Benefit from Surgery in Stage IIIA N2 (NSCLC) in Medically Fit Patients
According to results presented at the plenary session at the 45th annual meeting of the American Society for Therapeutic Radiation and Oncology, therapeutic benefits achieved with surgery following chemotherapy and radiation may be cancelled out by deaths caused by the procedure in patients with stage IIIA N2 non-small cell lung cancer.
1 However, a subset of patients that respond well to initial therapy and are in good medical condition may achieve benefit from the addition of surgery.
Lung cancer is the leading cause of cancer deaths in the United States. Non-small cell lung cancer refers to the type of cell within the lung that the cancer originated. Stage IIIA NSCLC means that cancer has not spread outside the lung but has invaded local lymph nodes. Patients with stage IIIA N2 NSCLC have cancer that has spread to the mediastinal (middle of the chest) lymph nodes. Surgical removal of mediastinal lymph nodes is difficult and these patients do not have optimal long-term outcomes. Clinical trials have been ongoing to address the issue of multimodality treatment including the effectiveness of surgery in stage IIIA N2 NSCLC.
Researchers affiliated with the Radiation Therapy Oncology Group (RTOG) recently conducted a clinical trial directly comparing the addition of surgery following chemotherapy and radiation in patients with stage IIIA N2 NSCLC. At the initiation of the trial, patients were divided into two groups: those treated with chemotherapy (etoposide and Platinol®) and radiation followed by surgery and additional chemotherapy, and those treated with chemotherapy and radiation alone. Cancer recurrences within the lung occurred in 17% of patients treated with surgery, compared with 26% of patients treated with chemotherapy/radiation only. The average duration of progression-free survival was comparable between the two groups: 13.4 months for those treated with surgery and 11.8 months for those not treated with surgery. The average duration of overall survival in both groups was 22 months, and at 3 years, survival was approximately 30% in both groups of patients. Deaths caused by treatment in patients undergoing surgery was 7%, which cancelled out any overall treatment benefit in terms of survival in those treated with surgery. However, within the group of patients who were treated with surgery, those who tolerated pre-surgery chemotherapy/radiation well and had no additional medical conditions appeared to benefit from surgery.
The researchers conducting this trial concluded that the addition of surgery to chemotherapy and radiation therapy does not appear to provide an overall survival advantage to chemotherapy and radiation alone in patients with stage IIIA N2 NSCLC. However, they suggest that a subset of patients who tolerate pre-surgery treatment well and are medically fit may be able to tolerate surgery better than their counterparts, and thus, appear to achieve a survival benefit from the addition of surgery. This suggestion is consistent with results presented at the 2003 annual meeting of the American Society of Clinical Oncology, demonstrating a survival benefit from the addition of surgery to chemotherapy and radiation in medically fit patients with stage IIIA N2 NSCLC.
2 Patients with stage IIIA N2 NSCLC may wish to discuss the risks and benefits of the addition of surgery to chemotherapy and radiation therapy in their individual case with their physician.
1.Turrisi AT, Scott CB, Rusch VR, et al. Randomized Trial of Chemoradiotherapy to 61 Gy (no S) Versus Chemoradiotherapy to 45 Gy Followed by Surgery (S) Using Cisplatin Etoposide in Stage IIIa Non-Small Cell Lung Cancer (NSCLC): Intergroup Trial 0139, RTOG (9309). Proceedings of the 45th Annual Meeting of the American Society for Therapeutic Radiology and Oncology. International Journal of Radiation Oncology Biology Physics 2003;57, Number 2, Supplement, Abstract Number 4:S125.
- Albain K, Scott C, Rush V, et al. Phase III comparison of concurrent chemotherapy plus radiotherapy (CT/RT) and CT/RT followed by surgical resection for stage IIIA (pN2) non-small cell lung cancer (NSCLC): Initial results from intergroup trial 0139 (RTOG 93-09). Proceedings from the 39th annual meeting of the American Society of Clinical Oncology. May 2003. Abstract #2497.
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