Lung Cancer.pdf

102 W.R. Smythe
nation for these survival findings may lie in staging bias, and true stagespecific
survival may be improved in the near future by the application of
newer imaging modalities such as positron emission tomography. In addition
to improvements in staging, neoadjuvant chemotherapy and other
novel therapies may bring about changes in the current treatment algorithm
and allow for improved survival as well.
Introduction
Of the more than 150,000 patients diagnosed with non–small cell lung carcinoma
(NSCLC) in the United States each year, only a minority present
with early-stage (stage I or II) disease as defined by the American Joint
Committee on Cancer (AJCC) TNM staging system. In the latest National
Cancer Institute Surveillance, Epidemiology, and End Results Program
data analysis, 15% of patients diagnosed with NSCLC in the United States
between 1989 and 1996 were found to have “localized” as opposed to “regional”
(23%), “distant” (48%), or “unstaged” (14%) disease.
We are often somewhat heartened when a patient appears with a 1-cm
peripheral lung cancer nodule without evidence of mediastinal or distant
metastases rather than disseminated disease. Before stating that a “cure is
certain,” however, we must remember that a substantial proportion of
patients treated for early-stage NSCLC eventually succumb to this aggressive
neoplasm. Again according to Surveillance, Epidemiology, and
End Results Program data, 5-year survival rates for patients with NSCLC
improved only slightly between the mid-1970s and the mid-1990s, from
12.4% during the 1974–1979 reporting period to 14.1% during the
1989–1996 reporting period, the last period analyzed. In a review evaluating
all recently published data regarding outcomes in patients with
stage I or II NSCLC, Nesbitt et al (1995) estimated overall 5-year reported
survival rates to be 64.6% for patients with stage I and 41.2% for patients
with stage II disease. Naruke and colleagues and Mountain published 2
of the largest series to date evaluating postsurgical survival in patients
with NSCLC (Naruke et al, 1988; Mountain, 1997). In these studies, survival
was retrospectively assessed in 2,322 patients with stage I or II
NSCLC (1997 AJCC TNM system designation) who were treated surgically.
The 5-year survival rate for patients with T3N0M0 disease was 38%
in the Mountain study and 33% in the Naruke study, and the survival rate
in the most favorable subgroup (patients with T1N0M0 disease) was 67%
in the Mountain study and 75% in the Naruke study (Table 6–1).
Clearly, we cannot promise a cure to patients with a diagnosis of NSCLC
at any stage. However, there is no doubt that survival following treatment in
patients with this disease is stage related and that patients with lower-stage
disease have the best chance for cure. This fact underscores the importance
of appropriate treatment of patients with earlier-stage disease, in whom the
potential for a lost curative opportunity if inappropriate treatment is deliv-