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Impact of comorbidity on survival after surgical resection in patients with stage I non-small cell lung cancer

2003; Elsevier BV; Volume: 125; Issue: 2 Linguagem: Inglês

10.1067/mtc.2003.251

1097-685X

Branislav Jeremić,

Advanced Radiotherapy Techniques

I read with interest the recent article by Battafarano and associates1Battafrano RJ Piccirillo JF Meyers BF Hsu HS Guthrie RN Cooper JD et al.Impact of comorbidity on survival after surgical resection in patients with stage I non-small cell lung cancer.J Thorac Cardiovasc Surg. 2002; 123: 280-287Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar on significantly adverse impact of comorbidity on survival of patients with resected stage I non-small cell lung cancer. Although the vast majority of patients with early stage (I and II) disease are treated with surgery, a small subset of these patients are not candidates for surgery because of preexisting comorbidity. Such patients are treated with radiotherapy alone.2Slotman BJ Karim AB Curative radiotherapy for technically operable stage I nonsmall cell lung cancer.Int J Radiat Oncol Biol Phys. 1994; 29: 33-37Abstract Full Text PDF PubMed Scopus (60) Google Scholar, 3Krol AD Aussems P Noordijk EM Hermans J Leer JW Local irradiation alone for peripheral stage I lung cancer: could we omit the elective regional nodal irradiation?.Int J Radiat Oncol Biol Phys. 1996; 34: 297-302Abstract Full Text PDF PubMed Scopus (195) Google Scholar, 4Kupelian PA Komaki R Allen P Prognostic factors in the treatment of node-negative nonsmall cell lung carcinoma with radiotherapy alone.Int J Radiat Oncol Biol Phys. 1996; 36: 607-613Abstract Full Text PDF PubMed Scopus (109) Google Scholar, 5Sibley GS Jamieson TA Marks LB Anscher MS Prosnitz LR Radiotherapy alone for medically inoperable stage I non-small-cell lung cancer: the Duke experience.Int J Radiat Oncol Biol Phys. 1998; 40: 149-154Abstract Full Text Full Text PDF PubMed Scopus (319) Google Scholar, 6Hayakawa K Mitsuhashi N Saito Y Nakayama Y Furuta M Sakurai H et al.Limited field irradiation for medically inoperable patients with peripheral stage I non-small cell lung cancer.Lung Cancer. 1999; 26: 137-142Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 7Jeremic B Shibamoto Y Acimovic L Milisavljevic S Hyperfractionated radiotherapy alone for clinical stage I nonsmall cell lung cancer.Int J Radiat Oncol Biol Phys. 1997; 38: 521-525Abstract Full Text PDF PubMed Scopus (93) Google Scholar, 8Jeremic B Shibamoto Y Acimovic LJ et al.Hyperfractionated radiotherapy for clinical stage II nonsmall cell lung cancer.Radiother Oncol. 1999; 51: 141-145Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 9Ono R Egawa S Suemasu K Sakura M Kitagawa T Radiotherapy in inoperable stage I lung cancer.Jpn J Clin Oncol. 1991; 21: 125-128PubMed Google Scholar In this patient population high-dose, standard fraction, or hyperfractionated radiotherapy is capable of achieving median survivals as long as 30 months and 5-year survivals as great as 30%,7Jeremic B Shibamoto Y Acimovic L Milisavljevic S Hyperfractionated radiotherapy alone for clinical stage I nonsmall cell lung cancer.Int J Radiat Oncol Biol Phys. 1997; 38: 521-525Abstract Full Text PDF PubMed Scopus (93) Google Scholar, 8Jeremic B Shibamoto Y Acimovic LJ et al.Hyperfractionated radiotherapy for clinical stage II nonsmall cell lung cancer.Radiother Oncol. 1999; 51: 141-145Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar with values going up to approximately 40 months and 40%, respectively, for T1 N0 cases.9Ono R Egawa S Suemasu K Sakura M Kitagawa T Radiotherapy in inoperable stage I lung cancer.Jpn J Clin Oncol. 1991; 21: 125-128PubMed Google Scholar This patient population clearly represents a case of extremely negative selection in which, as observed in their surgical counterparts, numerous cancer-unrelated events seriously distort the overall picture of the effectiveness of radiotherapy. Indeed, when additional end points such as cause-specific or disease-free survivals are offered, the magnitude of the difference between overall and cause-specific survivals in these reports2Slotman BJ Karim AB Curative radiotherapy for technically operable stage I nonsmall cell lung cancer.Int J Radiat Oncol Biol Phys. 1994; 29: 33-37Abstract Full Text PDF PubMed Scopus (60) Google Scholar, 3Krol AD Aussems P Noordijk EM Hermans