Induction chemotherapy employing dose-intense cisplatin with mitomycin and vinblastine (MVP400), followed by thoracic surgery or irradiation, for patients with stage III nonsmall cell lung carcinoma

Inductive and adjuvant treatment strategies for localized nonsmall cell lung cancer in operable and inoperable patients

For many years, surgery has been considered the best treatment modality for resectable nonsmall cell lung cancer. However, survival has not increased over the last few decades. The reported 5-year survival rates for the early stages (stage I and II) show failures of 35 to 65%. Therefore, a combined modality approach has been taken in patients with N2 (lymph node) disease to improve results. These adjuvant treatments, consisting of chemotherapy, radiotherapy, or both, have yielded mixed responses. Adjuvant radiation therapy alone has shown a decrease in local recurrence but no significant improvement in survival. Randomized trials of adjuvant chemotherapy have shown mixed results, and large, randomized trials are currently being evaluated. Combinations of radiation and chemotherapy in the adjuvant setting have failed to show a survival benefit so far. In the neoadjuvant setting, chemotherapy has aroused great attention because it has significantly improved survival in patients with locally advanced nonsmall cell lung cancer (N2 disease). This result led to the use of neoadjuvant chemotherapy in early-stage lung cancer. Multinational and multi-institutional studies have been initiated recently. In the future, researchers will have clear insight into the effects of the classical chemotherapy regimen as induction therapy in the early stages of nonsmall cell lung cancer. Tyrosine kinase inhibitors, antisense therapies, and antiangiogenesis therapies are the most promising developments of the last few years. Implementation of these agents is expected to have great impact on the survival in patients with nonsmall cell lung cancer.

The role of chemotherapy in early non-small-cell lung cancer management

Great advances have been made in chemotherapy in advanced and metastatic non-small-cell lung cancer (NSCLC), and a major milestone was reached with the administration of neoadjuvant chemotherapy in stage IIIA N2 disease. The systemic nature of lung cancer has been confirmed by many genetic analyses documenting micrometastases in negative lymph nodes and bone marrow, and mRNA gene overexpression as a surrogate of cancer cells has been identified in peripheral blood. Furthermore, serum or plasma cell-free tumor DNA has been observed even in tumors with a diameter of less than 2 cm. Pharmacogenetic screening can lead to tailored chemotherapy even in patients with early disease through the use of a genetic tool kit that will allow us to optimize the use of chemotherapy by using serial measurements of serum DNA that can help to detect residual disease and re-assess the chemosensitivity of sub-clinical micrometastatic disease. The ongoing (neo)adjuvant taxol/carboplatin hope (NATCH) trial is testing the value of three cycles of chemotherapy given pre- or post-operatively compared with surgery alone and will analyze genetic abnormalities in serum DNA at three different points during patient follow-up. Our major concern in this review is to analyze the pros and cons of chemotherapy in NSCLC. Although this review is not a formal meta-analysis, we have discussed the most relevant published studies in this field. We conclude that not only is there no evidence of detrimental effects of chemotherapy, in fact, there are many indications that chemotherapy induces response in up to 80% of patients and downgrades N2 disease in up to 50% of patients. This translates into significantly better survival when accompanied by complete resection. Since at least 50% of patients with stage IB disease develop distant metastases, it seems logical to explore the role of chemotherapy in early disease.

Mitomycin C: a clinical update

Mitomycin C was reviewed in this journal 25 years ago and an update of its clinical usefulness is appropriate. The current review is based on representative publications covering clinical trials performed throughout the world. Single agent activity in each of the major neoplastic diseases has been reassessed when possible and the most important combinations evaluated. It is concluded that mitomycin C has a definite place in the treatment of localized bladder cancer, is active, but needs to be redefined, in the context of newer regimens for breast, head and neck, and non-small cell lung cancers, is active in, but is being displaced by, other drugs in cervical, gastric and pancreatic cancers, and is probably no longer of therapeutic value in colon cancer. It is also recognized that as many newer treatments have clinical success, the therapeutic role of mitomycin C will require continuing re-investigation.

Communication in advanced disease

Communication between physician, patient, and family becomes intense and fraught with problems in the setting of advanced disease. Protocols for end-of-life communication have been developed by various authors, but they have focused primarily on delivery of "bad news" in an individual encounter. This article addresses the need for ongoing conversation throughout the progression from life-prolonging treatment to hospice care. A case study illustrates the utility of this approach.

Staging and the surgical management of lung cancer

Small cell lung cancer remains a nonsurgical disease with the majority (80%) of cases presenting in higher stages. The primary treatment modalities for small cell lung cancer are radiation therapy and systemic chemotherapy, often administered concomitantly. This article focuses on the staging and surgical management of non-small-cell lung cancer.