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Eur Respir J 2002; 20:1065-1066
Copyright ©ERS Journals Ltd 2002

Regular follow­up for patients irradiated for early stage nonsmall­cell lung cancer too!

B. Jeremic1, J. Classen2 and M. Bamberg2

1 Dept of Radiotherapy, Technical University Munich, Munich, 2 University Hospital, Tuebingen, Germany

To the Editor:

It was with interest that we read the recent article by EGERMANN et al. 1 on the outcome of regular follow­up in patients with nonsmall­cell lung cancer (NSCLC) treated with curative resection, including cost­effectiveness analysis. We wholeheartedly agree with the conclusions of the study, but would like to extend this observation to another subset of patients, namely those with technically operable, but medically inoperable early stage NSCLC, usually treated with radiation therapy (RT) alone 2–5. There are a number of similarities and differences between these two patient groups.

First, contrary to surgical series, RT patients developing metachronous second primary lung cancer (mSPLC) are not treated differently from those relapsing locally from their first malignancy. Owing to pre­existing comorbidities, they are always treated the same way (with RT) 6. While some of those patients relapsing locally may be treated palliatively 7, 8, a number of them may be treated curatively, particularly those with recurrences confined to the bronchial stump 7–10. In the latter, high­dose RT alone can achieve median survival times of ≤30 months and 5-yr survival rates of ≤30% 7, 9, 10.

Secondly, in contrast to surgical series where second curative resections in mSPLC are rare clinical events, a second RT course in mSPLC diagnosed using the same criteria by MARTINI and MELAMED 11 achieved 5-yr cause­specific and overall survival of 53 and 30% respectively, in patients with Stage I/II NSCLC 6. In addition, there were neither RT­related treatment deaths, contrasting (30­day) preoperative mortality of 13% in the series of EGERMANN et al. 1, nor significant (high­grade) acute or late toxicity, due to the "limited" RT treatment fields used in the patients with mSPLC 6. RT results in this patient population are, therefore, at least comparable with those of surgical series 12–16 of second lung cancer, with a resectability rate of ~50%, median survival times of 1–2 yrs, and 5-yr survivals ranging from 4–32% 17.

Thirdly, while we agree with EGERMANN et al. 1 that the outcome of their patient population may have been burdened by advanced age and pre­existing comorbidities, this was even more the case for the RT­treated patients who were not surgical candidates, with the exception of a few patients who refused surgery for their initial early NSCLC 2–5. We have used a very similar follow­up approach to that of EGERMANN et al. 1 in our patient population, and, although we did not perform cost­effectiveness analysis, we are almost certain that the same would have happened with RT.

Finally, we think that more clinical research should be performed to identify patients who may be at greater risk for developing secondary cancer or cancer that is recurring. Identification of various prognostic factors, such as clinical (patient or tumour­related), laboratory and "biological", could be included, if not before, then at least as part of a comprehensive follow­up plan, in order to direct some or all of the follow­up procedures towards the subset of patients at greatest risk for developing either metachronous second primary lung cancer or local recurrence. Although this may decrease the cost­effectiveness of any follow­up programme in this patient population, it would be instantly rewarding as it would increase the ability to diagnose such patients earlier, and, therefore, offer them more curative approaches, leading to more life­years gained, which is an ultimate goal in this disease.

REFERENCES

  1. Egermann U, Jaeggi K, Habicht JM, Perruchoud AP, Dalquen P, Soler M. Regular follow­up after curative resection of nonsmall cell lung cancer: a real benefit for patients. Eur Respir J 2002;19:464–468.[Abstract/Free Full Text]
  2. Jeremic B, Shibamoto Y, Acimovic LJ, Milisavljevic S. Hyperfractionated radiotherapy alone for clinical stage I nonsmall cell lung cancer. Int J Radiat Oncol Biol Phys 1997;38:521–525.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  3. Jeremic B, Shibamoto Y, Acimovic LJ, Milisavljevic S. Hyperfractionated radiotherapy for clinical Stage II nonsmall cell lung cancer. Radiother Oncol 1999;51:141–145.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  4. Ono R, Egawa S, Suemasu K, Sakura M, Kitagawa T. Radiotherapy in inoperable stage I lung cancer. Jpn J Clin Oncol 1991;21:125–128.[Abstract/Free Full Text]
  5. Hayakawa K, Mitsuhashi N, Saito Y, et al. Limited field irradiation for medically inoperable patients with peripheral stage I non­small cell lung cancer. Lung Cancer 1999;26:137–142.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  6. Jeremic B, Shibamoto Y, Acimovic LJ, et al. Second cancers occurring in patients with early stage non­small cell lung cancer treated with chest radiation therapy alone. J Clin Oncol 2001;19:1056–1063.[Abstract/Free Full Text]
  7. Jeremic B, Shibamoto Y, Milicic B, et al. External beam radiation therapy alone for loco­regional recurrence of non­small­cell lung cancer after complete resection. Lung Cancer 1999;23:135–142.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  8. Jeremic B, Bamberg M. External beam radiation therapy for bronchial stump recurrence of non­small­cell lung cancer after complete resection. Radiother Oncol 2002; (in press).
  9. Kagami Y, Nishio M, Narimatsu N, et al. Radiotherapy for locoregional recurrent tumours after resection of non­small cell lung cancer. Lung Cancer 1998;20:31–35.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  10. Kono K, Murakami M, Sasaki R, et al. Radiation therapy for non­small cell lung cancer with postoperative intrathoracic recurrence. Nippon Igaku Hoshasen Gakkai Zasshi 1998;58:18–24.[Medline] [Order article via Infotrieve]
  11. Martini N, Melamed MR. Multiple primary lung cancers. J Thorac Cardiovasc Surg 1975;70:0606–612.[Abstract]
  12. Thomas P, Rubinstein L, the Lung Cancer Study Group. Cancer recurrence after resection: T1 N0 non­small cell lung cancer. Ann Thorac Surg 1990;49:242–247.[Abstract]
  13. Verhagen AFTM, Tavilla G, van de Wal HJCM, Cox AL, Lacquet LK. Multiple primary lung cancers. Thorac Cardiovasc Surg 1994;42:40–44.[Web of Science][Medline] [Order article via Infotrieve]
  14. Ribet M, Dambron P. Multiple primary lung cancers. Eur J Cardiothorac Surg 1995;9:231–236.[Abstract]
  15. Rosengart TK, Martini N, Ghosn P, Burt M. Multiple primary lung carcinomas: prognosis and treatment. Ann Thorac Surg 1991;52:773–779.[Abstract]
  16. Fleisher AG, McElvaney G, Robinson CL. Multiple primary bronchogenic carcinomas: treatment and follow­up. Ann Thorac Surg 1991;51:48–51.[Abstract]
  17. Johnson BE. Second lung cancers in patients after treatment for an initial lung cancer. J Natl Cancer Inst 1998;90:1335–1345.[Abstract/Free Full Text]




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