Preoperative chemoradiotherapy for stage III unresectable nonsmall cell lung cancer: Results of a phase II study Reboul F, Chauvin G, Vincent P, Brewer Y, Felix-Faure C, Taulelle M. Unite de Trait. des Cancers Bmnch., Clinique Sainte-Catherine, BP 846,84082 Avignon Ceder. Bull Cancer 1996; 83:300-6. Prognosis of Stage III NSCLC remains dismal, particularly when mediastinal nodal involvement is present. In order to improve local control and to reduce early distant failures, we have treated Stage III patients with concurrent chemoradiotherapy since 1989. From September 1989 to February 1994, 140 patients were treated with concurrent chemoradiotherapy. Among these, 24 initially inoperable patients became operable after induction chemoradiotherapy. Characteristics: median age 5 1 years (35-70); squamous: 45.8%; non squamous: 41.7%; median tumor size: 8 cm; T3 (79.2%); T4a (12.5%); N2 (62.5%) and N3 (8.3%). Preoperative radiotherapy was delivered at a dose of 45 Gy (25 f) over 5 weeks to the mediastinum. Concurrent chemotherapy was continuous infusion cispiatin (n = IO) or cisplatin plus etoposide (n = 14). Five weeks later, radical surgery was carried out (lobectomy n = 14. pneumonectomy n = 106 followed by additional chemotherapy (n = 12) and/or radiotherapy (n = 6). according to histological response. Pathological CR rate was 29.2%. Grade III toxicities were digestive (12.5%) hematologic (8.3%) and infectious (4.2%). Three patients had severe non-lethal postoperative complications with one hemorrhage and two pneumothorax (12.5%). With a median follow-up of 41 months, overall survival at 2 and 5 years was 77.5%. and 72%, respectively. Actuarial local control at 5 years was 82.4%. Nine patients presented with distant metastases, including six with isolated brain metastases. This preoperative chemoradiotherapy regimen appears feasible without overwhelming toxicity and with an acceptable rate of postoperative complications. Despite a significant incidence of isolated brain metastases (25%). 5-year survival is highly encouraging since and appears substantially better than primary surgery.
Reviews Treatment of small cell lung carcinoma in the elderly Dajczman E, Li Yi Fu, Small D, Wolkove N, Kreisman H. Department of Pulmonary Medicine, Sir M. B. DavisJewish General Hosv.. 3755 Cote St. Catherine Rd., Montreal, Que H3T-IE2. CANCER 1996;77:2032-8. Background: The number of elderly people with small cell lung carcinoma (SCLC) is increasing and currently nearly 25% are older than 70 years. Elderly patients may not tolerate intensive therapy and, therefore, often do not receive such treatment. Additionally, age may be an independent predictor for response and survival. We compared the investigation, staging procedure, and management of patients less thau 60 years, 60 to 69, and older than 70 years who were diagnosed with SCLC between 1985 and 1991. We hypothesized that elderlv oatients were investigated and treated less aggressively, and that their outcome was poorer than that of younger patients with SCLC. Methods: Information on weight loss, performance status, coexisting disease, staging investigations, and treatment was recorded. Treatment was categorized as optimal or suboptimal using predetermined criteria, and correlated with patient age. Toxicity grade, response to treatment, and survival were noted. Results: There were no differences among the 3 age groups with respect to disease stage, and weight loss, although poorer performance status and comorbidity were more common in those patients older than 70 years. Elderly patients were investigated and treated less aggressively than the 2 younger patients groups. The oldest group received smaller chemotherapy dosage, fewer cycles, and had more dose reductions compared to the younger patients. Only I of 81 elderly patients was enrolled on an experimental protocol as compared with 19% ._
and 28% of the younger patient groups. Furthermore, elderly patients had the highest frequency of supportive care alone. There was a signiticant relationship between advancedage and suboptimal treatment, with those older than 70 years having an odds ratio (OR) of 0.30 (95% confidence interval (CI) 0.15-0.61). for having received optimal treatment. Despite, this survival was similar for younger and older groups of patients (OR 0.89, CI 0.6-1.3). Conclusions: Elderly patients had poorer pre-treatment performance status, greater comorbidity, were more likely to have suboptimal therapy and were almost never entered into clinical trials. Despite this their survival did not differ from that of younger patients with SCLC. Randomized trials of treatment, with assessment of quality of life, are necessary to determine the effect of modified regimens for elderly patients with SCLC.
Miscellaneous Economic considerations in the care of lung cancer patients Desch CE, Hillner BE, Smith TJ. Massey Cancer Cente,: Box 980037, 401 College Street, Richmond, VA 23298-0037. Curr Opin Ocol 1996;8: 126-32. Lung cancer has been characterized as an expensive, futile, and self-induced illness. One of the most common questions pertaining to treatment is, ‘Is it worth it?’ In the era of health care reform, attention has been directed toward common, high-cost illnesses that may benefit from closer examination of the clinical decisions that drive costs. This review explores the economic considerations of tung cancer treatment from the perspective of the patient, society, and those at risk for the costs of care. The concept of value is proposed as a framework to guide how lung cancer treatments should and should not be routinely used. Cost-effectiveness studies are highlighted that do not paint as dim a view of lung cancer therapy as may have been thought, However, it is clear that the 10 billion dollars spent yearly on lung cancer might be better used by limiting expenditures to the aspects of care that produce the best outcomes. This review includes comparisons of the cost-effectiveness of lung cancer care and treatments for other common cancers. It concludes with some strategies to use resources allocated to lung cancer more effectively.
Quality of life and supportive care in the treatment of NSCLC Manegold C, Schwarz R. Chest Hospital, Amalientrasse 5. D-69126 Heidelberg. Chest 1996;109:Suppl: I1 3-4. The definition of quality of life (QGL) for individual patients with non-small cell lung cancer (NSCLC) is unclear and its evaluation difficult because of the heterogeneity of the patients involved. More research is needed to determine the best means of routinely expressing and comparing QGL assessments and implementing the results of these studies into daily patient care. The role of broad supportive care in optimizing patient comfort and functionality is also an important issue. Because it incorporates not only specific palliative treatment, but also nontumor-specific measures and medical intervention, supportive care is relevant to all patients with NSCLC, whether terminally ill or suffering treatment-related toxic reactions. More education, research, and financial support are needed to optimize QOL and supportive care of patients.