Second primary tumors following adjuvant therapy of resected stages II and IIIa non-small cell lung cancer

Disease Recurrence and Second Tumors in Long-term Survivors of Lung Cancer

INTRODUCTION AND OBJECTIVES

As cancer survival improves, the appearance of multiple tumors in a single patient is becoming more common. The aim of this study was to analyze long-term evolution, focusing particularly on disease recurrence and second primary tumors, in patients with lung cancer (LC) and ≥ 3 years overall survival.

MATERIAL AND METHODS

Retrospective study of 1,769 patients with LC. A total of 218 (136 treated with surgery and 82 with other treatments), followed up for between 5 and 23 years were enrolled. LC progress and intercurrent diseases were recorded.

RESULTS

A total of 65 patients presented tumor relapse, of which 60.9% occurred in the first 3 years; 26 patients developed secondary primary tumors (84.6% after 5 years) and 24 developed 2 or more second extrapulmonary tumors (66.6% after 5 years), most of which were smoking-related. The incidence of second primaries was greater than the expected incidence of cancer in the general population matched for age and sex.

CONCLUSION

The multiple carcinogenic effect of smoking persists and manifests in various organs, more than 5 years after the diagnosis of LC, even in patients with long survival. After 5 years, a second tumor is more likely than a relapse of the primary disease, and the lung is the most common site of development of a second tumor.

Randomized phase III trial of vinorelbine plus cisplatin compared with observation in completely resected stage IB and II non-small-cell lung cancer: updated survival analysis of JBR-10

PURPOSE Adjuvant cisplatin-based chemotherapy (ACT) is now an accepted standard for completely resected stage II and III A non-small-cell lung cancer (NSCLC). Long-term follow-up is important to document persistent benefit and late toxicity. We report here updated overall survival (OS) and disease-specific survival (DSS) data. PATIENTS AND METHODS Patients with completely resected stage IB (T2N0, n = 219) or II (T1-2N1, n = 263) NSCLC were randomly assigned to receive 4 cycles of vinorelbine/cisplatin or observation. All efficacy analyses were performed on an intention-to-treat basis. Results Median follow-up was 9.3 years (range, 5.8 to 13.8; 33 lost to follow-up); there were 271 deaths in 482 randomly assigned patients. ACT continues to show a benefit (hazard ratio [HR], 0.78; 95% CI, 0.61 to 0.99; P = .04). There was a trend for interaction with disease stage (P = .09; HR for stage II, 0.68; 95% CI, 0.5 to 0.92; P = .01; stage IB, HR, 1.03; 95% CI, 0.7 to 1.52; P = .87). ACT resulted in significantly prolonged DSS (HR, 0.73; 95% CI, 0.55 to 0.97; P = .03). Observation was associated with significantly higher risk of death from lung cancer (P = .02), with no difference in rates of death from other causes or second primary malignancies between the arms. CONCLUSION Prolonged follow-up of patients from the JBR.10 trial continues to show a benefit in survival for adjuvant chemotherapy. This benefit appears to be confined to N1 patients. There was no increase in death from other causes in the chemotherapy arm.

Second primary tumors following tobacco dependence treatments among head and neck cancer patients

OBJECTIVES

To estimate the cumulative percentage of second primary tumors (SPTs) in head and neck (H&N) cancer patients and primary cancers in general Nicotine Dependence Center (NDC) population controls following tobacco dependence consultation seen between 1988 and 2001.

METHODS

A 1:1 matched pair design and a stratified Cox proportional hazard model were used. General NDC population controls were matched on age, gender, and NDC consult (type and date) to the H&N cancer patients. The study population included 101 H&N cancer patients (66 male, 35 female) with mean (SD) age of 58.7 (10.1) years.

RESULTS

Baseline demographics and length of follow-up were similar between groups. However, H&N cancer patients smoked more cigarettes per day than controls (P < 0.003). For H&N cancer patients, the median time from initial H&N cancer diagnosis to NDC consult was 7 months (range, 0-292 months). Following the NDC consult, 27 H&N cancer patients developed 32 SPTs; whereas among the controls, 12 patients developed 12 other cancers (P = 0.013). There was no difference in the development of non-tobacco-related cancers (P = 0.273). However, H&N cancer patients were more likely to develop tobacco-related cancers (P = 0.01). Furthermore, there was a trend where the H&N cancer patients who continued to use tobacco were more likely to develop tobacco-related cancers than those who remained abstinent (P = 0.10).

CONCLUSIONS

These findings confirm that H&N cancer patients are more prone to the development of tobacco-related cancers. Further, these findings suggest that H&N cancer patients who stop using tobacco are able to decrease the development of tobacco-related SPTs.

