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Eur J Cardiothorac Surg 2004;25:297
© 2004 Elsevier Science NL
Letter to the Editor |
Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, D-81675 Munich, Germany
Received 25 August 2003; accepted 12 November 2003.
* Corresponding author. Tel.: +49-89-4140-4512; fax: +49-89-4140-4882
e-mail: bjeremic{at}lrz.tu-muenchen.de
Key Words: Early stage • Non small-cell lung cancer • Radiation therapy • Comorbidity
We read with interest the article by Ambrogi et al. [1] about the management of 247 patients with early stage (I and II) non-small-cell lung cancer (NSCLC), of whom 34 had cardiovascular comorbidity. In their article, Ambrogi et al. [1] clearly showed detrimental effect of cardiovascular comorbidity in terms of survival (5-year, 35.5%), with the multifocal vascular disease being the only factor independently and negatively influencing survival. In these patients, overall postoperative mortality was 9%, while morbidity was observed in 58.8%, negatively influencing quality of life. As observed earlier, up to 30% of early stage NSCLC patients can die of other diseases [2].
While surgery is the treatment of choice for fit patients with early stage NSCLC, there is a subgroup of patients with early stage NSCLC and coexisting morbidity which either never undergo surgery for the initial early NSCLC due to severe comorbidity (mostly cardiopulmonary), age, or refusal or are operated with the results such as those presented by Ambrogi et al. [1], including higher mortality and morbidity rate than that observed in their healthy counterparts. Contrary to that, in those never undergoing surgery, radiation therapy (RT) has been traditionally considered as the treatment of choice over the years. RT alone was capable of producing the median survival time of up to >30 months [3,4] (>40 months in T1N0) since the mid-1980s, with 5-year survival rates of up to 30% in stage I NSCLC [3] (40% in T1N0) [5] and up to 25% in stage II NSCLC [4]. Furthermore, patients undergoing RT initially present with more unfavourable characteristics and comorbidity (not just cardiovascular, but pulmonary and others as well, all being one of the major reasons for not undergoing surgery) than those presenting with severe comorbidity but still undergoing surgery. Also, RT patients are usually less precisely staged (i.e. understaged) (clinical in RT versus pathological in surgical series). Taken together, these facts additionally highlight RT results and strengthen the position of radical RT in the treatment of this disease.
We firmly believe the final decision about the most appropriate treatment for all patients with early stage NSCLC and existing comorbidity (regardless of its extent!) must be made in a comprehensive physician–patient setting, with radiation oncologist being an indispensable member of such setting. In particular, discussing all options with patients who, by virtue of their comorbidity, may experience high operative mortality and morbidity, is necessary, because radical RT as an alternative treatment option has been successfully applied over the years with results at least equivalent to those of surgery in these cases [3–5], and offered much less toxicity and, therefore, better quality of life.
Footnotes
The authors of the original paper [1] were invited to comment on this Letter to the Editor but declined the offer.
References
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