Primary Lung Cancer in a Chest Clinic: Diagnosis and Prognosis

Primary Lung Cancer in a Chest Clinic:. Diagnosis and Prognosis* Benedicte Strunge, M.D. This reports a retrospective study of primary cancer of the lung diagnosed in the chest clinics of the Odense and Assens counties in Denmark during the period 1960 to 1966. There were 212 patients, 171 of whom had been referred because of symptoms, and 41 who were found in group screening. Of the latter, 13 had no symptoms. The histologic diagnosis, the diagnostic procedures on

Jn the Danish chest clinics-previously called tu-

berculosis dispensaries-the work has changed in nature during the past decades. Now, the chest clinics act predominantly as centers for pulmonary diseases in general and lung cancer in particular. The patients attend when referred by general practitioners and for mass group screening. A retrospective study was made of all patients with primary cancer of the lung diagnosed during the period 1960 to 1966 in the chest clinics of the Odense and Assens counties. The object was to study the prognosis, in terms of five-year survival, for these patients and thereby the value of the chest clinics as diagnostic centers. METHODS AND MATERIAL

In the chest clinics during the period 1960 to 1966, a diagnosis of primary cancer of the lung was made in 212 patients, 192 men and 20 women. The data were collected from the clinic records, case notes from other departments, the national registry, and general practitioners. There were 205 patients between 40 and 80 years of age. Table 1 gives the age distribution and sex ratio. The population in these counties is about 275,000, and this population can freely go for examination in the chest clinics. Most people join as part of an annual, prophylactic examination for pulmonary tuberculosis, which is required for employment in many industries, hospitals, municipal offices et cetera. This population undergoes what is called here mass group screening. The other group includes single persons admitted by their practitioners because they display symptoms. As may be seen the difference between these two groups is based just on the method of admittance. The material was analyzed as of January 1, 1972. During the same period a total of 379 patients with primary cancer of the lung were recorded from the two counties in the Cancer Registry.l At the time of analysis, 43 °From the Department of Pulmonary Medicine, University Hospital, Odense, Denmark. Manuscript received November 9, 1973; revision accepted June 11. Reprint requests: Dr. Strunge, University Hospital, Odense, Denmark DK-5000

28 BENEDICTE STRUNGE

which the diagnosis was based, and the treatment are reported. Twenty percent of the patients were alive after five years, as compared with the calculated 13.5 percent for all cancers of the lung in the two counties. A close collaboration between general practitioners, chest clinics, and departments of thoracic surgery is stressed as a means of further improving the prognosis.

of our patients had not been recorded in the Cancer Registry. Thus, 422 cases in all were diagnosed in the Odense and Assens counties. REsULTS

The diagnosis was made in 171 patients who had been referred to the clinics because of symptoms, systemic as well as pulmonary, whereas 41 cases were found in group screening. One hundred four persons had been x-rayed in group screening three years or less before the diagnosis was made. Revision of the films disclosed in 19 cases overlooked abnormalities which could be related to the subsequently diagnosed cancer of the lung. Table 2 lists the histologic diagnosis and the survival in the individual types of cancer. A "mixed" type means that on the basis of the histologic examination the cancer could not be classified in any of the four types listed in the table. In 25 of these 38 cases the biopsies were from metastatic lesions. In four cases it was not possible to obtain tissue for histologic typing premortem or postmortem. The diagnosis was made by chest x-ray examination. In the same table is given the number of smokers and nonsmokers within each histologic type. Of 212 patients, 185 were smokers. Table 3 shows the diagnostic procedures on which the final diagnosis has been based. Table 4 presents the treatment given and the Table 1-Se% Ratio and Age Distribution of Patients with Primary Cancer of the Lung Age (yrs)

Men

Women

30-39 40-49 50-59 60-69 70-79

4 15 74 74 25 0

2 4 3 7 2 2

192

20

80-

CHEST, 67: 1, JANUARY, 1975

Table 2-Distribution of the Hiuologic Types of Lung Cancer (Men and Women) in Relation to Smolcera and Nonamolcera, and SunJi.,ora after Fi.,e Y eara

Men

Women

Type

Smoker

Nonsmoker

Squamous-cell

90

7

3

Adenomatous

10

0

3

Anaplastic

36

4

3

Alveolar

5

0

0

Mixed*

29

7

2

0

38

4

0

0

0

4

0

174

18

11

9

212

43

No histologic diagnosis

Smoker

Nonsmoker

Total

Survivors

101

34

7

20

3

0

43

3

6

2

*Classification by histologic type of cancer was impossible.

