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Correspondence |

Survival in Untreated Stage I Lung CancerUntreated Stage I Lung Cancer FREE TO VIEW

Jerome M. Reich, MD, FCCP; Jong S. Kim, PhD; James W. Asaph, MD
Author and Funding Information

From the Thoracic Oncology Program (Drs Reich and Asaph), Earle A. Chiles Research Institute; and Fariborz Maseeh Department of Mathematics and Statistics (Drs Reich and Kim), Portland State University.

Correspondence to: Jerome M. Reich, MD, FCCP, 7400 SW Barnes Rd, A242, Portland, OR 97225-7007; e-mail: Reichje@isp.com


Financial/nonfinancial disclosures: The authors have 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. doi:10.1378/chest.13-0087
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To the Editor:

The recommended management by Donington et al1 in a recent issue of CHEST (December 2012) of high-risk people with non-small cell, stage I lung cancer (SILC) is premised on a single report evaluating their survival absent intervention. Vrdoljak et al2 reported that 19 people with SILC (in a case series of 130-people with lung cancer declining all forms of intervention) experienced a 17-month median survival. This assessment of the natural history of untreated SILC is open to question:

  • 1. Vrdoljak et al2 confined their SILC analysis to stage IB because there were too few cases of untreated stage IA to permit a valid assessment of survival.

  • 2. They did not allocate deaths due to competing lethal morbidities (ie, overdiagnosed) vs those due to SILC.

  • 3. They did not state that all people declining intervention underwent surgical mediastinal exploration (ie, some may have been clinically staged [potentially understaged]).

  • 4. Vrdoljak et al2 explained the patients’ justification for declining intervention:

    • Many…had low sociocultural backgrounds with strong opinions about cancer as an incurable disease. Some patients refused therapy because they were afraid that it would drastically change the quality of their “remaining” years. Some patients simply did not accept the presence of lung cancer, denying the disease.

  • While these explanations are plausible, symptoms attributable to competing morbidities may have influenced the patients’ decision.

It is important to appreciate the dependency of growth rates on tumor size. Diameter is a function of the number of tumor volume doublings (TVDs). Tumor diameter in centimeters, D = cell diameter(cube root of 2)number of TVDs; D =0.001(1.26)x; log form: x =ln1,000D/ln1.26.3 For example, a 1-cm tumor (IA) has undergone 30 TVDs; a 5-cm tumor (IB), 37. With a IA TVD-time of (230 days), 1,610 days (54 months) would be required for a 1-cm tumor to grow to 5 cm.3 Assuming unchanging TVD-time, the growth rate ratios of diameter and volume are, respectively, D and D2 (eg, fivefold and 25-fold for a 5-cm vs a 1-cm tumor).3 The additional 4.4 years of growth required to achieve a 5-cm (stage B) size increases the likelihood of overdiagnosis (greater in high-risk patients) because of a lengthier exposure to smoking-related, lethal comorbidities. Resectional surgery diminishes life expectancy presumably by accelerating the course of competing, smoking-related, cardiopulmonary morbidities (J. M. Reich, MD, FCCP; J. S. Kim, PhD; J. W. Asaph, MD, unpublished data, 2013).

In conclusion, intervention in high-risk patients with slow-growing SILC is neither urgent nor compelling. Indeed, it may prove counterproductive.

References

Donington J, Ferguson M, Mazzone P, et al. 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]
 
Vrdoljak E, Mise K, Sapunar D, Rozga A, Marusić M. Survival analysis of untreated patients with non-small-cell lung cancer. Chest. 1994;106(6):1797-1800. [CrossRef] [PubMed]
 
Reich JM, Kim JS. Lung cancer growth dynamics. Eur J Radiol. 2011;80(3):e458-e461. [CrossRef] [PubMed]
 

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References

Donington J, Ferguson M, Mazzone P, et al. 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]
 
Vrdoljak E, Mise K, Sapunar D, Rozga A, Marusić M. Survival analysis of untreated patients with non-small-cell lung cancer. Chest. 1994;106(6):1797-1800. [CrossRef] [PubMed]
 
Reich JM, Kim JS. Lung cancer growth dynamics. Eur J Radiol. 2011;80(3):e458-e461. [CrossRef] [PubMed]
 
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