The epidemiology of lung cancer

Effect of benzo[a]pyrene on proliferation and metastasis of oral squamous cell carcinoma cells: A transcriptome analysis based on RNA-seq

Benzo[a]pyrene (BaP), a representative polycyclic aromatic hydrocarbon compound, is a carcinogen that causes head and neck cancers. Despite intensive research, the molecular mechanism of BaP in the development of oral squamous cell carcinoma (OSCC) remains largely unknown. In the present study, the SCC-9 human OSCC cell line was cultured in vitro, separated into treatment groups, and treated with dimethyl sulfoxide or BaP at various concentrations. The malignant behavior ascribed to the BaP treatment was investigated by cell proliferation, clony formation assay, and Transwell assays. Furthermore, transcriptome sequencing was performed to detect the differentially expressed genes, followed by quantitative real-time PCR to measure the expression levels of nine of these genes. Moreover, the Gene Ontology (GO) term and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses showed the biological processes and signaling pathways in which the target genes were involved. Significant effects on SCC-9 cell proliferation, tumorigenicity, cell migration, and invasion were observed after exposure to 8 μM BaP. Additional results revealed that BaP inhibited apoptosis in a dose-dependent manner. The transcriptome sequencing results showed 137 upregulated genes and 135 downregulated genes induced by BaP, associated with tumor-related biological processes and signaling pathways, mainly including transcriptional dysregulation in cancer, the tumor necrosis factor signaling pathway, metabolism of xenobiotics by cytochrome P450, mitogen-activated protein kinase signaling pathway, and so forth. Our study demonstrates that BaP may regulate the expression of certain genes involved in tumor-associated signaling pathways, thereby promoting the proliferative, tumorigenic, and metastatic behaviors of OSCC cells while suppressing their apoptosis.

Observational studies assessing the pharmacological treatment of obstructive lung disease: strengths, challenges and considerations for study design

Randomised controlled trials (RCTs) are the gold standard for evaluating treatment efficacy in patients with obstructive lung disease. However, due to strict inclusion criteria and the conditions required for ascertaining statistical significance, the patients included typically represent as little as 5% of the general obstructive lung disease population. Thus, studies in broader patient populations are becoming increasingly important. These can be randomised effectiveness trials or observational studies providing data on real-world treatment effectiveness and safety data that complement efficacy RCTs. In this review we describe the features associated with the diagnosis of asthma and chronic obstructive pulmonary disease (COPD) in the real-world clinical practice setting. We also discuss how RCTs and observational studies have reported opposing outcomes with several treatments and inhaler devices due to differences in study design and the variations in patients recruited by different study types. Whilst observational studies are not without weaknesses, we outline recently developed tools for defining markers of quality of observational studies. We also examine how observational studies are capable of providing valuable insights into disease mechanisms and management and how they are a vital component of research into obstructive lung disease. As we move into an era of personalised medicine, recent observational studies, such as the NOVEL observational longiTudinal studY (NOVELTY), have the capacity to provide a greater understanding of the value of a personalised healthcare approach in patients in clinical practice by focussing on standardised outcome measures of patient-reported outcomes, physician assessments, airway physiology, and blood and airway biomarkers across both primary and specialist care.

Cisplatin-Vinorelbine Combination Chemotherapy in Locally Advanced Non-Small Cell Lung Cancer

Aim

The North Milan Group presents the results of a phase II study on a cisplatin-vinorelbine combination schedule in the treatment of locally advanced non-small cell lung cancer to evaluate its activity and tolerability.

Methods

Seventy-six consecutive patients entered the study. Patients’ characteristics were the following: males/females 69/7; median age, 61.4 years (range, 40-73); ECOG performance status, 0-1; 17 stage IIIa and 59 stage IIIb. There were 49 squamous cell carcinomas, 20 adenocarcinomas, and 7 large cell carcinomas. All patients had not been previously treated and showed measurable disease. Treatment consisted of vinorelbine, 25 mg/m2 on days 1 and 8, plus cisplatin, 80 mg/m2 on day 1, administered intravenously every 21 days for three standard courses.

