0
Communications to the Editor |

Stage IA Non-small Cell Lung Cancer A Small Proportion of Cases in the General Population FREE TO VIEW

Emanuele Crocetti, MD; Eugenio Paci, MD
Author and Funding Information

Affiliations: CSPO–AO Careggi Florence, Italy,  *Duke University Medical Center Durham, NC

Correspondence to: Emanuele Crocetti, MD, U.O. Epidemiologia Clinica e Descrittiva, CSPO–AO Careggi, Via di San Salvi 12, 50135 Florence, Italy; e-mail: epid2@user.ats.it



Chest. 2001;119(1):313-315. doi:10.1378/chest.119.1.313
Text Size: A A A
Published online

To the Editor:

A recent article by Patz and colleagues (June 2000)1 evidenced no correlation between decrease in tumor dimension and improvement in survival among patients with stage IA non-small cell lung cancer (NSCLC). The authors used this result to caution against the use of low-dose spiral CT as an effective tool for early diagnosis of lung cancer.

Lung cancer represents one of the most frequently diagnosed cancers, with a rather poor prognosis, and which accounts for most of all cancer deaths. Stage IA non-small cell lung cancer is, unfortunately, only a small proportion of the total case series.

The Tuscany Cancer Registry (RTT) has been active in the provinces of Florence and Prato in central Italy (about 1,200,000 inhabitants) since 1985.2In 1995 and 1996, lung cancer ranked first in this area among the most frequently diagnosed cancers in men, with a standardized (World Standard Population) incidence rate of 56 cases for every 100,000 inhabitants; it was seventh among women, 10.4 cases per 100,000. The corresponding incident rates for white men and women in the National Cancer Institute’s Surveillance, Epidemiology, and End Results program were 55.4 and 35.2, from 1993 to 1997. Lung cancer was also the first cancer cause of death among men (48.3 deaths per 100,000) and the fourth among women (7.1 deaths per 100,000). In the United States, the corresponding rates were 51.5 and 27.0, per 100,000 inhabitants, from 1993 to 1997 for men and women.3 We went through the RTT archive and retrieved all case reports of the 4,212 lung cancer cases diagnosed during the period from 1992 to 1996. Among these, 62% had a pathology verification and 21% were surgically treated. According to the registry stage classification, it is possible to define the diffusion of the disease for about 37% of the whole case series; 16% of cases were localized, 35% showed regional diffusion, and 49% of cases were metastasized at the time of diagnosis. The extent of disease in the Surveillance, Epidemiology, and End Results databases for the period of 1989 to 1996 was similar, with 15% localized cases, 23% regionally diffused, and 47% with distant diffusion; however, the percentage of non-staged cases was only 15% in the United States, vs 63% in the RTT area.3

Table 1 shows the distribution by pathologic T and N for non-small cell lung cancer4 cases (about 86% of the pathologically verified series) diagnosed in the RTT area during the years 1992 through 1996. Stage IA represented, at least in the RTT area and in the period considered, less than one tenth of those patients who underwent surgical intervention and about 29% (63 of 218) of those with the best prognosis (T1–2N0). Overall, at the time the diagnosis for lung cancer was made, the extent of the disease was very advanced in the population analyzed, with a relevant percentage of cases with metastases at diagnosis, and a high percentage of advanced stages among those who had undergone surgery, eg, 33.5% N2 or plus, 14% pathologic T3 and plus.

A second important issue, already addressed in the accompanying editorial by Black,5 is the statistical power of the Patz’s series, which is not sufficient to exclude a survival difference within stage IA. Nevertheless, in our opinion, the main concern is the small proportion of cases in the general population classified as IA. The impact of screening depends on the stage shift to operable diseases and smaller tumors in the population. About 50% of lung cancer cases are still diagnosed with distant metastases, both in central Italy and in the United States. The challenge of the new screening tool is its capacity for anticipating the majority of lung cancer cases and for evaluating, through a randomized clinical trial, the impact on mortality rates.

Table Graphic Jump Location
Table 1. Distribution (No. and Marginal Percentages) of Pathologic T and N for NSCLC Diagnosed During the Years 1992 Through 1996 in the Tuscany Cancer Registry Area*
* 

pT = pathologic tumor size; pN = pathologic nodal status according to Sobin and Wittekind.4

References

Patz, EF, Rossi, S, Harpole, DH, et al (2000) Correlation of tumor size and survival in patients with stage IA non-small cell lung cancer.Chest117,1568-1571. [CrossRef] [PubMed]
 
Parkin DM, Muir CS, Whelan SL, et al. Cancer incidence in five continents (vol VII). Lyon, France: IARC Scientific Publications, 1997; Publication No. 143.
 
Ries, LAG Eisner, MP Kosary, CLet al eds. SEER Cancer Statistics Review, 1973–1997.  Bethesda, MD: National Cancer Institute, 2000.
 
Sobin, LH Wittekind, CH eds.TNM classification of malignant tumors 5th ed. New York, NY: Wiley-Liss, 1997
 
Black, WC Unexpected observations on tumor size and survival in stage IA non-small cell lung cancer.Chest2000;117,1532-1534. [CrossRef] [PubMed]
 
To the Editor:

We too are very interested in seeing that the diagnosis of lung cancer is addressed in the best scientific fashion. Our article, correlating tumor size with survival in patients with stage IA non-small cell lung cancer, was intended to bring to light the fact that the biology of lung cancer and its natural course are perhaps not well understood. Other work that we have done and which is now being prepared for publication would further suggest that size alone is a poor predictor of ultimate death from lung cancer.

Despite the intuitive feeling that detecting smaller tumors is better, there now exist some experimental data suggesting that the metastatic potential of very small neoplasms exists and that the fate of a particular cancer may be decided before it is radiologically detectable. Nevertheless, we agree with Dr. Crocetti that screening tests should undergo thorough randomized clinical trials to evaluate their impact on mortality. Furthermore, we believe that this should be done before these tests become the standard of care. If appropriate scientific steps and reasoning are overlooked and if subsequent evaluation of otherwise untested diagnostic tools reveals no benefit, we would have used valuable resources and diverted attention and funding from perhaps more promising directions.


Figures

Tables

Table Graphic Jump Location
Table 1. Distribution (No. and Marginal Percentages) of Pathologic T and N for NSCLC Diagnosed During the Years 1992 Through 1996 in the Tuscany Cancer Registry Area*
* 

pT = pathologic tumor size; pN = pathologic nodal status according to Sobin and Wittekind.4

References

Patz, EF, Rossi, S, Harpole, DH, et al (2000) Correlation of tumor size and survival in patients with stage IA non-small cell lung cancer.Chest117,1568-1571. [CrossRef] [PubMed]
 
Parkin DM, Muir CS, Whelan SL, et al. Cancer incidence in five continents (vol VII). Lyon, France: IARC Scientific Publications, 1997; Publication No. 143.
 
Ries, LAG Eisner, MP Kosary, CLet al eds. SEER Cancer Statistics Review, 1973–1997.  Bethesda, MD: National Cancer Institute, 2000.
 
Sobin, LH Wittekind, CH eds.TNM classification of malignant tumors 5th ed. New York, NY: Wiley-Liss, 1997
 
Black, WC Unexpected observations on tumor size and survival in stage IA non-small cell lung cancer.Chest2000;117,1532-1534. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543