Double whammy of chemo plus surgery extends life for lung cancer patients

Recent research which has shown that chemotherapy can significantly lengthen life in many patients with lung cancer, has meant that doctors, for the first time in decades, have begun making major changes in the treatment of the disease.

Chemotherapy had previously been thought to be worse than useless in these cases.

This change in thinking will apply to about 50,000 people a year in the United States who have early cases of the most common form of the disease, non-small-cell lung cancer. These tumors are removed by surgery and until just a few years ago would have been treated with surgery alone, but patients are now being given chemotherapy as well, just as it is routinely given after surgery for breast or colon cancer.

This new approach has considerably brightened a picture that was often quite bleak.

Dr. John Minna, a lung cancer expert and research director at the University of Texas Southwestern Medical Center in Dallas, says that the benefit is at least as good, and maybe better than in the other cancers, and new discoveries were helping to eliminate doctors' negative attitudes about chemotherapy for lung cancer.

Dr. Christopher G. Azzoli, a lung cancer specialist at Memorial Sloan-Kettering Cancer Center in New York, says that the standard of care has changed.

Two studies presented at a cancer conference a year ago showed marked increases in survival in patients who received adjuvant chemotherapy, meaning the drugs were given after surgery and this created the major impetus for the change in treatment.

One study of 482 patients in Canada and the United States, led by Dr. Timothy Winton, a surgeon from the University of Alberta, demonstrated that 69 percent of patients who had surgery and chemotherapy were still alive five years later, as compared to only 54 percent who had only surgery.

The patients were given a combination of two drugs, cisplatin and vinorelbine, once a week for 16 weeks.

A survival difference of 15 percentage points is enormous in the world of lung cancer research. Over all, the patients given chemotherapy lived 94 months, versus 73 months in those who had only surgery, a huge difference in a field in which a treatment is hailed as a success if it gives patients even three or four extra months.

A second study last year, had similar findings, as did a third, presented just a month ago at the annual meeting of the American Society of Clinical Oncology.

Doctors at major medical centers quickly put the results into practice.

Dr. Pasi Janne, a lung cancer specialist at the Dana Farber Cancer Institute in Boston, says the findings were "so stunning" from these studies that they changed the standard of care,and the number of patients they have had referred for adjuvant chemotherapy has steadily risen.

Dr. Winton says that some doctors are hesitant in making changes, and wait first to see the studies published in a medical journal, which would mean the data had stood up to the scrutiny of editors and expert reviewers.

Patients in the study did suffer from side effects, including lowered blood counts, fatigue, nausea, vomiting, nerve damage and constipation. Generally, the reactions were not severe, though two patients (0.8 percent) died from toxic effects - not an unexpected finding with the powerful drugs used to treat cancer.

Dr. Katherine M. S. Pisters, a lung cancer specialist at the M. D. Anderson Cancer Center in Houston, says that the Oncology Society and the American College of Chest Physicians were both rewriting their formal guidelines to say chemotherapy should be given after surgery for early-stage lung tumors like the ones in the studies.

She and Dr. Azzoli said that although medical oncologists, the cancer doctors who prescribe chemotherapy, knew about the lung-cancer findings, surgeons and internists may not have heard about or accepted them.

Worldwide, lung cancer is the most common cancer and the leading cause of cancer death, with more than a million new cases and a million deaths every year. In the United States, it is expected to kill 163,510 people this year - more than breast, prostate, colon cancer and leukemia combined.

Nearly all the cases are caused by smoking.

From 80 percent to 85 percent of lung cancers are the type that Dr. Winton studied, non-small-cell cancers. His findings apply to 25 percent to 30 percent of newly diagnosed cases, those that can be removed surgically and are at an early point in the disease classified as stage IB or stage II.

According to Dr. Pisters, with surgery alone, five-year survival ranges from 23 percent to 67 percent, depending on the size of the tumor and how much it has begun to spread.

For many years, patients with early tumors were advised to have surgery and no other treatment. Many relapsed and died.

Now new chemotherapy drugs, along with better medicines for side effects, like nausea and low blood counts have been developed.

Dr. Winton says because the two drugs fight cancer in different ways, it becomes a collective attack on two different components of cell division and growth.

The entire treatment costs $4,500 in Canadian dollars, $3,646 in the United States, he said.

Other drug combinations can also be used, Dr. Pisters said, as long as one is a platinum-based drug like cisplatin or carboplatin.

Dr. Winton began his study in 1994. It was paid for by the governments of Canada and the United States, and by GlaxoSmithKline, which makes vinorelbine.

Dr. Winton said the company did not write or edit the report on the study or control the data in any way.

The study is published this week in The New England Journal of Medicine, along with an editorial by Dr. Katherine M. S. Pisters, a lung cancer specialist at the M. D. Anderson Cancer Center in Houston.

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