0
Correspondence |

ResponseResponse FREE TO VIEW

Jessica S. Donington, MD
Author and Funding Information

From NYU School of Medicine.

Correspondence to: Jessica S. Donington, MD, NYU School of Medicine, 530 First Ave, Ste 9V, New York NY 10016; e-mail: Jessica.Donington@nyumc.org


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(5):1518-1519. doi:10.1378/chest.13-0346
Text Size: A A A
Published online
To the Editor:

I read with interest the comments of Dr Reich and colleagues regarding our recent consensus statement1 and the counterproductivity of treatment of high-risk patients with stage I non-small cell lung cancer (NSCLC). Their opinion arises from the belief that early-stage NSCLC is a nonfatal disease, the biology of which can be predicted through mathematical models of tumor doubling time. This is a common theme throughout their letters and comments. Because even small NSCLCs have a proclivity for metastasis, and most patients succumb to metastatic disease rather than primary tumors, the relevance of doubling-time models to discussions of the treatment of high-risk patients is unclear.

There are fewer reports on the clinical course of untreated early-stage NSCLC than for other NSCLC populations and significant ethical difficulty in randomizing between treatment and no treatment even among those at high risk, but there is sufficient evidence to define the survival in this group as dismal. In addition to the cited work, three institutional series2-4 and a population-based review from the California Cancer Registry5 report on the natural history of untreated early-stage NSCLC. Although retrospective reviews are imperfect, and the subject difficult because of the multifaceted reasons for which patients forgo treatment, three salient points are clearly conveyed across all the series: (1) comorbid pulmonary disease is the primary reason for nontreatment, (2) 5-year overall survival in the untreated is <10%, and (3) at least one-half of the deaths are attributed to NSCLC. The California Cancer Registry review identified adenocarcinoma in situ as a common histology among the small number of untreated survivors at 5 years, outlining an indolent tumor type that may have an altered risk-benefit ratio related to treatment. The high-risk population is diverse, and for some, but not all, competing comorbidity is a valid reason to abstain from treatment, especially if not amenable to less invasive modalities.

Novel cancer treatments are typically introduced in patients with the fewest options. For chemotherapeutics, it is those who have progressed after standard therapy, and for local therapies, it is those who cannot tolerate lobectomy. The prospective American College of Surgeons Oncology Group (ACOSOG) and Radiation Therapy Oncology Group (RTOG) trials demonstrate that in well-selected high-risk patients, novel therapies can be delivered safely, with curative intent and minimal impact on pulmonary function. No one advocates treatment in this population without careful clinical judgment, but the treatments reviewed in our manuscript1 provide new hope for a population that once had very little.

References

Donington J, Ferguson M, Mazzone P, et al; Thoracic Oncology Network of American College of Chest Physicians; for the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. Chest. 2012;142(6):1620-1635. [CrossRef] [PubMed]
 
Chadha AS, Ganti AK, Sohi JS, Sahmoun AE, Mehdi SA. Survival in untreated early stage non-small cell lung cancer. Anticancer Res. 2005;25(5):3517-3520. [PubMed]
 
Kyasa MJ, Jazieh AR. Characteristics and outcomes of patients with unresected early-stage non-small cell lung cancer. South Med J. 2002;95(10):1149-1152. [PubMed]
 
McGarry RC, Song G, des Rosiers P, Timmerman R. Observation-only management of early stage, medically inoperable lung cancer: poor outcome. Chest. 2002;121(4):1155-1158. [CrossRef] [PubMed]
 
Raz DJ, Zell JA, Ou SH, Gandara DR, Anton-Culver H, Jablons DM. Natural history of stage I non-small cell lung cancer: implications for early detection. Chest. 2007;132(1):193-199. [CrossRef] [PubMed]
 

Figures

Tables

References

Donington J, Ferguson M, Mazzone P, et al; Thoracic Oncology Network of American College of Chest Physicians; for the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. Chest. 2012;142(6):1620-1635. [CrossRef] [PubMed]
 
Chadha AS, Ganti AK, Sohi JS, Sahmoun AE, Mehdi SA. Survival in untreated early stage non-small cell lung cancer. Anticancer Res. 2005;25(5):3517-3520. [PubMed]
 
Kyasa MJ, Jazieh AR. Characteristics and outcomes of patients with unresected early-stage non-small cell lung cancer. South Med J. 2002;95(10):1149-1152. [PubMed]
 
McGarry RC, Song G, des Rosiers P, Timmerman R. Observation-only management of early stage, medically inoperable lung cancer: poor outcome. Chest. 2002;121(4):1155-1158. [CrossRef] [PubMed]
 
Raz DJ, Zell JA, Ou SH, Gandara DR, Anton-Culver H, Jablons DM. Natural history of stage I non-small cell lung cancer: implications for early detection. Chest. 2007;132(1):193-199. [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