrospective trials have indicated better prognosis for those undergoing lobectomy versus sublobar resection (anatomical segmentectomy or wedge resection), the issue remains equivocal. This is particularly true for patients with significant comorbid cardiorespiratory disease compromising postoperative recovery. This review will describe landmark retrospective studies related to the topic, in an attempt to highlight the difficulties associated with surgical decision making. Key factors in the characteristics of the lesions will be examined equally with the ultimate objective of allowing the decision of lobectomy versus sublobar resection to be centered around the need of the individual patient per se. This review article will also provide an insight into ongoing randomized, prospective clinical trials on the subject, investigating into some of the emerging technologies from the laboratory and the clinic that will hopefully enable the provision of a solidly acceptable treatment plan for the Stage I NSCLC patient, with maximum survival rates and low disease recurrence.

Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer

CONTEXT

Lung cancer is the leading cause of cancer death in the United States. Surgical resection for stage I or II non-small cell cancer remains the only reliable treatment for cure. Patients who do not undergo surgery have a median survival of less than 1 year. Despite the survival disadvantage, many patients with early-stage disease do not receive surgical care and rates are even lower for black patients.

OBJECTIVES

To identify potentially modifiable factors regarding surgery in patients newly diagnosed with early-stage lung cancer and to explore why blacks undergo surgery less often than whites.

DESIGN, SETTING, AND PATIENTS

Prospective cohort study with patients identified by pulmonary, oncology, thoracic surgery, and generalist practices in 5 communities through study referral or computerized tomography review protocol. A total of 437 patients with biopsy-proven or probable early-stage lung cancer were enrolled between December 2005 and December 2008. Before establishment of treatment plans, patients were administered a survey including questions about trust, patient-physician communication, attitudes toward cancer, and functional status. Information about comorbid illnesses was obtained through chart audits.

MAIN OUTCOME MEASURE

Lung cancer surgery within 4 months of diagnosis.

RESULTS

A total of 386 patients met full eligibility criteria for lung resection surgery. The median age was 66 years (range, 26-90 years) and 29% of patients were black. The surgical rate was 66% for white patients (n = 179/273) compared with 55% for black patients (n = 62/113; P = .05). Negative perceptions of patient-physician communication manifested by a 5-point decrement on a 25-point communication scale (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.32-0.74) and negative perception of 1-year prognosis postsurgery (OR, 0.27; 95% CI, 0.14-0.50; absolute risk, 34%) were associated with decisions against surgery. Surgical rates for blacks were particularly low when they had 2 or more comorbid illnesses (13% vs 62% for <2 comorbidities; OR, 0.04 [95% CI, 0.01-0.25]; absolute risk, 49%) and when blacks lacked a regular source of care (42% with no regular care vs 57% with regular care; OR, 0.20 [95% CI, 0.10-0.43]; absolute risk, 15%).

CONCLUSIONS

A decision not to undergo surgery by patients with newly diagnosed lung cancer was independently associated with perceptions of communication and prognosis, older age, multiple comorbidities, and black race. Interventions to optimize surgery should consider these factors.

Open lobectomy for patients with stage I non-small cell lung cancer

Until additional multi-institutional, randomized, controlled trials provide evidence to the contrary, open lobectomy with mediastinal lymphadenectomy should be considered the gold standard for treating patients with stage I NSCLC with sufficient cardiopulmonary reserve, including older patients. It is the operation with which alternative pulmonary resections, including video-assisted thoracoscopic lobectomy and sublobar resection, should be compared. In treating stage I NSCLC patients, sublobar resection should be reserved for patients with inadequate physiologic reserve to tolerate lobectomy and for those enrolled in clinical trials.

Hypofractionated high-dose proton beam therapy for stage I non-small-cell lung cancer: preliminary results of a phase I/II clinical study

PURPOSE

To present treatment outcomes of hypofractionated high-dose proton beam therapy for Stage I non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

Twenty-one patients with Stage I NSCLC (11 with Stage IA and 10 with Stage IB) underwent hypofractionated high-dose proton beam therapy. At the time of irradiation, patient age ranged from 51 to 85 years (median, 74 years). Nine patients were medically inoperable because of comorbidities, and 12 patients refused surgical resection. Histology was squamous cell carcinoma in 6 patients, adenocarcinoma in 14, and large cell carcinoma in 1. Tumor size ranged from 10 to 42 mm (median, 25 mm) in maximum diameter. Three and 18 patients received proton beam irradiation with total doses of 50 Gy and 60 Gy in 10 fractions, respectively, to primary tumor sites.

