Chemotherapy for lung cancer
Authors: Rose J Papac
Journal: The Lancet (1997)

In his July 19 commentary on the CHART trial Everett Vokes1Vokes EE CHART for non-small-cell lung cancer—promises and limitations.Lancet. 1997; 350: 156-157Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar suggests that induction chemotherapy for stage III non-small-cell lung cancer has been validated by two important randomised trials and a meta-analysis, and is currently standard therapy. One of the randomised trials cited showed an increased 5-year survival rate of 7% versus 17%;2Dillman RO Herndon J Seagren SL Eaton WL Green MR Improved survival in stage III non-small-cell lung cancer: seven-year follow-up of Cancer and Leukemia Group-B (CALGB) trial.J Natl Cancer Inst. 1996; 88: 1210-1215Crossref PubMed Scopus (886) Google Scholar the actual numbers of patients alive at 5 years were four in the radiotherapy arm and 12 in the combined treatment arm, which may be regarded as too few patients on which to base definitive conclusions. Interestingly, the disease-free survival at 5 years was identical—ie, four patients in each category—and was subsequently better in the radiotherapy arm, but there were fewer than four patients in each arm. Moreover, the response rate, though higher in the combined treatment arm, was not significantly different in the two arms of the study (p<0·092). So if there were a survival advantage with induction chemotherapy it must be unrelated to antitumour treatment. A reasonable interpretation is that the differences in outcome probably reflect biological differences in the disease or in the supportive measures used. The second randomised trial cited was larger and included some stage II cases. It also emphasised the importance of careful preselection criteria for these treatments.3Sause WT Scott C Taylor S et al.Radiation Therapy Oncology Group (RTOG) 88–08 and Eastern Cooperative Oncology Group (ECOG) 4588: preliminary results of a phase III trial in regionally advanced, unresectable non-small-cell lung cancer.J Natl Cancer Inst. 1995; 87: 198-205Crossref PubMed Scopus (683) Google Scholar Although a survival difference was detected, it was 2·4 months rather than 4·1 months, as reported by Dillman and colleagues.2Dillman RO Herndon J Seagren SL Eaton WL Green MR Improved survival in stage III non-small-cell lung cancer: seven-year follow-up of Cancer and Leukemia Group-B (CALGB) trial.J Natl Cancer Inst. 1996; 88: 1210-1215Crossref PubMed Scopus (886) Google Scholar In fact the difference in median survival between the hyperfractionated radiation therapy and combined treatment groups was only 1·5 months. In a 3-year follow-up of the second study,3Sause WT Scott C Taylor S et al.Radiation Therapy Oncology Group (RTOG) 88–08 and Eastern Cooperative Oncology Group (ECOG) 4588: preliminary results of a phase III trial in regionally advanced, unresectable non-small-cell lung cancer.J Natl Cancer Inst. 1995; 87: 198-205Crossref PubMed Scopus (683) Google Scholar the differences between the groups decreased slightly and the survival difference between hyperfrationated radiation therapy and combined therapy was 1%.4Sause WT Scott C Taylor S Johnson D et al.RTOG 8808 ECOG 4588, preliminary analysis of a phase III trial in regionally advanced unresectable non-small-cell lung cancer with minimum three year follow-up. Proceedings of the 37th Annual ASTRO meeting.Int J Radiat Oncol Biol Phys. 1995; 32: 95Google Scholar The meta-analysis suggests a benefit for chemotherapy of early-stage surgical patients but no demonstrable advantage for stage III surgical patients.5Non-small Cell Lung Cancer Collaborative GroupChemotherapy in non-small-cell lung cancer: a meta-analysis using updated data on individual patients from 52 randomised clinical trials.BMJ. 1995; 311: 899-909Crossref PubMed Scopus (562) Google Scholar For surgery and radiotherapy in stage III cases an advantage was present. In all instances of benefit the effect was modest. We do not regard induction chemotherapy as the standard treatment for non-small-cell lung cancer stage III, but as an option to be considered for carefully selected patients and those included in clinical trials.