Results

Seventy-four patients were evaluable for response. Objective responses were documented in 42/74 patients with an overall response rate (CR+PR) of 56.7%; 18/74 patients (24.3%) showed stable disease and the remaining 14/74 (18.9%) went into progression. Twelve patients (16.2%) were suitable for a subsequent surgery. The median duration of response was 13.3 months. Survival time ranged from 4 to 36 months: it was 14.6 months for PR patients, 8.6 months for NC and 5 months for PD. Mean survival time is presently 12.85 months (SE, 1.2 months). Toxicity evaluated on 222 cycles administered was acceptable, and it was necessary to use G-CSF or delay the treatment because of severe leukopenia in only a few cases.

Conclusions

The regimen is active and safe: the slight survival increase is likely due to the small amenability to surgery achieved (16.2%). However, our results are fully comparable to others obtained with vinorelbine in two/three drug combination chemotherapy regimens.

Evaluation of potential confounding by smoking in the presence of misclassified smoking data in a cohort study of workers exposed to acrylonitrile

OBJECTIVES

To evaluate the extent to which lung cancer mortality risk estimates in relation to acrylonitrile (AN) exposure may have been confounded by smoking in the presence of misclassified smoking data.

METHODS

Subjects were 992 white men employed for three or more months between 1960 and 1996 at a chemical plant in Lima, Ohio. We used Monte Carlo-based sensitivity analysis to address possible confounding by smoking.

RESULTS

In Monte Carlo simulations that accounted for the relationship between smoking and AN exposure, mean relative risks for lung cancer mortality in relation to AN exposure decreased and we observed somewhat less evidence of an exposure-response relationship.

CONCLUSIONS

Our simulations suggest that the relationship between AN exposure and lung cancer mortality was positively confounded by smoking in the original Lima cohort study.

Alpha-5 and -3 nicotinic receptor gene variants predict nicotine dependence but not cessation: findings from the COMMIT cohort

Smoking many cigarettes per day (CPD) and short interval to first cigarette (TTF) after waking are two of the most heritable smoking phenotypes and comprise the Heavy Smoking Index (HSI). These phenotypes are often used as proxies for nicotine dependence (ND) and are associated with smoking cessation outcomes. Case-control and genome-wide association studies have reported links between single nucleotide polymorphisms (SNPs) in the alpha-5 and -3 nicotinic receptor subunit (CHRNA5 and CHRNA3) genes and CPD but few have examined TTF or cessation outcomes. In this study we longitudinally assessed 1301 European-American smokers at four time-points from 1988 to 2005. One CHRNA5 (rs16969968) and two CHRNA3 (rs1051703, rs6495308) SNPs were examined for their ability to predict smokers who "ever" reported ND based on three phenotypic classifications: (1) 25+ CPD, (2) TTF < 10 min, and (3) HSI ≥ 4. In a subsample of 1157 quit attempters, we also examined each SNP's ability to predict "ever" quitting for a period of >6 months. Demographically adjusted logistic regressions showed significant allelic and genotypic associations between all three SNPs and CPD but not TTF, HSI, or smoking cessation. Carriers of both the rs16969968-AA and rs6495308-TT genotypes had approximately twofold greater odds for ND defined using CPD or TTF. Results suggest nicotinic receptor variants are associated with greater odds of ND according to CPD and to a lesser extent TTF. Research examining the effect of nicotinic receptor genetic variation on ND phenotypes beyond CPD is warranted.

FRAGMATIC: a randomised phase III clinical trial investigating the effect of fragmin added to standard therapy in patients with lung cancer

Background

Venous thromboembolism (VTE) occurs when blood clots in the leg, pelvic or other deep vein (deep vein thrombosis) with or without transport of the thrombus into the pulmonary arterial circulation (pulmonary embolus). VTE is common in patients with cancer and is increased by surgery, chemotherapy, radiotherapy and disease progression. Low molecular weight heparin (LMWH) is routinely used to treat VTE and some evidence suggests that LMWH may also have an anticancer effect, by reduction in the incidence of metastases. The FRAGMATIC trial will assess the effect of adding dalteparin (FRAGMIN), a type of LMWH, to standard treatment for patients with lung cancer.