RESULTS

Of 21 patients, 2 died of cancer and 2 died of pneumonia at a median follow-up period of 25 months. The 2-year overall and cause-specific survival rates were 74% and 86%, respectively. All but one of the irradiated tumors were controlled during the follow-up period. Five patients showed recurrences 6-29 months after treatment, including local progression and new lung lesions outside of the irradiated volume in 1 and 4 patients, respectively. The local progression-free and disease-free rates were 95% and 79% at 2 years, respectively. No therapy-related toxicity of Grade > or =3 was observed.

CONCLUSIONS

Hypofractionated high-dose proton beam therapy seems feasible and effective for Stage I NSCLC. Proton beams may contribute to enhanced efficacy and lower toxicity in the treatment of patients with Stage I NSCLC.

Effect of Histologic Type on Recurrence Pattern in Radiation Therapy for Medically Inoperable Patients with Stage I Non-Small-Cell Lung Cancer

Japanese randomized trials showed that there was a significant impact on survival from stage I adenocarcinoma (AD) of the lung by adjuvant chemotherapy with uracil-tegaful after complete resection but there was no effect for patients with squamous cell carcinoma (SQ). The purpose of this study was to examine the correlation of tumor histology and clinical outcome of radiation therapy (RT) for stage I non-small-cell lung cancer (NSCLC) and to consider the necessity of adjuvant chemotherapy after RT for these patients. The subjects were 83 patients, 54 with SQ and 29 with AD; they had received definitive RT with the total dose ranging from 60 to 80 Gy with conventional fractionation at a daily dose of 2 Gy. The differences between SQ and AD with respect to survival and recurrence pattern were investigated. The 5-year overall survival and cause-specific survival rates were 26.5% and 49.1%, respectively. No difference in survival was observed between SQ and AD patients, and the recurrence rates were almost identical (44% for SQ and 45% for AD). However, the 5-year primary control rate of SQ was significantly poorer than that of AD (SQ: 61.5%; AD: 87.6%; p = 0.03). Conversely, the 5-year metastasis-free survival rate of SQ was significantly better than that of AD (SQ: 88.2%; AD: 53.0%; p = 0.005). The different failure pattern, according to tumor histology, indicates that taking into consideration the difference in their clinical behaviors would also be important for planning RT and surgery for early lung cancer.

[Characteristics of lung cancer in a region in northern Spain]

OBJECTIVE

To gather information on the disease characteristics and survival rate of patients diagnosed with bronchogenic carcinoma in the respiratory medicine departments of hospitals in Asturias, Spain.

PATIENTS AND METHODS

This was a retrospective observational study carried out using a standardized data collection protocol. All cases of lung cancer diagnosed during 2001 were included provided there was cytologic or histologic confirmation or they fulfilled a series of clinical, radiological, and/or endoscopic criteria consistent with such a diagnosis.

RESULTS

Standard incidence rates adjusted to the world population were 22.4, 42.6, and 4.6 per 100,000 population for the whole population, men, and women respectively. The mean (SD) age was 67 (10.9) years, and 92% of the patients were men. Overall, 98% of the men and 44% of the women were smokers. Diagnosis was confirmed by cytologic or histologic findings in 92% of patients, and the majority were non-small cell tumors (81.4%). At the time of diagnosis, 65% of the patients had advanced disease, with distant metastasis in 26.6% of the non-small cell cancers and 52.8% of the small cell cancers. Patients received surgical treatment in 21.3% of cases, chemotherapy alone or combined with radiation therapy in 43.1%, and radiation therapy alone in 9.3%. In 26.2% of patients only palliative care was given. Overall, median survival in weeks was 36.4 (95% confidence interval [CI], 29.4-43.4). Median survival by treatment type was as follows: 69.3 (95% CI, 49-9.5) for surgery; 39.6 (95% CI, 31.2-48) for chemotherapy alone or with radiation therapy; 30 (95% CI, 15.4-44.6) for radiation therapy alone; and 13.3 (95% CI, 5.9-20.6) for patients who received palliative care alone (P< .05).

