Long term survival of small cell lung cancer patients after chemotherapy

Cancer survivors in the United States: a review of the literature and a call to action

BACKGROUND

The number of cancer survivors in the U.S. has increased from 3 million in 1971, when the National Cancer Act was enacted, to over 12 million today. Over 70% of children affected by cancer survive more than 10 years, and most are cured. Most cancer survivors are adults, with two-thirds of them 65 years of age or older and two-thirds alive at five years. The most common cancer diagnoses among survivors include breast, prostate and colorectal cancers. This review was conducted to better appreciate the challenges associated with cancer survivors and the opportunities healthcare providers have in making a difference for these patients.

METHODS

Comprehensive review of literature based on PubMed searches on topics related to cancer survivorship, and associated physical, cognitive, socio-economic, sexual/behavioral and legal issues.

RESULTS

At least 50% of cancer survivors suffer from late treatment-related side effects, often including physical, psychosocial, cognitive and sexual abnormalities, as well as concerns regarding recurrence and/or the development of new malignancies. Many are chronic in nature and some are severe and even life-threatening. Survivors also face issues involving lack of appropriate health maintenance counseling, increased unemployment rate and workplace discrimination.

CONCLUSIONS

Advances in the diagnosis and treatment of cancer will lead to more survivors and better quality of life. However, tools to recognize potentially serious long-lasting side effects of cancer therapy earlier in order to treat and/or prevent them must be developed. It is incumbent upon our health care delivery systems to make meeting these patients' needs a priority.

Small-cell lung cancer

Small-cell lung carcinoma is an aggressive form of lung cancer that is strongly associated with cigarette smoking and has a tendency for early dissemination. Increasing evidence has implicated autocrine growth loops, proto-oncogenes, and tumour-suppressor genes in its development. At presentation, the vast majority of patients are symptomatic, and imaging typically reveals a hilar mass. Pathology, in most cases of samples obtained by bronchoscopic biopsy, should be undertaken by pathologists with pulmonary expertise, with the provision of additional tissue for immunohistochemical stains as needed. Staging should aim to identify any evidence of distant disease, by imaging of the chest, upper abdomen, head, and bones as appropriate. Limited-stage disease should be treated with etoposide and cisplatin and concurrent early chest irradiation. All patients who achieve complete remission should be considered for treatment with prophylactic cranial irradiation, owing to the high frequency of brain metastases in this disease. Extensive-stage disease should be managed by combination chemotherapy, with a regimen such as etoposide and cisplatin administered for four to six cycles. Thereafter, patients with progressive or recurrent disease should be treated with additional chemotherapy. For patients who survive long term, careful monitoring for development of a second primary tumour is necessary, with further investigation and treatment as appropriate.

Small cell lung cancer survival: 3 years as a minimum for predicting a favorable outcome

OBJECTIVES

To define the minimum survival time indicating a significantly reduced risk of recurrence of small cell lung cancer (SCLC) basing on the evaluation of survival of patients (pts) with SCLC who underwent anatomic staging and were exposed to combination chemotherapy (CT) (including combined modality treatment).

METHODS

Eight pts being our 'historic' group submitted to the NCI Registry for Long Term Survivors with SCLC (est. 1977) and a following 657 unselected pts diagnosed, staged, treated and undergoing life-long follow-up at a single institution between the years 1981 and 1996. For those among our pts who had no evidence of metastatic disease, but had not undergone thorough staging, we have arbitrarily created an intermediate group referred to as 'XD'.

RESULTS

Of the 657 pts 111 survived 2 years or more. Among these 111 there were 88 pts with LD at presentation, 11 with 'XD' and 12 with ED. Of the 111 pts surviving 2 years 51 (51/111) were re-treated for relapse before 24 months. From this group of 111 2 year-or-more survivors 45 (41%) died between 2 and 3 years. From year 3 onwards mortality decreased substantially-eight pts died in the 3-4 year interval and eight in the 4-5 interval-accounting for 14% of all the 2 year survivors. We did not observe any failure of the primary tumor beyond a period of 5 years-both in our 'historic' and the analyzed group. After 5 years development of a second primary tumor, mainly lung cancer, is one of the major causes of death in pts 'cured' of their primary tumor.

CONCLUSION

The shortest survival-time which allows predicting a significantly reduced risk of recurrence of SCLC is 3 years. The same landmark was achieved with the estimation of hazard function and allowed to find a remarkably decreased risk of death at the point of 3 years.