Methods/Design

The study design is a randomised multicentre phase III trial comparing standard treatment and standard treatment plus daily LMWH for 24 weeks in patients with lung cancer. Patients eligible for this study must have histopathological or cytological diagnosis of primary bronchial carcinoma (small cell or non-small cell) within 6 weeks of randomisation, be 18 or older, and must be willing and able to self-administer 5000 IU dalteparin by daily subcutaneous injection or have it administered to themselves or by a carer for 24 weeks. A total of 2200 patients will be recruited from all over the UK over a 3 year period and followed up for a minimum of 1 year after randomisation. Patients will be randomised to one of the two treatment groups in a 1:1 ratio, standard treatment or standard treatment plus dalteparin. The primary outcome measure of the trial is overall survival. The secondary outcome measures include venous thrombotic event (VTE) free survival, serious adverse events (SAEs), metastasis-free survival, toxicity, quality of life (QoL), levels of breathlessness, anxiety and depression, cost effectiveness and cost utility.

Trial registration

Current Controlled Trials ISRCTN80812769

Screening in the dark: ethical considerations of providing screening tests to individuals when evidence is insufficient to support screening populations

During the past decade, screening tests using computed tomography (CT) have disseminated into practice and been marketed to patients despite neither conclusive evidence nor professional agreement about their efficacy and cost-effectiveness at the population level. This phenomenon raises questions about physicians' professional roles and responsibilities within the setting of medical innovation, as well as the appropriate scope of patient autonomy and access to unproven screening technology. This article explores how physicians ought to respond when new screening examinations that lack conclusive evidence of overall population benefit emerge in the marketplace and are requested by individual patients. To this end, the article considers the nature of evidence and how it influences decision-making for screening at both the public policy and individual patient levels. We distinguish medical and ethical differences between screening recommended for a population and screening considered on an individual patient basis. Finally, we discuss specific cases to explore how evidence, patient risk factors and preferences, and physician judgment ought to balance when making individual patient screening decisions.

Nicotinic receptor gene variants influence susceptibility to heavy smoking

Heavy smoking is a strong predictor of nicotine dependence, which is a major impediment to smoking cessation. Although both heavy smoking and nicotine dependence are highly heritable, previous attempts to identify genes influencing these phenotypes have been largely unsuccessful until very recently. We studied 1,452 heavy smokers (defined as smoking at least 30 cigarettes per day for at least 5 years) and 1,395 light smokers (defined as smoking <5 cigarettes per day for at least 1 year) to investigate the association of common variants in nicotinic receptor subunit genes with smoking behavior. Compared with the most common allele, two separate groups of single nucleotide polymorphisms (SNP) in the CHRNA5-CHRNA3-CHRNB4 gene cluster were associated with heavy smoking with a very high statistical significance. One group of eight SNPs, which included a nonsynonymous SNP in the CHRNA5 gene, was in strong linkage disequilibrium and associated with increased risk of heavy smoking. A second group of SNPs not strongly correlated with the first was associated with decreased risk of heavy smoking. Analyses that combined both groups of SNPs found associations with heavy smoking that varied by >2-fold. Our findings identify two loci in the CHRNA5-CHRNA3-CHRNB4 gene cluster that predict smoking behavior and provide strong evidence for the involvement of the alpha5 nicotinic receptor in heavy smoking.