CONCLUSIONS

The findings with respect to age, sex, incidence, histology, extent of tumor, and smoking status of patients with bronchogenic carcinoma in our region does not differ significantly from those reported for other areas of Spain. Current smoking is the primary cause of the high prevalence of this disease. Twenty-six percent of patients received only palliative care. The percentage of patients treated with surgery was low.

Cancer-associated loss of TARSH gene expression in human primary lung cancer

PURPOSE

We have previously identified mouse Tarsh as one of the cellular senescence-related genes and showed the loss of expression of TARSH mRNA in four human lung cancer cell lines. TARSH is a presumptive signal transduction molecule interacting with NESH, which is implicated to have some roles in lung cancer metastasis.

METHODS

The amplification of complete ORF-encoding TARSH cDNA was done with reverse transcription-PCR. Northern blotting was carried out using TARSH cDNA probes. To clarify the relationship between TARSH and lung cancer, we quantified TARSH mRNA expression in 15 human lung cancer cell lines and 32 primary non-small cell lung cancers.

RESULTS

We first determined the complete ORF-encoding cDNA sequence which is expressed in the human lung. On the Northern hybridization analysis, TARSH was strongly expressed in the human lung. The expression of TARSH mRNA is remarkably downregulated in all the lung cancer cell lines examined. Furthermore, TARSH expression was significantly low in all of the tumor specimens when compared to the expression in corresponding non-neoplastic lung tissue specimens.

CONCLUSION

The cancer-associated transcriptional inactivation of TARSH suggests that TARSH could be used as a biomarker for lung cancer development as well as a molecular adjunct for lung carcinogenesis in human.

Ethnic disparities in the treatment of stage I non-small cell lung cancer

RATIONALE

Important variations exist in the treatment of non-small cell lung cancer. Because resection is the most effective treatment for patients with early disease, disparities in surgical rates can generate considerable differences in outcomes.

OBJECTIVE

We analyzed data from a national population-based registry to evaluate disparities in the treatment of Hispanic and white patients with stage I lung cancer and to assess the extent to which these inequalities explain survival differences.

METHODS

This study included 16,036 Hispanic and white patients with stage I lung cancer diagnosed between 1991 and 2000. Cases were identified from the Surveillance, Epidemiology, and End Results registry. Survival was compared among white and Hispanics using Kaplan-Meier curves. Stratified survival curves and Cox regression were used to evaluate whether inequalities in stage (IA vs. IB) and resection could explain survival differences.

RESULTS

Hispanics had worse overall and lung cancer-specific survival compared with whites (p = 0.04 and 0.008, respectively). Five-year lung cancer survival was 54% for Hispanics versus 62% for whites. Hispanics were more frequently diagnosed with stage IB disease (p = 0.0002) and less likely to undergo resection (p = 0.03). Among resected patients, survival was similar for the two groups, as it was among those who did not undergo unresection. After adjusting for surgery and stage, there was no difference in survival between groups.

CONCLUSIONS

Hispanics with stage I lung cancer had worse survival as compared with whites. These disparities are largely explained by lower rates of resection and higher probability of diagnosis at stage IB. Future work must delineate why Hispanics are receiving less surgery.