Management of small cell lung cancer

Small cell lung carcinoma typically presents as a central endobronchial lesion in chronic cigarette smokers with hilar enlargement and disseminated disease. The diagnostic pathology should be reviewed by a pathologist accomplished in reading pulmonary pathology, and, if any doubt exists in the diagnosis, additional special stains or diagnostic material should be obtained. Patients with extensive stage disease should be managed by combination chemotherapy, whereas patients with limited stage disease should be treated with etoposide/cisplatin plus concurrent chest irradiation. The chemotherapy should be administered for 4 to 6 months and then should be discontinued. Prophylactic cranial irradiation should be given to patients who achieve a complete remission. Patients should be retreated with chemotherapy if they develop a relapse of their small cell lung cancer. The patients who are followed in complete remission should be observed carefully for second cancers, and appropriate therapy should be administered if the cancer reappears.

Trends in incidence and prognosis of the histological subtypes of lung cancer in North America, Australia, New Zealand and Europe

BACKGROUND

Since the incidence of the histological subtypes of lung cancer in industrialised countries has changed dramatically over the last two decades, we reviewed trends in the incidence and prognosis in North America, Australia, New Zealand and Europe, according to period of diagnosis and birth cohort and summarized explanations for changes in mortality.

METHODS

Review of the literature based on a computerised search (Medline database 1966-2000).

RESULTS

Although the incidence of lung cancer has been decreasing since the 1970s/1980s among men in North America, Australia, New Zealand and north-western Europe, the age-adjusted rate continues to increase among women in these countries, and among both men and women in southern and eastern Europe. These trends followed changes in smoking behaviour. The proportion of adenocarcinoma has been increasing over time; the most likely explanation is the shift to low-tar filter cigarettes during the 1960s and 1970s. Despite improvement in both the diagnosis and treatment, the overall prognosis for patients with non-small-cell lung cancer hardly improved over time. In contrast, the introduction and improvement of chemotherapy since the 1970s gave rise to an improvement in - only short-term (<2 years) - survival for patients with small-cell lung cancer.

CONCLUSIONS

The epidemic of lung cancer is not over yet, especially in southern and eastern Europe. Except for short-term survival of small cell tumours, the prognosis for patients with lung cancer has not improved significantly.

Second lung cancers in patients after treatment for an initial lung cancer

BACKGROUND

Prospectively and retrospectively identified patient cohorts that were successfully treated for primary lung cancer have been followed to document the rate of development of and the effectiveness of treatment of second lung cancers. This review was performed to assess rates of second lung cancer development, factors associated with the development of these cancers, and the success of their treatment.

METHODS

The MEDLINE database was searched to identify articles published in English concerning lung cancers, second primary cancers, treatment of these cancers, and patient survival.

RESULTS

The risk of developing a second lung cancer in patients who survived resection of a non-small-cell lung cancer is approximately 1%-2% per patient per year. Approximately one half of the patients who develop second non-small-cell lung cancers can have these tumors resected. The median survival from diagnosis of a second lung cancer in these patients is between 1 and 2 years, with a 5-year survival of approximately 20% (range, 4%-32%). The average risk of developing a second lung cancer in patients who survived small-cell lung cancer is approximately 6% per patient per year. For patients who survived small-cell cancer, the risk increases from approximately 2% to greater than 10% per patient per year 10 years after initial treatment. Only 7% (range, 6%-12%) of patients treated for small-cell lung cancer survive 2 years or more. Survivors who continue to smoke cigarettes have an increased risk of developing a second lung cancer.

CONCLUSIONS

In patients surviving an initial lung cancer, the cumulative risk for the development of a second primary lung cancer makes this cancer a common cause of death. The high risk of developing a second lung cancer makes patients with these cancers an important population for study of surveillance strategies and chemoprevention agents.

Improvement and plateau in survival of small-cell lung cancer since 1975: a population-based study

BACKGROUND

Cytotoxic therapy appears to have improved short-term survival for patients with small-cell lung cancer, but little is known about the results for unselected patients and trends in long-term survival.

PATIENTS AND METHODS

One thousand seven hundred ninety-six patients with small-cell lung cancer diagnosed between 1975 and 1994 in southeastern Netherlands. We studied treatment policy for and survival of unselected patients since 1975, when cytotoxic therapy emerged.

RESULTS

The proportion patients receiving chemotherapy, with or without irradiation, almost tripled from 30% to 82% for patients younger than 70 years of age and from 15% to 56% for those over 70, whereas the proportion receiving only radiotherapy decreased from 36% to 5% in both age groups. The short-term (< 2 year) survival rate improved markedly between 1975 and 1989, especially for patients younger than 70 (median survival increased from five to 10 months). Two-year survival remained poor (8%). Two percent of all patients younger than 70 years at diagnosis survived for at least eight years, but these patients still represent an excess five-year mortality of 39%.

CONCLUSIONS

In southeastern Netherlands short-term survival of patients with small-cell lung cancer improved markedly up to the end of the 1980s, but a major impact on cure rates has not been achieved.