J Leer JW Local irradiation alone for peripheral stage I lung cancer: could we omit the elective regional nodal irradiation?.Int J Radiat Oncol Biol Phys. 1996; 34: 297-302Abstract Full Text PDF PubMed Scopus (195) Google Scholar, 4Kupelian PA Komaki R Allen P Prognostic factors in the treatment of node-negative nonsmall cell lung carcinoma with radiotherapy alone.Int J Radiat Oncol Biol Phys. 1996; 36: 607-613Abstract Full Text PDF PubMed Scopus (109) Google Scholar, 5Sibley GS Jamieson TA Marks LB Anscher MS Prosnitz LR Radiotherapy alone for medically inoperable stage I non-small-cell lung cancer: the Duke experience.Int J Radiat Oncol Biol Phys. 1998; 40: 149-154Abstract Full Text Full Text PDF PubMed Scopus (319) Google Scholar, 6Hayakawa K Mitsuhashi N Saito Y Nakayama Y Furuta M Sakurai H et al.Limited field irradiation for medically inoperable patients with peripheral stage I non-small cell lung cancer.Lung Cancer. 1999; 26: 137-142Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar have usually been between 15% and 20%.2Slotman BJ Karim AB Curative radiotherapy for technically operable stage I nonsmall cell lung cancer.Int J Radiat Oncol Biol Phys. 1994; 29: 33-37Abstract Full Text PDF PubMed Scopus (60) Google Scholar, 3Krol AD Aussems P Noordijk EM Hermans J Leer JW Local irradiation alone for peripheral stage I lung cancer: could we omit the elective regional nodal irradiation?.Int J Radiat Oncol Biol Phys. 1996; 34: 297-302Abstract Full Text PDF PubMed Scopus (195) Google Scholar, 4Kupelian PA Komaki R Allen P Prognostic factors in the treatment of node-negative nonsmall cell lung carcinoma with radiotherapy alone.Int J Radiat Oncol Biol Phys. 1996; 36: 607-613Abstract Full Text PDF PubMed Scopus (109) Google Scholar, 5Sibley GS Jamieson TA Marks LB Anscher MS Prosnitz LR Radiotherapy alone for medically inoperable stage I non-small-cell lung cancer: the Duke experience.Int J Radiat Oncol Biol Phys. 1998; 40: 149-154Abstract Full Text Full Text PDF PubMed Scopus (319) Google Scholar, 6Hayakawa K Mitsuhashi N Saito Y Nakayama Y Furuta M Sakurai H et al.Limited field irradiation for medically inoperable patients with peripheral stage I non-small cell lung cancer.Lung Cancer. 1999; 26: 137-142Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar It is therefore obvious that in this patient population the use of cause-specific or disease-free survival is mandatory to correct for events that are not cancer related. Similarly to surgical series, it is observed that intercurrent deaths are directly correlated with increasing age and preexisting comorbidity (21%-43%).5Sibley GS Jamieson TA Marks LB Anscher MS Prosnitz LR Radiotherapy alone for medically inoperable stage I non-small-cell lung cancer: the Duke experience.Int J Radiat Oncol Biol Phys. 1998; 40: 149-154Abstract Full Text Full Text PDF PubMed Scopus (319) Google Scholar, 6Hayakawa K Mitsuhashi N Saito Y Nakayama Y Furuta M Sakurai H et al.Limited field irradiation for medically inoperable patients with peripheral stage I non-small cell lung cancer.Lung Cancer. 1999; 26: 137-142Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 7Jeremic B Shibamoto Y Acimovic L Milisavljevic S Hyperfractionated radiotherapy alone for clinical stage I nonsmall cell lung cancer.Int J Radiat Oncol Biol Phys. 1997; 38: 521-525Abstract Full Text PDF PubMed Scopus (93) Google Scholar, 8Jeremic B Shibamoto Y Acimovic LJ et al.Hyperfractionated radiotherapy for clinical stage II nonsmall cell lung cancer.Radiother Oncol. 1999; 51: 141-145Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 9Ono R Egawa S Suemasu K Sakura M Kitagawa T Radiotherapy in inoperable stage I lung cancer.Jpn J Clin Oncol. 1991; 21: 125-128PubMed Google Scholar Although patients with early stage non-small cell lung cancer treated with surgery and those treated with radiotherapy cannot be meaningfully compared, they share the risk of cancer-unrelated death from serious comorbidity. As we have seen from this article,1Battafrano RJ Piccirillo JF Meyers BF Hsu HS Guthrie RN Cooper JD et al.Impact of comorbidity on survival after surgical resection in patients with stage I non-small cell lung cancer.J Thorac Cardiovasc Surg. 2002; 123: 280-287Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar these risks could be identified and stratified or grouped, which knowledge could be used to optimally address the treatment in this disease.