Betty J. Flehinger

The Role of Surgery in N2 Lung Cancer

Whereas most physicians believe that long-term survival is unlikely when mediastinal lymph node metastases are present, a significant number of these patients do have resectable tumors with encouraging long-term survival results. Data are presented to support this view, and steps identified to guide the physicians in selecting the patients who can benefit from this surgical approach.

Preoperative chemotherapy for stage IIIa (N2) lung cancer: The Sloan-Kettering experience with 136 patients

From 1984 to 1991, 136 patients with histologically confirmed non-small cell lung cancer and stage IIIa (N2) disease received two to three cycles of MVP (mitomycin + vindesine or vinblastine + high-dose cisplatin) chemotherapy. All patients had clinical N2 disease, defined as bulky mediastinal lymph node metastases or multiple levels of lymph node involvement in the ipsilateral mediastinum or subcarinal space on chest roentgenograms, computed tomographic scans, or mediastinoscopy. The overall major response rate to chemotherapy was 77% (105/136). Thirteen patients had a complete response and 92 patients had a partial but major response (> 50%). The overall complete resection rate was 65% (89/136) with a complete resection rate of 78% (82/105) in patients with a major response to chemotherapy. There was no histologic evidence of tumor in the resected specimens of 19 patients. The overall survival was 28% at 3 years and 17% at 5 years (median, 19 months). For patients who had complete resection, the median survival was 27 months and the 3-year and 5-year survivals were 41% and 26%, respectively. There were seven treatment-related deaths, five of which were postoperative deaths. To date, 33 patients, all of whom had complete resection, have had no recurrence after treatment. These results demonstrate that (1) preoperative chemotherapy with MVP produces high response rates in stage IIIa (N2) disease, (2) high complete resection rates occur after response to chemotherapy, and (3) survival is longest in patients who have a complete resection after major response to chemotherapy.

Progress report on controlled trial of fecal occult blood testing for the detection of colorectal neoplasia

Our controlled trial of screening for colorectal cancer has now been in progress for almost five years. Screening is accomplished by rigid sigmoidoscopy in control and study groups and, in addition, by fecal occult blood testing in the study group. Patients screened are men and women age 40 and older, mostly at average risk. Fecal occult blood testing is with Hemoccult slides with patients on a meat‐free, high‐bulk diet without hydration, and with a four‐day storage interval between slide preparation and testing. Patients with positive slides undergo diagnostic investigation that includes both colonoscopy and double‐contrast barium enema and, in some, an upper gastrointestinal series. Preliminary results to date include: patient baseline statistics and subgroup comparability, rate of positive slides of 1–4%, predictive value for neoplasia of 44–50%, false‐positives of 0.5–2.1%, favorable Dukes staging of cancers in the study group, and high patient compliance. Considerably more follow‐up is needed in our study and control population, and issues such as mortality and cost need to be addressed. Additional time will be necessary to provide firm conclusions.

Factors influencing ten-year survival in resected stages I to IIIA non-small cell lung cancer

OBJECTIVEnThe purpose of this study was to determine (in survivors of 5 years after resection of their lung cancer) whether age, sex, histologic condition, and age have any influence on furthering survival beyond 5 years.nnnMETHODSnFrom 1973 to 1989, 686 patients were alive and well 5 years after complete resection of their lung cancers. Survival analysis was carried out with only deaths from lung cancer treated as deaths. Deaths from other causes were treated as withdrawals. Multivariate Cox regression was used to test the relationship of survival to age, sex, histologic condition, and stage.nnnRESULTSnThe population in this study had the following characteristics at the time of operation: The male/female ratio was 1.38:1, and the median age was 61 years. The histologic condition of their lung cancer was adenocarcinoma in 412 patients, squamous cell in 244 patients, large cell carcinoma in 29 patients, and small cell carcinoma in 1 patient. The stage of the disease was stage IA in 263 patients, IB in 261 patients, IIA in 12 patients, IIB in 68 patients, and IIIA in 82 patients. The extent of resection was a lobectomy or bilobectomy in 579 patients, pneumonectomy in 55 patients, and wedge resection or segmentectomy in 52 patients. A recurrence or a new lung primary occurrence was considered as failure to remain free of lung cancer. The median follow-up on all patients was 122 months from initial treatment. Of the 686 patients, 26 patients experienced the development of late recurrence and 36 new cancers, beyond 5 years. Overall survival for 5 additional years after a 5-year check point was 92.4%. Likewise, survival by nodal status was 93% for N0 tumors, 95% for N1 tumors, and 90% for N2 tumors. Survival by stage was 93% for stage I tumors and 91% for stage II or IIIA tumors.nnnCONCLUSIONSnIn patients with surgically treated lung cancer, neither age, sex, histologic condition, nor stage is a predictor of the risk of late recurrence or new lung cancer. The only prognostic factor appears to be the survival of the patient free of lung cancer for 5 years from the initial treatment, with a resultant favorable outlook to remain well for 10 or more years.