number of five-year survivors. All survivors had undergone operation. It is apparent from Tables 2 and 4 that 43 of 212 patients ( 20 percent) were alive five years after the operation for cancer of the lung. Of all 212 patients, 114 had resection ( 54 percent ) , and another 20 ( 9 percent) had exploratory thoracotomy. The number of survivors who underwent pneumonectomy was the same as those who had lobectomy. Among the 101 patients with squamous-cell carcinoma 75 underwent resection, and 34 were alive at five years (Table 5). Another nine patients with squamous-cell carcinoma had exploratory thoracotomy, but resection could not be performed. Table 5 also lists the primary causes of death. The radiologic findings are not included, as they are outside the present subject. It may be mentioned, however, that three patients did not exhibit any radiologic abnormalities at the time of diagnosis. Le Roux 2 has reported normal radiologic apTable 3--Procedure• on Which the Diagno•i• of Primary Lung Cancer waa Baaed

Method

Men

Women

Total

Bronchoscopy

76

7

83

Exploratory thoracotomy

73

7

80

Biopsy from a cervical node

12

2

14

Postmortem examination

10

Mediastinoscopy

8

Metastases in other organs

5

Tumor cells in sputum

5

X-ray film only

3

192

CHEST, 67: 1, JANUARY, 1975

11 1

9

20

DISCUSSION

The material is a selected one. The patients were able to join the chest clinic on an outpatient basis because the lung disease was not so advanced in pulmonary or general symptoms that admittance to a ward was necessary immediately. Some patients consulted their practitioner because of pulmonary symptoms and thereafter atTable 4--Treatment of Primary Lung Cancer

Men

Women

Total

Survivors (5 yr)

Pneumonectomy

61

4

65

23

Lobectomy

37

6

43

19

2

0

2

4

0

4

0

26

0

Segmental resection Resection therapy

+

radio-

Radiotherapy

25

5

Exploratory thoracotomy

20

0

20

0

4

No treatment

43

9

52

0

192

20

212

43

6 0

pearances in only three out of 4000 patients with cancer of the lung. Of the 171 patients who had been referred to the clinics, 32 ( 18.8 percent) were alive at five years, whereas 11 out of 41 ( 26.8 percent) found at group screening were alive at five years. Only 13 of the 41 cases found at group screening had no pulmonary symptoms. During the same period 47,000 patients were examined after referral and 458,000 in group screening. In other words, cancer of the lung was found in about one of 300 of the referred patients and in about one of 10,000 of the persons examined in group screening.

212

PRIMARY LUNG CANCER IN A CHEST CLINIC 29

Table 5--Car..e of Death Within FitJe Years /or Patients with Primary Cancer of the Lung Cause of Death Cancer of the lung

Squamous-cell Care • +*

Adenom Care +

31

25

8

Postoperative complications

6

0

1

Cardiovascular diseases

2

0

0

Pneumonia

1

0

Other causes

Alveol Care

Anapi Care +

"Mixed" Care

No Histol Diagn

+

+

+

Total

29

2

2

7

29

0

3

151

2

0

0

0

0

0

0

0

10

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

2

0·

0

0

0

0

0

0

0

0

0

2

0

0

0

43

30

0

4

212

69

Alive at five years

34

0

3

0

3

0

2

0

Total

75

26

13

7

14

29

4

2

8

0

4

*+and -:Number of patients who had and who had not resection.

tended the chest clinic for further investigation. Persons, who joined the mass group screening had no or slight symptoms from the lungs, but those with symptoms had neglected them until examination took place in the chest clinic. Therefore, these two groups of patients have presumably presented themselves at an earlier stage of their disease than a number of patients who have never been at the chest clinic and have therefore not been followed up. Out of 379 patients certified to the Cancer Registry 1 from the counties of Odense and Assens 53 ( 14 percent) were alive five years later. If the 43 not yet reported patients are included, the figure is 57 of 422 ( 13.5 percent). In our analysis 20 percent were alive at five years. Thus, the prognosis of lung cancer diagnosed in the chest clinics see.ms to be better than that for all cases from the counties of Odense and Assens ( l = 3.2, p = 0.062). The chest clinics have had a close collaboration with the Department of Thoracic Surgery where the patients were admitted as soon as malignancy was suspected. Since cancer of the lung can be cured only by surgery, 3 such collaboration is of the utmost importance. Radiotherapy may have a favorable palliative effect, whereas cytotoxic agents have little effect. 3 An investigation of the prognosis in relation to the duration of symptoms showed no difference. Holbraad and Thybo 4 found a better prognosis for squamous-cell carcinomas with a brief duration of symptoms ( < 2 months). In their material,4 37 percent of 271 patients had pulmonary resection in the same department of thoracic surgery as our patients, but during the period 1960 to 1964. Fifty-four percent of the patients from the Chest Clinic had resection during the period 1960 to 1966. Resection was performed on 75 percent of our 30 BENEDICTE STRUNGE

