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Thoracic surgery participation in cooperative group studies of cancer therapy
Thoracic Surgery Participation in Cooperative Group Studies of Cancer Therapy Richard H. Feins, MD Division of Cardiothoracic Surgery, University of Rochester School of Medicine, Rochester, New York
A
11 of us in thoracic surgery lost a friend when the National Cancer Institute ended funding for the Lung Cancer Study Group (LCSG). For 12 years this thoracic surgically directed group was the mainstay of thoracic surgical cooperative studies. During its life the LCSG activated 18 protocols and completed 17. It set standards for surgical staging of lung cancer [l],determined survival by TNM classification [2], and compiled modern morbidity and mortality statistics for lung resection (31. Important questions about the role of radiation therapy in selected postoperative situations [4], the efficacy of limited lung resection [5], and tolerance and benefit of postoperative chemotherapy were answered [61. With the demise of the LCSG, the nonsurgical cooperative cancer groups established Thoracic Surgical Committees to develop protocols. There are now Thoracic Surgical Committees or subcommittees in the Eastern Cooperative Oncology Group, the Radiation Therapy Oncology Group, the Southwestern Oncology Group, and the Cancer and Leukemia Group B. It is fair to say, however, that protocols involving thoracic surgery have never before been a high priority for these groups. The Eastern Cooperative Oncology Group’s thoracic-related committees (lung, gastrointestinal, sarcoma) developed 97 protocols over the same 12-year period, of which only three involved thoracic surgery. One was closed after 12 months, accruing only 11patients. The second, done with the Radiation Therapy Oncology Group, was basically a chemotherapyhadiation protocol for squamous cell carcinoma of the esophagus. It had a surgical resection option tacked on, but predictably it never produced meaningful surgical data. The third protocol studied the role of surgical resection in small cell carcinoma and was done in collaboration with the LCSG. The results of this study point out the importance of a committed thoracic surgical study group, for 75% of all patients came from the LCSG; 80% of the patients randomized to operation from the LCSG had complete resection, but only 55% randomized to operation from other sources had complete resection. The Radiation Therapy Oncology Group has had a similar track record, developing 27 protocols in the same 12 years but no surgical treatment arms in any of its lung cancer protocols and only the one esophageal protocol with a surgical option mentioned above. Neither the Southwestern Oncology Group nor the Cancer and Leukemia Group B completed a large randomized cooperative thoracic surgical protocol. Address reprint requests to Dr Feins, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642.
0 1992 by The Society of Thoracic Surgeons
The National Cancer Institute has created a considerable challenge for thoracic surgeons. We are now being asked to develop and perform thoracic surgical protocols in four different groups, each traditionally weighted toward either chemotherapy or radiation therapy. Most data managers in these groups are not familiar with thoracic surgical procedures and the many nuances that can make an operation a success or a failure. Detailed thoracic surgical quality assurance protocols must be developed. Substantial long-standing nonsurgical hierarchies exist within each group which may encumber the development of protocols targeted primarily for surgical patients. Total funding for the four groups will be in excess of $20 million dollars in 1991 (as compared with about $1.2 million dollars annually for the LCSG). At each institution, these funds are now given to the radiation oncologist or medical oncologist who is the group’s principal investigator and not to the thoracic surgeon who may be the actual principal investigator. It is reasonable to expect the National Cancer Institute to require a major commitment by these groups toward thoracic surgical protocols and to the thoracic surgeons who will participate in them. We, as thoracic sur eons, realize that improved results in the treatment of t oracic malignancies will require a cooperative effort involving adjuvant and neoadjuvant therapy. It is, therefore, incumbent upon us to continue the important work of the LCSG. Continued diligence by members of the thoracic surgical committees, intergroup cooperation among the surgeons in the four groups, and active participation in the protocols by as many thoracic surgeons as possible will be essential. On the other hand, the Eastern Cooperative Oncology Group, the Radiation Therapy Oncology Group, the Southwestern Oncology Group, and the Cancer and Leukemia Group B must establish a level of responsiveness to thoracic surgery that has been lacking in the past. This goal will not be easily attained, but success will strengthen us as a specialty and our patients will be the ultimate beneficiaries. The LCSG has provided a standard of excellence by which to measure our accomplishments.
a
References 1. The Lung Cancer Study Group (Prepared by Thomas PA, Piantadosi S, Mountain CF). Should subcarinal lymph nodes be routinely examined in patients with non-small cell lung cancer? J Thorac Cardiovasc Surg 1988;95:883-7. 2. Mountain CF, Lukeman JM, Hammar SP, et al. Lung cancer classification:the relationship of disease extent and cell type to survival in a clinical trials population. J Surg Oncol 1987;35: 147-56. 3. Ginsberg RJ, Hill LD, Eagan RT, et al. Modem 30-day opera-
Ann Thorac Surg 1992;53:9-10
OOO3-4975/92/$3.50
10
EDITORIAL FENS COOPERATIVE CANCER STUDIES
tive mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983;86:654-7. 4. The Lung Cancer Study Group (prepared by Weisenburger T, Gail M). Effects of postoperative mediastinal radiation in completely resected stage I1 and stage I11 epidermoid cancer of the lung. N Engl J Med 1986;315:1377-81. 5. Ginsberg RJ for the Lung Cancer Study Group. Limited
Ann Thorac Surg 1!392;539-10
resection for peripheral TIN0 tumors. Lung cancer (Suppl). Fifth World Conference, Interlaken, Switzerland, 1988;4A80. 6. The Lung Cancer Study Group (prepared by Holmes EC). Seven year follow-up of surgical adjuvant therapy for adenocarcinoma and large cell undifferentiated carcinoma of the lung. Lung cancer (Suppl). Fifth World Conference, Interlaken, Switzerland, 1988;4A119.