Impact of Early Detection on the Clinical Course of Lung Cancer

The Memorial Sloan-Kettering Lung Cancer Detection Program is described, and data from this study are reported and analyzed. The program enrolled 10,040 cigarette-smoking men who were screened for at least 5 years by annual chest radiographs; half the men randomly selected also had 4-monthly sputum cytologic examinations. Of the 354 lung cancers that developed in these men during the screening period and a 2-year post-screening period, nearly half were adenocarcinomas and nearly one third were epidermoid (or squamous) carcinomas. Lung cancers detected by screening were more likely to be early stage (53 per cent) and resectable (65 per cent) than were those discovered by other means (for example, symptoms) or in the post-screening period (20 per cent early stage, 32 per cent resectable). Sputum cytology was most effective in detecting squamous carcinomas early; chest radiographs were most effective for detecting adenocarcinoma. However, sputum cytology did not reduce lung cancer mortality among these men who were in a program of annual chest radiographic examinations. Overall 5-year survival for all of the men who developed lung cancer was 35 per cent, compared with the national average of 13 per cent.

Decision theory in cancer therapy

Decision theory, which has been greatly developed in the last two decades and which is today widely applied to economic, political and military problems, appears useful for decision making in cancer management. As an example, the application of its principles and practice to the so‐called “prophylactic neck dissection” is presented. This question, whether or not to carry out a radical neck dissection in a patient with oral cancer without palpable neck metastasis, has been the subject of controversy for more than 50 years, with nearly as many surgeons favoring it as rejecting it. Application of the decision theory, which requires only simple arithmetic, greatly clarifies the problem and shows that, if certain hypotheses are accepted, in most cases the best results can be expected after prophylactic neck dissection only in patients with primary cancers over 2 cm diameter. For clinical use, a “decision table” was developed, which without calculation permits the cancer therapist to find the optimal decision immediately.

A retrospective analysis of 10‐year survivors from carcinoma of the lung

From 1949 to 1972, 4732 patients with carcinomas of the lung were seen. Of these, 118 patients were found alive at 10 years from their initial diagnosis and treatment. This number represents only 2.5% of all lung cancers seen because many have been lost to follow‐up within the first ten years, and their true status is not known. The authors attempted to look at the patient characteristics that might have influenced long‐term survival. A case‐matched study was also done of patients with carcinoma of the lung who lived less than 2 years and who had the same age, sex, histology, and year of diagnosis. In the long‐term survivors, the median age was 57 years, 2 of 3 had epidermoid carcinoma, 86% were smokers, 76% were symptomatic, and 70% had one or both parents alive at age 70 years or older. There was no difference in these variables in the case‐matched group. Of the 118 long‐term survivors, 91 were men and 27 were women. Sixty‐seven percent had Stage I disease, 13% Stage II, and 20% Stage III. None had distant metastasis at presentation. Of the 118 patients, 115 had surgery. Eighteen of the 115 surgically treated patients also had postoperative external radiation. Three patients with Stage III disease received radiation without surgery. None had recurrence of their cancer, 27 developed new cancers, and 70% of these were new lung cancers. Although the majority of the long‐term survivors had Stage I cancers, a third had Stage II or III disease. No long‐term survivor died of his original disease, suggesting that a 10‐year survival is adequate proof of cure in carcinoma of the lung. Cancer 53:1405‐1408, 1984.

Early incidence rates of precancerous cervical lesions in women using contraceptives

Abstract This report describes the continuation of a study on the occurrence of early cervical neoplasia in relation to method of contraception used by women attending Planned Parenthood of New York City, Inc. An earlier paper indicated a small but significant excess in prevalence rates of carcinoma in situ for steroid users compared with diaphragm users. We now estimate incidence rates of carcinoma in situ and lesser precancerous cervical lesions in steroid, diaphragm, and IUD contraceptors who are initially proved free of cervical neoplasia. These data do not prove any statistically significant differences although the estimates exhibit variations not inconsistent with our previous findings.

Results of surgical treatment in N2 lung cancer.

Eighty patients were treated by resection for carcinoma of the lung with mediastinal lymph node metastases. Complete resection of the primary tumor and a mediastinal lymph node dissection were performed on all patients. The majority also received postoperative external radiation therapy to the mediastinum. Survival after resection was 47% at 3 years and 38% at 4 years. Survival was better when the histologic diagnosis was adenocarcinoma, when the primary tumor was small, and when the mediastinum appeared normal on regular chest roentgenograms.RésuméQuatre-vingts malades ont été traités par exérèse du cancer du poumon et des adénopathies cancéreuses médiastinales. La résection complète de la tumeur et la dissection des ganglions médiastinaux furent pratiquées chez tous les malades. La majorité des opérés curent leur médiastin irradié après lintervention. Le taux de survie fut de 47% à 3 ans et de 38% à 4 ans. Ce taux fut meilleur quand il sagissait dadénocarcinome, que la tumeur était petite et que le médiastin était normal sur les clichés thoraciques.