Second cancers discovered by 18FDG PET/CT imaging for choroidal melanoma

BACKGROUND

Positron-emission tomography/computed tomography (PET/CT) is a unique imaging tool that aids in the detection of cancerous lesions. It is currently and widely used for cancer staging (both initial and follow-up). Here we report our findings of second primary cancers incidentally discovered during PET/CT staging of patients with choroidal melanomas.

METHODS

We performed a retrospective case review of 139 patients with uveal melanoma who were subsequently evaluated by whole-body [18-fluorine-labeled] 2-deoxy-2-fluoro-D-glucose ((18)FDG) PET/CT imaging. In this series, 93 were scanned before treatment and 46 during the course of their follow-up systemic examinations. Their mean follow-up was 50.9 months.

RESULTS

Six patients (4.3%) had second primary cancers revealed by PET/CT imaging. Three patients (50%) were synchronous (found at initial staging), and the remaining 3 patients (50%) were metachronous (found at follow-up staging). Second primary cancers were found in the lung, breast, uterus, colon, and thyroid.

CONCLUSIONS

Although whole-body PET/CT scans were ordered as part of the staging process of patients with diagnosed choroidal melanoma, both synchronous and metachronous second primary cancers were found. PET/CT has become an indispensable tool for staging, diagnosis, and treatment planning for choroidal melanoma. The possibility of detecting second primary cancers should also be considered valuable.

Long-term survivorship in lung cancer: a review

While outcome research in lung cancer has focused mainly on short-term survival and quality of life (QoL), information on long-term (ie, > 5 years postdiagnosis) lung cancer survivorship remains limited. This review addresses the epidemiologic significance of long-term lung cancer (LTLC) survivors, summarizes the current knowledge on their health and QoL, and suggests areas for further research in LTLC survivorship. Based on a small body of literature, lung cancer survivors do not experience the same quantity and QoL as their age-matched peers or as survivors of other cancers. Survival among 5-year survivors of lung cancer relative to the general US population with the same demographic characteristics is approximately 60%, and lung cancer survivors score lowest in health utility among long-term survivors of other cancers. Approximately one-quarter of long-term lung cancer (LTLC) survivors were significantly restricted in physical ability or reported significant depressive symptoms. There is a need to identify and intervene with subgroups of survivors who are at an elevated risk of premature death and diminished QoL. Lung cancer-specific survival alone does not reflect the overall illness burden in LTLC survivors. Patient care in lung cancer survivors should be continuous and comprehensive in considering multiple causes of health deterioration. Multidisciplinary research in epidemiologic, clinical, and basic science approaches is warranted to further our knowledge base for optimal long-term management and to develop the necessary intervention strategies among LTLC survivors.

Testing treatment effects in the presence of competing risks

Competing risks are often encountered in clinical research. In the presence of multiple failure types, the time to the first failure of any type is typically used as an overall measure of the clinical impact for the patients. On the other hand, use of endpoints based on the type of failure directly related to the treatment mechanism of action allows one to focus on the aspect of the disease targeted by treatment. We review the methodology commonly used for testing failure specific treatment effects. Simulation results demonstrate that the cause-specific log-rank test is robust (in the sense of preserving the nominal level of the test) and has good power properties for testing for differences in the marginal latent failure-time distributions, whereas the use of a popular cumulative incidence based approach may be problematic for this aim.

Postoperative Radiation Therapy for Patients Who Have Resected Non–Small Cell Lung Cancer

The role of adjuvant postoperative therapy for patients who have resected non-small cell lung cancer (NSCLC) has been controversial. Recent large trials and meta-analysis support a modest, but significant, survival benefit for postoperative adjuvant chemotherapy. Postoperative radiation therapy has little potential benefit in patients who have N(0) or N(1) disease and should not be used routinely in these patients. There are suggestions of benefit for patients who have N(2) disease, but adequately powered trials have not been conducted to demonstrate a possible small, but clinically worthwhile, survival benefit in this subgroup. Central nervous system relapse has emerged as an increasing problem for patients who have NSCLC; trials of prophylactic cranial irradiation are underway in several cooperative trial groups.

Resected non-small-cell lung cancer stage I/II: indication for adjuvant/ neoad j uvant therapy?

Complete surgical resection remains the current standard of care for operable patients with stage-I or stage-II non-small-cell lung cancer. However, there is a strong rationale that supports the concept of the addition of systemic therapy to surgery either preoperatively or postoperatively even in patients with early-stage disease, as distant relapse continues to be the dominant form of relapse after surgical resection of NSCLC. Earlier trials of adjuvant therapy have yielded mixed results and the survival gains demonstrated have been modest at best. However, recently presented data of randomised phase-III trials showed an absolute survival benefit of 12-15% for patients with completely resected stage-IB and stage-II NSCLC receiving adjuvant platinum-based chemotherapy compared with observation alone. These trials provide resounding approval for adjuvant chemotherapy being the new standard of care for patients with early-stage non-small-cell lung cancer who have undergone complete resection of the tumour.