Risk acceptance and risk aversion: patients' perspectives on lung surgery

Patients express risk aversion toward surgery, particularly if surgery can lead to lifelong debility and loss of independence. When faced with a guarantee of progressive lung cancer and no alternatives for cure, however, patients are willing to take extremely high risks of postoperative complications and surgery-related death. This result occurs because risk aversion toward unrelenting cancer death supersedes patients' risk attitudes toward almost all other health states. By adding conditions such as misunderstanding of prognosis, diagnostic uncertainty, a patient's denial of diagnosis, an actual alternative cure such as radiation therapy, or a perceived alternative cure such as prayer, decisions can be shifted so that risk aversion to surgery can predominate. In practical terms, the following statements can be made: 1. For patients who surely have operable stage I or stage II non small cell lung cancer, if patient risk preferences are taken seriously, the pulmonary function level and comorbidities that are acceptable for the offer of surgical care probably need to be liberalized. Patients with short life expectancies because of advanced age or comorbid illness and patients with severe preoperative functional debility (eg, bed-to-chair limitation as defined earlier) should not be candidates, however. 2. The diagnosis of cancer needs to be confirmed absolutely as often as possible before lung resection surgery. 3. Physicians or a staff member must communicate prognosis to a patient as precisely and numerically as possible and ensure the patient's understanding of the data presented. 4. This communicator also must explore a patient's trust in the diagnosis and probe for beliefs in alternative solutions. Important areas for future study include the search for methods that most accurately communicate risk information to patients, especially patients with low numeracy skills. Part of this communication effort should involve the exploration and discussion of patients' alternative beliefs and ways of using these belief systems to help them make the best possible decisions for their long-term health and quality of life. Also, clinicians must identify pulmonary and other predictors of mortality rates and the debility states that patients' cite as most important according to their risk preferences and give up the predictors of transient postoperative complications that patients find acceptable.

A systematic overview of radiation therapy effects in non-small cell lung cancer

A systematic review of radiation therapy trials in several tumour types was performed by The Swedish Council of Technology Assessment in Health Care (SBU). The procedures for evaluation of the scientific literature are described separately (Acta Oncol 2003; 42: 357-365). This synthesis of the literature on radiation therapy for non-small cell lung cancer (NSCLC) is based on data from 4 meta-analyses and 31 randomized trials. Moreover, data from 12 prospective studies, 12 retrospective studies and 6 other articles were used. In total, 65 scientific articles are included, involving 18 310 patients. The results were compared with those of a similar overview from 1996 including 28 172 patients. The conclusions reached can be summarized as follows: Extensive clinical experience indicates that radiotherapy for medically inoperable patients or patients refusing surgery with NSCLC stage I/II prolongs survival, 15 -20% of these patients reaching long-term (5-year) survival. However, no randomized trials have addressed this issue. There is strong evidence that postoperative radiotherapy in radically resected stage I/II NSCLC does not prolong survival compared with observation alone. There is some evidence that continuous hyperfractionated accelerated radiotherapy (CHART) is associated with increased survival compared to conventional radiotherapy in locally advanced NSCLC and also in medically unfit patients with stage I/II NSCLC. However, the benefit is limited to squamous cell histology. There is strong evidence that combined modality treatment with platinum-based chemotherapy and radiotherapy, either neoadjuvant or concomitant, is superior to radiotherapy alone in terms of survival in locally advanced unresectable NSCLC and should be the standard of care in patients with good performance status. There is some evidence that concomitant chemo-radiotherapy is associated with increased survival compared with sequential chemo-radiotherapy, albeit at the price of increased toxicity Comment: Combined chemo-radiotherapy of primary non-resectable stage III NSCLC followed by surgery in responders lacks evidence from prospective randomized trials and cannot be recommended for routine use. There is strong evidence that radiotherapy can palliate symptoms associated with the intrathoracic tumour burden. There is some evidence that two large fractions may be as effective as conventional schedules consisting of 10-13 smaller fractions in terms of palliation of symptoms. There is some evidence that endobronchial brachytherapy for palliation of symptoms associated with endobronchial tumours is not superior to external beam radiotherapy.

Surgical decisions for early stage, non-small cell lung cancer: which racially sensitive perceptions of cancer are likely to explain racial variation in surgery?

OBJECTIVES

Twenty-three percent of white and 36% of African American patients who suffer from early stage non-small cell lung cancer do not undergo potentially curative surgery A simple decision model is presented to probe for elements of surgical decision making that could explain decisions against lung cancer surgery and racial variation in these decisions.

