Is Surgery Mandated in the Treatment of Stage IIIA Non-Small Cell Lung Cancer?

10/20/2003

From: Beth Bukata, 703-227-0141, Katherine Egan Bennett, 703-227-0156, both of the American Society for Therapeutic Radiology and Oncology

WASHINGTON, Oct. 20 -- Is surgery required in the treatment of stage IIIA non-small cell lung cancer? Clinicians have posed this question for some time, and most have presumed that surgery clearly will improve survival and benefit patients. Many think that chemotherapy before surgery will be as effective and that the addition of thoracic radiotherapy will only exacerbate toxicity. However, according to a study presented on October 20, 2003, at the American Society for Therapeutic Radiology and Oncology's 45th Annual Meeting in Salt Lake City, more up-to-date chemotherapy and better defined thoracic radiotherapy targeting may improve chemoradiotherapy results and even reduce surgical morbidity and mortality if surgery is used.

This study sought to further define best treatment for IIIA, N2 positive non-small cell lung cancer. Small phase III trial results have been reported from single institutions that have supported the use of chemotherapy followed by surgery. Increasingly, concurrent chemoradiotherapy has shown substantial 2- and 3-year survival. This study was designed to isolate the value of surgery and to measure the progression free, median and overall survival, as well as patterns of failure in two groups.

There were 392 eligible patients for this 92 month study, divided into two randomized groups - 201 used chemoradiotherapy to 45 Gy followed by surgery, and 191 used chemoradiotherapy to 61 Gy with no surgery.

All patients were randomized to surgery or no surgery at entry and received cisplatin days 1 and 8 and etoposide for two, three-week cycles, concurrent with 45 Gy thoracic radiotherapy. Patients randomized to surgery were operated on four to six weeks later while patients randomized to no surgery continued without break off cord to 61 Gy. The thoracic radiotherapy target volume mandated initial sites of the disease and subcarinal nodes in all fields. All patients were to receive two additional cycles of cisplatin and etoposide after the initial therapy.

Some of the conclusions drawn from this trial were that although surgery does reduce the progression, it is associated with more non-cancer deaths. Despite better compliance with the chemotherapy protocol, the no surgery group had more cancer deaths, and local failure was a component of failure in 15 percent of the surgery group and 28 percent of the no surgery group. Despite significantly improved progression free survival, surgery does not improve overall median survival; however, patients with pathological complete response in N-2 nodal stations at time of surgery seem to survive better.

"Both treatment arms performed well, with an over 30 percent 3-year survival in each arm, despite the older cisplatin etoposide chemotherapy," said Andrew Turrisi, M.D., Chair of the Department of Radiation Oncology at Wayne State University in Detroit and lead author of the study. " We are pleased with the outcome of this study and think that longer follow-up may demonstrate significant survival for the surgical group, but we have not proven that with this early analysis."

If you would like a copy of the abstract entitled, "Randomized Trial of Chemoradiotherapy to 61 Gy (No S) vs. Chemoradiotherapy to 45 Gy Followed by Surgery (S) Using Cosplatin Etoposide in Stage IIIa non-small Cell Lung Cancer (NSCLC): Intergroup Trial 0139, RTOG (9309)," or you would like to speak to the lead author of the study, Andrew Turrisi, M.D., please call Beth Bukata after October 18 in the ASTRO Press Room at the Salt Palace Convention Center at 801-534-4743 or e-mail her at bethb@astro.org.

The American Society for Therapeutic Radiology and Oncology is the largest radiation oncology society in the world, with more than 7,000 members who specialize in treating patients with radiation therapies. As a leading organization in radiation oncology, biology and physics, the Society's mission is to advance the practice of radiation oncology by promoting excellence in patient care, providing opportunities for educational and professional development, promoting research and disseminating research results and representing radiation oncology in a rapidly evolving socioeconomic healthcare environment.