|Reviewer: Ryan Smith, MD|
|The Abramson Cancer Center of the University of Pennsylvania|
Authors: A Depierre, B Millerson, D Moro-Sibilot, et al.
Early stage non-small cell lung cancer (NSCLC) is usually treated with surgical resection. Although early stage (NSCLC) is obviously more curable than more advanced stages, mortality continues to be quoted as approaching 50% or greater. A substantial number of patients will fail with distant metastatic disease. For these reasons, preoperative chemotherapy is investigated in this study to determine if it has an impact on increasing survival in patients with Stage I, II, and IIIa NSCLC.
This study reports on a randomized trial investigating the use of preoperative therapy in patients with earlier stage NSCLC. Although there was no significant survival advantage seen in the entire group, on subset analysis it was shown that patients with N0 or N1 disease did benefit from preoperative chemotherapy. Patients with N2 disease had no advantage to receiving preoperative chemotherapy. This conflicts with previously published papers that demonstrate the efficacy of preoperative chemotherapy in Stage IIIa (N2) patients. The reasoning given in this paper was that perhaps chemotherapy is not effective in bulkier N2 disease, though this was obviously not the case in the aforementioned papers. More likely is that this study staged patients preoperatively, which was demonstrated to be inaccurate, as only 56% of the patients judged to have N2 disease actually had N2 disease on pathologic examination. In addition, less than half of the patients underwent a full mediastinal dissection, further clouding the accuracy of their conclusions. Also, this study was not stratified or statistically powered to evaluate subset analyses. Therefore, the conclusions regarding patients in the N2 group as well as the positive finding in the N0 and N1 group is statistically flawed.
This report speaks to the feasibility of preoperative chemotherapy in early stage NSCLC and presents the conclusion that preoperative chemotherapy may indeed be beneficial in these patients. However, because of the reasons listed above, a definitive conclusion cannot be reached from this study alone.