Treatment of Stage I and II Non-Small-Cell Lung Cancer
Treatment of Stage I and II Non-Small-Cell Lung Cancer
Background: The appropriate staging and treatment of patients with stage I and II non-small-cell lung cancer (NSCLC) are important in that the potential for a lost curative opportunity in this population is greater than for those presenting with advanced NSCLC.
Methods: Treatment options -- surgery, radiation therapy, and chemotherapy -- for stage I and II NSCLC are reviewed, and the impact of newer staging modalities on patient survival is discussed, including altering both the lead-time and clinicopathologic stage biases that exist in the diagnosis and treatment of NSCLC. Some predictions are also made regarding how that standard may change for clinicians in the near future, and methods for further improvements in posttreatment survival in this group are discussed.
Results: Whenever possible, patients with early-stage NSCLC should be treated with surgical resection. Patients for whom resection is not an option may benefit from radiation as definitive therapy. Positive results with neoadjuvant chemotherapy have led to an ongoing randomized trial (Intergroup S9900) to compare surgery alone to neoadjuvant chemotherapy plus surgery. Conclusions: Staging bias may affect the overall low survival of early-stage NSCLC. However, true stage-specific survival may improve with newer imaging modalities. Future advances, including closed transthoracic radiation, thermal ablative therapy techniques, and gene therapy, may supplant the need to surgically resect these tumors to achieve local control.
Of the more than 150,000 patients diagnosed with non-small-cell lung cancer (NSCLC) in the United States each year, a woeful minority will present with stage I or II disease as defined by the TNM staging system of the American Joint Commission on Cancer(AJCC). While we may appreciate a patient who presents with a 1-cm peripheral lung cancer nodule without evidence of mediastinal or distant metastases rather than disseminated disease,cure of such a patient is not certain. A substantial number of patients who are treated for early-stage NSCLC will eventually die of this neoplasm. The latest Surveillance, Epidemiology and End Results (SEER) Program data analysis indicates that 15% of patients diagnosed from 1989 to 1996 with NSCLC in the United States were reported to have"localized" disease compared with 23% with "regional"disease, 48% with "distant" disease, and 14% with "unstaged" disease. According to SEER data, NSCLC survival improved from 12.4% during the 1974-1979 reporting period to only 14.1% in the last period analyzed (1989-1996).
In a review evaluating recent published data for outcomes in patients with stage I or II NSCLC, Nesbitt and colleagues estimated overall cumulative reported survival rates to be 64.6% for stage I and 41.2% for stage II.Naruke et al and Mountain published two of the largest series evaluating post surgical survival in NSCLC.In these studies, 2,322 patients with stage I or II (1997 AJCC system designation) NSCLC were treated surgically,and survival was retrospectively assessed. The 5-year survival rate for patients with T3 N0 M0 IIB disease was no greater than 38%, and when patients in the most favorable subgroup (T1 N0 M0 stage I disease) were analyzed,the survival rates ranged from 67% to 75% (Table).
Clearly, a cure to patients with a diagnosis of NSCLC cannot be promised at any stage. However, survival following treatment of this disease is stage related,and patients with lower-stage disease have the best chance for curative treatment. With this in mind, the appropriate treatment of patients with early-stage disease assumes perhaps even greater importance than for those who present with advanced NSCLC, as the potential for a lost curative opportunity is greatest. The survival rate increase from 12.4% to 14.1% previously mentioned may seem trivial, but a 2% increase in a group of 150,000 patients/year means an additional 21,000 lives were saved during this time period compared with 20 years earlier.
This review addresses the "standard of care" for treatment of stage I and II NSCLC, as supported by past experience. Some predictions are also made regarding how that standard may change for clinicians in the near future, and methods for further improvements in post-treatment survival in this group are discussed. In addition,the impact of newer screening modalities on patient survival is discussed. by altering both the lead time and clinicopathologic stage biases that exist in the diagnosis and treatment of NSCLC.
Background: The appropriate staging and treatment of patients with stage I and II non-small-cell lung cancer (NSCLC) are important in that the potential for a lost curative opportunity in this population is greater than for those presenting with advanced NSCLC.
Methods: Treatment options -- surgery, radiation therapy, and chemotherapy -- for stage I and II NSCLC are reviewed, and the impact of newer staging modalities on patient survival is discussed, including altering both the lead-time and clinicopathologic stage biases that exist in the diagnosis and treatment of NSCLC. Some predictions are also made regarding how that standard may change for clinicians in the near future, and methods for further improvements in posttreatment survival in this group are discussed.
Results: Whenever possible, patients with early-stage NSCLC should be treated with surgical resection. Patients for whom resection is not an option may benefit from radiation as definitive therapy. Positive results with neoadjuvant chemotherapy have led to an ongoing randomized trial (Intergroup S9900) to compare surgery alone to neoadjuvant chemotherapy plus surgery. Conclusions: Staging bias may affect the overall low survival of early-stage NSCLC. However, true stage-specific survival may improve with newer imaging modalities. Future advances, including closed transthoracic radiation, thermal ablative therapy techniques, and gene therapy, may supplant the need to surgically resect these tumors to achieve local control.
Of the more than 150,000 patients diagnosed with non-small-cell lung cancer (NSCLC) in the United States each year, a woeful minority will present with stage I or II disease as defined by the TNM staging system of the American Joint Commission on Cancer(AJCC). While we may appreciate a patient who presents with a 1-cm peripheral lung cancer nodule without evidence of mediastinal or distant metastases rather than disseminated disease,cure of such a patient is not certain. A substantial number of patients who are treated for early-stage NSCLC will eventually die of this neoplasm. The latest Surveillance, Epidemiology and End Results (SEER) Program data analysis indicates that 15% of patients diagnosed from 1989 to 1996 with NSCLC in the United States were reported to have"localized" disease compared with 23% with "regional"disease, 48% with "distant" disease, and 14% with "unstaged" disease. According to SEER data, NSCLC survival improved from 12.4% during the 1974-1979 reporting period to only 14.1% in the last period analyzed (1989-1996).
In a review evaluating recent published data for outcomes in patients with stage I or II NSCLC, Nesbitt and colleagues estimated overall cumulative reported survival rates to be 64.6% for stage I and 41.2% for stage II.Naruke et al and Mountain published two of the largest series evaluating post surgical survival in NSCLC.In these studies, 2,322 patients with stage I or II (1997 AJCC system designation) NSCLC were treated surgically,and survival was retrospectively assessed. The 5-year survival rate for patients with T3 N0 M0 IIB disease was no greater than 38%, and when patients in the most favorable subgroup (T1 N0 M0 stage I disease) were analyzed,the survival rates ranged from 67% to 75% (Table).
Clearly, a cure to patients with a diagnosis of NSCLC cannot be promised at any stage. However, survival following treatment of this disease is stage related,and patients with lower-stage disease have the best chance for curative treatment. With this in mind, the appropriate treatment of patients with early-stage disease assumes perhaps even greater importance than for those who present with advanced NSCLC, as the potential for a lost curative opportunity is greatest. The survival rate increase from 12.4% to 14.1% previously mentioned may seem trivial, but a 2% increase in a group of 150,000 patients/year means an additional 21,000 lives were saved during this time period compared with 20 years earlier.
This review addresses the "standard of care" for treatment of stage I and II NSCLC, as supported by past experience. Some predictions are also made regarding how that standard may change for clinicians in the near future, and methods for further improvements in post-treatment survival in this group are discussed. In addition,the impact of newer screening modalities on patient survival is discussed. by altering both the lead time and clinicopathologic stage biases that exist in the diagnosis and treatment of NSCLC.