METHODS

A survey of 181 diverse individuals to measure health utility scores for conditions relevant to lung cancer surgery was performed. These scores were inserted into a simple model that calculates quality-adjusted survival related to decisions for and against cancer surgery

RESULTS

The health utility score (HUS) for progressive lung cancer, as determined by a survey using the standard gamble approach, is nearly twice as high in African Americans as whites (0.32 v. 0.18). However, in a model incorporating African American utility data, lung cancer surgery remains heavily favored compared to the no-surgery decision (2.32 v. 0.48 quality-adjusted life years). Sensitivity analysis shows that factors that lead to a belief of cancer "cure" in the absence of surgical intervention are much more important than variations of HUS in directing model results away from surgery.

CONCLUSION

This analysis illustrates that racial differences in quality-of-life ratings of progressive lung cancer as measured by HUS exist but may not explain decisions against surgery as much as other elements of patient care.

Treatment of stage II non-small cell lung cancer

Based on clinical assessment alone, patients with stage II non-small cell lung cancer (NSCLC) comprise only 5% of all patients with NSCLC. In addition, patients with stage II NSCLC represent a heterogeneous group, since stage II consists of patients with T1-2N1 or T3N0 tumors. By definition, patients with tumor invading the chest wall apex, mediastinum, diaphragm, or even the mainstem bronchus may all have T3 tumors. The extent of the data available regarding treatment of each of these different groups is therefore limited. The quality of the data is limited as well, because information often comes from small series of patients. Studies of adjuvant therapy after complete resection of stage II NSCLC are an important exception to this generalization, since data from large, randomized studies of adjuvant radiation therapy, chemotherapy, or a combination of the two are available for analysis. Superior sulcus tumors are discussed elsewhere in these guidelines.

Best supportive care versus palliative chemotherapy in nonsmall-cell lung cancer

The incidence of lung cancer continues to rise. The need and demand for more effective treatment to improve survival and palliate symptoms increases at a great rate. The most recent evidence for the use of chemotherapy in the palliative setting is summarized in this review of the literature from the last few years. It indicates that in advanced nonsmall-cell lung cancer survival, symptom control and physical functioning can be improved with the use of chemotherapy not only in the first-line but also in the second-line setting, in the elderly, and at disease relapse.

Observation-only management of early stage, medically inoperable lung cancer: poor outcome

STUDY OBJECTIVES

To assess the treatments received and outcomes of patients with early stage non-small cell lung carcinoma (NSCLC).

DESIGN

A retrospective study of patients identified from the institutional tumor registry between 1994 and 1999.

SETTING

The Richard L. Roudebush VA Medical Center, Indianapolis, IN.

PATIENTS

All patients with stage I and II NSCLC as identified above.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Of 128 patients identified, 49 patients received no cancer treatment, 36 patients received radiation therapy only, and 43 patients were treated with primary surgery. Median +/- SD survival time following surgery was 46.2 +/- 3.15 months; for no treatment, 14.2 +/- 2.37 months (p = 3.2 x 10(-6)); and radiotherapy alone, 19.9 +/- 5.6 months (p = 0.0005). Of those who received no specific cancer treatment, 14 patients refused treatment and the remainder were not treated for a variety of medical reasons. Cause of death was cancer in 53% of untreated patients and 43% for those receiving radiotherapy. Radiotherapy was administered for postobstructive atelectasis, hemoptysis, increasing tumor size, pain, pleural effusion, and medical inoperability. Radiation dosages had no apparent standard. No significant differences in survival were found for patients receiving radiotherapy with either curative or palliative intent (20.3 months vs 16.0 months, respectively; p = 0.229).

CONCLUSIONS

Within the limitations of this retrospective study, it appears that untreated early stage lung cancer has a poor outcome, with > 50% of patients dying of lung cancer. Surgery remains the treatment of choice, but lung cancer screening programs will result in increasing numbers of medically inoperable patients with no clear policies for their management.

Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable): a systematic review

OBJECTIVES

To determine the effectiveness of radical radiotherapy in medically inoperable stage I/II non-small cell lung cancer (NSCLC) and the extent of treatment related morbidity.