patients with squamous-cell carcinoma and on 62 percent of Holbraad and Thybo's 4 109 patients. For the anaplastic carcinomas the corresponding values were 33 percent out of 43 and 14 percent out of 97. The surgical results in our material showed no difference even if a pneumonectomy or a lobectomy was done, which had been stressed by Ochsner. 5 The five-year survival for cancer of the lung in Odense county was 12 percent during the period 1960 to 1964. 6 Sture Larsson's 7 analysis revealed that the mortality of lung cancer for all of Sweden was 86 percent of the incidence during the four-year period 1963 to 1966. Out of 998 cases in one Swedish area 21 percent had resection, and the five-year survival was 6 percent. The Swedish material contained 30 percent squamous-cell and about 50 percent anaplastic carcinomas. Similar histologic findings have been reported from Iceland. 8 Screening for lung cancer should be directed at high-risk groups, as pointed out by Kubik and associates9: cigarette smokers, patients with a cough, possibly exacerbation or alteration of cough, patients with expectoration, hemoptysis, and over 40 years of age. The group of screened patients from our analysis had a five-year survival rate of 26.8 percent and patients referred with symptoms, 18.8 percent, a difference which indicates a better prognosis for the former group, but evaluation is difficult because of the small size of the material. As 19 of the 104 previously examined patients had overlooked xray lesions, and as 458,000 were included in group screening, the value of this form of investigation must be regarded with some scepticism in the early diagnosis of cancer. Wynder and co-workers 10 found the risk of acquiring cancer of the lung to decrease when CHEST, 67: 1, JANUARY, 1975

people stopped smoking. In a prospective study Weiss and colleagues 11 •12 demonstrated that the risk of lung cancer became higher and the prognosis poorer with increasing use of tobacco. Through 10 years Boucot and Weiss 13 followed 6,136 men by semiannual 70-mm chest photofluorograms. The 5year survival for the lung cancer patients found was so poor, 8 percent out of 121, that this is at any rate not the way to solve the lung cancer problem. CoNCLUSION

On the basis of the present findings it must be concluded, that the collaboration between general practitioners and the chest clinics should be greater, so that patients with pulmonary symptoms can be referred as quickly as possible. REFERENCES

1 Clemmensen J: Cancerregistret. Personal communication 2 LeRoux BT: Bronchial Carcinoma. London, Livingstone, 1968 3 NIH Conference: Lung Cancer: Perspectives and Pros-

pects. Ann Intern Med 73:1003-1024, 1970 4 Holbraad L, Thybo E: Treatment of lung cancer in a Danish county. Acta Chir Scand (suppl) 356:163-170, 1966 5 Ochsner A: Lobectomy or pneumonectomy. Surg Clin N Am 46:1255-1264, 1966 6 Sorensen HR: Bronchialcancerens diagnostik, behandling og senresultater. Med Arb 151-166: 1970 7 Larsson S: Comparison of lung cancer morbidity and mortality in Sweden 1959-1966. Acta Path Microbiol Scand [A] 79:524-528, 1971 8 Petersen GF: Incidence of pulmonary carcinoma in Iceland between 1931 and 1964. Acta Radio) [Ther] ( Stockh) 11:321-326, 1972 9 Kubik A, Krivinka R, Stasek V, eta!: Screening for lung cancer high-risk groups. Scand J Resp Dis 51:290-300, 1970 10 Wynder EL, Mabuchi K, Beattie EJ: The epidemiology of lung cancer. JAMA 213:2221-2228, 1970 11 Weiss W, Boucot KR, Cooper DA: The Philadelphia pulmonary neoplasm research project. JAMA 216:21192123, 1971 12 Weiss W, Boucot KR, Seidman H, et al: Risk of lung cancer according to histologic type and cigarette dosage. JAMA 222:799-801, 1972 13 Boccot KR, Weiss W: Is curable lung cancer detected by semiannual screening? JAMA 224:1361-1365, 1973

Temperament of Famous Musicians Composers have often shared the spotlight of temperament with musical performers, the fabulous Franz Liszt making an almost unique reputation in both fields. Beethoven was noted for his boorish ways and complete independence of social conventions even in his relation with his noble patrons. Haydn, on the other hand, accepted life with complete equanimity, always thanking God for his creative inspiration. The great Bach was similar in his religious humility. Brahms also showed few signs of temperament, although he could be decidedly rude to disguise his essential shyness. Wagner, on the other hand, possessed a Oamboyant personality that consistently ignored common courtesy. One of the most

CHEST, 67: 1, JANUARY, 1975

modest composers of all time was Robert Shumann, yet eventually he attempted suicide and died in a mental institution at the age of forty-six. Both Mozart and Schubert, famous for their sunny disposition and easygoing manner of life, died in their thirties, while Mendelssohn, perhaps the most temperamental of composers, also failed to reach his fortieth year, as did the contrastingly mercurial Chopin. Apparently temperament has little to do with longevity or, for that matter, personal popularity. But its effect on the success of an artist can hardly be denied. Spaeth S: The Importance of Music, New York, Fleet, 1963

PRIMARY LUNG CANCER IN A CHEST CLINIC 31