A
11 of us in thoracic surgery lost a friend when the National Cancer Institute ended funding for the Lung Cancer Study Group (LCSG). For 12 years this thoracic surgically directed group was the mainstay of thoracic surgical cooperative studies. During its life the LCSG activated 18 protocols and completed 17. It set standards for surgical staging of lung cancer [l],determined survival by TNM classification [2], and compiled modern morbidity and mortality statistics for lung resection (31. Important questions about the role of radiation therapy in selected postoperative situations [4], the efficacy of limited lung resection [5], and tolerance and benefit of postoperative chemotherapy were answered [61. With the demise of the LCSG, the nonsurgical cooperative cancer groups established Thoracic Surgical Committees to develop protocols. There are now Thoracic Surgical Committees or subcommittees in the Eastern Cooperative Oncology Group, the Radiation Therapy Oncology Group, the Southwestern Oncology Group, and the Cancer and Leukemia Group B. It is fair to say, however, that protocols involving thoracic surgery have never before been a high priority for these groups. The Eastern Cooperative Oncology Group’s thoracic-related committees (lung, gastrointestinal, sarcoma) developed 97 protocols over the same 12-year period, of which only three involved thoracic surgery. One was closed after 12 months, accruing only 11patients. The second, done with the Radiation Therapy Oncology Group, was basically a chemotherapyhadiation protocol for squamous cell carcinoma of the esophagus. It had a surgical resection option tacked on, but predictably it never produced meaningful surgical data. The third protocol studied the role of surgical resection in small cell carcinoma and was done in collaboration with the LCSG. The results of this study point out the importance of a committed thoracic surgical study group, for 75% of all patients came from the LCSG; 80% of the patients randomized to operation from the LCSG had complete resection, but only 55% randomized to operation from other sources had complete resection. The Radiation Therapy Oncology Group has had a similar track record, developing 27 protocols in the same 12 years but no surgical treatment arms in any of its lung cancer protocols and only the one esophageal protocol with a surgical option mentioned above. Neither the Southwestern Oncology Group nor the Cancer and Leukemia Group B completed a large randomized cooperative thoracic surgical protocol. Address reprint requests to Dr Feins, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642.
0 1992 by The Society of Thoracic Surgeons
The National Cancer Institute has created a considerable challenge for thoracic surgeons. We are now being asked to develop and perform thoracic surgical protocols in four different groups, each traditionally weighted toward either chemotherapy or radiation therapy. Most data managers in these groups are not familiar with thoracic surgical procedures and the many nuances that can make an operation a success or a failure. Detailed thoracic surgical quality assurance protocols must be developed. Substantial long-standing nonsurgical hierarchies exist within each group which may encumber the development of protocols targeted primarily for surgical patients. Total funding for the four groups will be in excess of $20 million dollars in 1991 (as compared with about $1.2 million dollars annually for the LCSG). At each institution, these funds are now given to the radiation oncologist or medical oncologist who is the group’s principal investigator and not to the thoracic surgeon who may be the actual principal investigator. It is reasonable to expect the National Cancer Institute to require a major commitment by these groups toward thoracic surgical protocols and to the thoracic surgeons who will participate in them. We, as thoracic sur eons, realize that improved results in the treatment of t oracic malignancies will require a cooperative effort involving adjuvant and neoadjuvant therapy. It is, therefore, incumbent upon us to continue the important work of the LCSG. Continued diligence by members of the thoracic surgical committees, intergroup cooperation among the surgeons in the four groups, and active participation in the protocols by as many thoracic surgeons as possible will be essential. On the other hand, the Eastern Cooperative Oncology Group, the Radiation Therapy Oncology Group, the Southwestern Oncology Group, and the Cancer and Leukemia Group B must establish a level of responsiveness to thoracic surgery that has been lacking in the past. This goal will not be easily attained, but success will strengthen us as a specialty and our patients will be the ultimate beneficiaries. The LCSG has provided a standard of excellence by which to measure our accomplishments.
a
References 1. The Lung Cancer Study Group (Prepared by Thomas PA, Piantadosi S, Mountain CF). Should subcarinal lymph nodes be routinely examined in patients with non-small cell lung cancer? J Thorac Cardiovasc Surg 1988;95:883-7. 2. Mountain CF, Lukeman JM, Hammar SP, et al. Lung cancer classification:the relationship of disease extent and cell type to survival in a clinical trials population. J Surg Oncol 1987;35: 147-56. 3. Ginsberg RJ, Hill LD, Eagan RT, et al. Modem 30-day opera-
Ann Thorac Surg 1992;53:9-10
OOO3-4975/92/$3.50
10
EDITORIAL FENS COOPERATIVE CANCER STUDIES
tive mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983;86:654-7. 4. The Lung Cancer Study Group (prepared by Weisenburger T, Gail M). Effects of postoperative mediastinal radiation in completely resected stage I1 and stage I11 epidermoid cancer of the lung. N Engl J Med 1986;315:1377-81. 5. Ginsberg RJ for the Lung Cancer Study Group. Limited
Ann Thorac Surg 1!392;539-10
resection for peripheral TIN0 tumors. Lung cancer (Suppl). Fifth World Conference, Interlaken, Switzerland, 1988;4A80. 6. The Lung Cancer Study Group (prepared by Holmes EC). Seven year follow-up of surgical adjuvant therapy for adenocarcinoma and large cell undifferentiated carcinoma of the lung. Lung cancer (Suppl). Fifth World Conference, Interlaken, Switzerland, 1988;4A119.