METHODS

Randomised trials were sought by electronically searching the Cochrane Clinical Trials Register, and both randomised and non-randomised trials were sought by searching Medline and Excerpta Medica (Embase). Further studies were identified from references cited in those papers already identified by electronic searching. The studies included were those of patients of any age with stage I/II NSCLC receiving radiotherapy at a dose of >40 Gy in 20 fractions over 4 weeks or its radiobiological equivalent.

RESULTS

Two randomised and 35 non-randomised studies were identified. One randomised and nine non-randomised studies did not meet the selection criteria, leaving one randomised and 26 non-randomised studies for analysis. In the randomised trial 2 year survival was higher following continuous hyperfractionated accelerated radiotherapy (CHART; 37%) than following 60 Gy in 30 fractions over 6 weeks (24%). An estimated 2003 patients were included in the 26 non-randomised studies; overall survival was 22-72% at 2 years, 17-55% at 3 years, and 0-42% at 5 years. Following treatment, 11-43% of patients died from causes other than cancer. Cancer specific survival was 54-93% at 2 years, 22-56% at 3 years, and 13-39% at 5 years. Complete response rates were 33-61% and local failure rates were 6-70%. Distant metastases developed in approximately 25% of patients. Better response rates and survival were seen in those with smaller tumours and in those receiving higher doses although the reasons for prescribing higher doses were not clearly stated. The outcome was worse in those with prior weight loss or poor performance status. Assessment of treatment related morbidity and effects on quality of life and symptom control were inconclusive because of the lack of prospective evaluation and paucity of data.

CONCLUSIONS

No randomised trials compared a policy of immediate radical radiotherapy with palliative radiotherapy given when patients develop symptoms. In the absence of such trials, radical radiotherapy appears to result in a better survival than might be expected had treatment not been given. A substantial, though variable, proportion of patients died during follow up from causes other than cancer. The optimal radiation dose and treatment technique (particularly with respect to mediastinal irradiation) remain uncertain.

Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable): a systematic review

OBJECTIVES

To determine the effectiveness of radical radiotherapy in medically inoperable stage I/II non-small cell lung cancer (NSCLC) and the extent of treatment related morbidity.

METHODS

Randomised trials were sought by electronically searching the Cochrane Clinical Trials Register, and both randomised and non-randomised trials were sought by searching Medline and Excerpta Medica (Embase). Further studies were identified from references cited in those papers already identified by electronic searching. The studies included were those of patients of any age with stage I/II NSCLC receiving radiotherapy at a dose of >40 Gy in 20 fractions over 4 weeks or its radiobiological equivalent.

RESULTS

Two randomised and 35 non-randomised studies were identified. One randomised and nine non-randomised studies did not meet the selection criteria, leaving one randomised and 26 non-randomised studies for analysis. In the randomised trial 2 year survival was higher following continuous hyperfractionated accelerated radiotherapy (CHART; 37%) than following 60 Gy in 30 fractions over 6 weeks (24%). An estimated 2003 patients were included in the 26 non-randomised studies; overall survival was 22–72% at 2 years, 17–55% at 3 years, and 0–42% at 5 years. Following treatment, 11–43% of patients died from causes other than cancer. Cancer specific survival was 54–93% at 2 years, 22–56% at 3 years, and 13–39% at 5 years. Complete response rates were 33–61% and local failure rates were 6–70%. Distant metastases developed in approximately 25% of patients. Better response rates and survival were seen in those with smaller tumours and in those receiving higher doses although the reasons for prescribing higher doses were not clearly stated. The outcome was worse in those with prior weight loss or poor performance status. Assessment of treatment related morbidity and effects on quality of life and symptom control were inconclusive because of the lack of prospective evaluation and paucity of data.

CONCLUSIONS

No randomised trials compared a policy of immediate radical radiotherapy with palliative radiotherapy given when patients develop symptoms. In the absence of such trials, radical radiotherapy appears to result in a better survival than might be expected had treatment not been given. A substantial, though variable, proportion of patients died during follow up from causes other than cancer. The optimal radiation dose and treatment technique (particularly with respect to mediastinal irradiation) remain uncertain.

Trends in incidence and prognosis of the histological subtypes of lung cancer in North America, Australia, New Zealand and Europe

BACKGROUND

Since the incidence of the histological subtypes of lung cancer in industrialised countries has changed dramatically over the last two decades, we reviewed trends in the incidence and prognosis in North America, Australia, New Zealand and Europe, according to period of diagnosis and birth cohort and summarized explanations for changes in mortality.

METHODS

Review of the literature based on a computerised search (Medline database 1966-2000).

RESULTS

Although the incidence of lung cancer has been decreasing since the 1970s/1980s among men in North America, Australia, New Zealand and north-western Europe, the age-adjusted rate continues to increase among women in these countries, and among both men and women in southern and eastern Europe. These trends followed changes in smoking behaviour. The proportion of adenocarcinoma has been increasing over time; the most likely explanation is the shift to low-tar filter cigarettes during the 1960s and 1970s. Despite improvement in both the diagnosis and treatment, the overall prognosis for patients with non-small-cell lung cancer hardly improved over time. In contrast, the introduction and improvement of chemotherapy since the 1970s gave rise to an improvement in - only short-term (<2 years) - survival for patients with small-cell lung cancer.

CONCLUSIONS

The epidemic of lung cancer is not over yet, especially in southern and eastern Europe. Except for short-term survival of small cell tumours, the prognosis for patients with lung cancer has not improved significantly.

Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable)

BACKGROUND

In general, surgery is believed to offer the best prospects for cure for early stage non-small cell lung cancer (NSCLC). In spite of the intention to consider all patients with stage I-II disease for surgery, there are those who, although technically operable, either refuse surgery or are considered inoperable because of insufficient respiratory reserve, cardiovascular disease or general frailty. This group may therefore be considered "medically inoperable". Some respiratory physicians refer these patients for radical radiotherapy whilst others believe that radiotherapy has little to offer and adopt a watch policy, referring patients for palliative radiotherapy only when they become symptomatic. Although there is little evidence from randomised trials to support the use of radical radiotherapy for stage I/II NSCLC, it is the perception of most clinical oncologists (radiotherapists) that patients should receive radical, as opposed to palliative, treatment (COIN 1999).

OBJECTIVES

To determine the effectiveness and the morbidity of radical radiotherapy for medically inoperable NSCLC.

SEARCH STRATEGY

Randomised trials were sought by electronic searching the Cochrane Clinical Trials Register and both randomised and non-randomised trials sought by searching Medline and Excerpta Medica (Embase). Further studies were identified from references cited in those papers already identified by electronic searching.

SELECTION CRITERIA

Studies of patients of any age with stage I/II NSCLC receiving radiotherapy at a dose greater than 40Gy in 20 fractions over four weeks or its radiobiological equivalent.

DATA COLLECTION AND ANALYSIS

Two randomised and thirty-five non-randomised studies were identified. One randomised and nine non-randomised studies did not meet the selection criteria and were not included in the review.

MAIN RESULTS

In the randomised trial comparing two radiotherapy schedules, two-year survival was superior following continuous hyperfractionated accelerated radiotherapy (CHART; 37%) compared to 60Gy in 30 fractions over six weeks (24%). There were 26 non-randomised retrospective studies including an estimated 2003 patients, in which overall survival results varied between 33-72% at two years, 17-55% at three years and 0-42% at five years. The proportion of deaths not due to cancer was 11-43%. Cancer-specific survival was between 54-93% at two years, 22-56% at three years and 13-39% at five years. Complete response rates were 33-61% and local failure rates between 6-70%. Distant metastases developed in approximately 25% of patients. Better response rates and survival were seen in those with smaller tumours and in those receiving higher doses though the reasons for prescribing higher doses were not clearly stated. Worse outcome was seen in those with prior weight loss or poor performance status. Assessment of treatment-related morbidity and effects on quality of life and symptom control were inconclusive because of the lack of prospective evaluation and paucity of data.

REVIEWER'S CONCLUSIONS

There were no randomised trials that compared a policy of immediate radical radiotherapy with palliative radiotherapy given when patients develop symptoms. In the absence of such trials, radical radiotherapy appears to result in a better survival than might be expected had treatment not been given. A substantial, though variable, proportion of patients died during follow-up from causes other than cancer. The optimal radiation dose and treatment technique (particularly with respect to mediastinal irradiation) remain uncertain.

Radical radiotherapy for inoperable non-small cell lung cancer: what factors predict prognosis?

We set out to determine the factors that predict the outcome of conventional radical radiotherapy for inoperable non-small cell lung cancer. A retrospective casenote review was carried out of all 69 patients treated between 1986 and 1992 at the Northern Ireland Centre for Clinical Oncology, Belfast, with radical radiotherapy for inoperable non-small cell lung cancer. The tumour dose ranged from 45 Gy to 67.5 Gy, delivered in 15-30 fractions, 5 days per week over 3-6 weeks. All patients were followed up for 5 years. The disease was TNM Stage T1-T4N0-N2M0. The majority of tumours (51) were squamous. Overall survival was 63.8% (44-patients; 95% confidence interval (CT) 51.3-75.2) at one year; median survival was 16 months and 5-year survival was 13% (nine patients; 95% CI 6.1-23.3). Five-year survival for the 36 patients with stage T1 or T2 disease was 5.6% (2 patients). Five-year survival for the 33 patients with stage T3 or T4 disease, all with tumours at or near the carina, was 21.2% (seven patients). A WHO performance status of 0 or 1 (P = 0.03, Cox proportional hazards model) was associated with a better chance of survival.

Adrenal mass evaluation in patients with lung carcinoma: a cost-effectiveness analysis

OBJECTIVE

This study evaluates the cost-effectiveness of various imaging and biopsy strategies for characterizing adrenal masses in patients with newly diagnosed non-small cell carcinoma of the lung.

MATERIALS AND METHODS

A decision-analysis model was used to compare the cost-effectiveness of nine strategies. Initial imaging included unenhanced CT using an adenoma or nonadenoma threshold of 0 or 10 H or in- and opposed-phase MR imaging. When initial imaging did not confirm an adenoma, CT-guided biopsy or subsequent imaging was performed. Medicare reimbursement was used as a surrogate of cost. Net costs were calculated as the difference in costs between two limbs of the decision tree. Net benefits were calculated as the difference between strategies and were calculated for life expectancy in years. MR imaging, CT, and biopsy accuracy, average life expectancy, and surgical mortality rates were based on the literature.

RESULTS

The base case analysis determined that the most cost-effective strategy was CT with an adenoma or nonadenoma threshold of 10 H followed by MR imaging, if necessary. CT with a threshold of 0 H followed by biopsy, if necessary, was the least costly. The incremental cost-effectiveness ratio between these two strategies was $16,370 per year of life gained.

CONCLUSION

Unenhanced CT using a 10 H threshold followed by MR imaging, if needed, was the most cost-effective strategy for evaluating an adrenal mass in a patient with newly diagnosed non-small cell lung cancer.

Phase II study of weekly gemcitabine in advanced non-small cell lung cancer

New active agents are needed to develop effective systemic therapy against Stage IIIB-IV non-small cell lung cancer (NSCLC). The aim of the present study was to assess the efficacy and toxicity of gemcitabine, a novel nucleoside analogue with significant preclinical activity, as a single-agent therapy. Forty-three patients with previously untreated Stage IIIB-IV NSCLC were included. Gemcitabine was administered intravenously over 30 min on Days 1, 8 and 15 of each 28-day cycle at a dose of 1250 mg m-2. Thirty-seven patients were evaluable for response. There were seven partial responses giving an overall response rate of 19% (95% confidence interval 8-35%). Median duration of response was 6 months. One-year survival and median survival for all patients were 33% and 8 months, respectively. Toxicity of the treatment was mild. World Health Organization (WHO) Grade 3-4 leukopenia was detected in 11% of the patients. Mild (WHO Grade 1-2) nausea was the most frequent subjective side-effect with a rate of 82%. Mild rash and peripheral oedema were typical side-effects of gemcitabine with rates of 19 and 9%, respectively. In conclusion, single-agent gemcitabine is an active and well-tolerated treatment for Stage IIIB-IV NSCLC patients.