Variation in lung cancer risk by smoky coal subtype in Xuanwei, China

Lung cancer rates in Xuanwei County have been among the highest in China for both males and females and have been causally associated with exposure to indoor smoky (bituminous) coal emissions that contain very high levels of polycyclic aromatic hydrocarbons. There are numerous coal mines across the County. Although lung cancer risk is strongly associated with the use of smoky coal as a whole, variation in risk by smoky coal subtype has not been characterized as yet. We conducted a population-based case-control study of 498 lung cancer cases and 498 controls, individually matched to case subjects on age (+/-2 years) and sex to examine risk by coal subtype. Odds ratios (ORs) and 95% confidence intervals (CIs) for coal subtype were calculated by conditional logistic regression, adjusting for potential confounders. Overall, smoky coal use was positively and statistically significantly associated with lung cancer risk, when compared with the use of smokeless coal or wood (OR = 7.7, 95% CI = 4.5-13.3). Furthermore, there was a marked heterogeneity in risk estimates for specific subtypes of smoky coal (test for heterogeneity: p = 5.17 x 10(-10)). Estimates were highest for coal of the Laibin (OR = 24.8, 95% CI = 12.4-49.6) and Longtan (OR = 11.6, 95% CI = 5.0-27.2) coal types and lower for coal from other subtypes. These findings strongly suggest that in Xuanwei and elsewhere, the carcinogenic potential of coal combustion products can exhibit substantial local variation by specific coal source.

Impact of respiratory symptoms on lung cancer: 30-year follow-up of an urban population

We investigated the relationship between respiratory symptoms reported at one time and incidence of lung cancer the subsequent 30 years in an urban Norwegian population. A cohort of 19,998 persons, aged 15-70 years living in Oslo, was randomly selected for a respiratory survey in 1972. The response-rate was 89% and 17,670 respondents were followed up. The relationship between respiratory symptoms and lung cancer incidence was investigated separately for each symptom group, symptom score and sex, with adjustment for age, smoking habits and occupational exposure. Lung cancer developed in 352 persons (228 men and 124 women) during follow up. We found a significant positive association between the incidence of lung cancer and cough symptoms in both sexes, asthma-like symptoms among women and dyspnoea when walking uphill among men. The relative risk for lung cancer increased with the number of symptoms reported at baseline and was strongest the first decade and decreased with duration of follow up. This association was more pronounced for non-small cell lung cancer than for small cell lung cancer.

Lung cancer resection combined with lung volume reduction in patients with severe emphysema

OBJECTIVE

Certain patients with resectable lung cancer and severe respiratory limitation due to emphysema may have a suitable operative risk by combining cancer resection with lung volume reduction surgery. The purpose of this study is to review our experience with such patients.

METHODS

A review was conducted on 21 patients with lung cancer in the setting of severe emphysema who underwent an operation designed to provide complete cancer resection and volume reduction effect.

RESULTS

In the 21 patients, the mean preoperative forced expiratory volume in 1 second was 0.7 +/- 0.2 L (29% predicted), residual volume was 5.5 +/- 1.0 L (271%), and diffusing capacity for carbon monoxide was 8.0 +/- 2.2 mL/min/mm Hg (34% predicted). In 9 patients, the cancer was located in a severely emphysematous lobe and the lung volume reduction surgery component of the procedure was accomplished with lobectomy alone. In the remaining 12 patients, the cancer resection lobectomy (n = 9) and wedge resection (n = 3) were supplemented with lung volume reduction surgery. Final pathologic staging was stage I in 16 patients, stage II in 2 patients, and stage III in 2 patients. One patient was found to have stage IV disease due to multifocal tumors in separate lobes. There were no hospital deaths. Postoperative complications included prolonged air leak in 11 patients, atrial fibrillation in 6 patients, and reintubation for ventilatory assistance in 2 patients. All patients showed improved lung function postoperatively. Survival was 100% and 62.7% at 1 and 5 years, respectively.

CONCLUSIONS

Patients with severe emphysema and resectable lung cancer who have a favorable anatomy for lung volume reduction surgery may undergo a combined cancer resection and lung volume reduction surgery with an acceptable risk and good long-term survival.

Smoking and the Risk of Lung Cancer

BACKGROUND

GSTP1 is a gene that helps detoxify foreign substances in the body. Functional polymorphisms of GSTP1 have been studied as risk factors for lung cancer. Past studies have compared the effect of the "at risk" polymorphism in two strata of smoking pack-years (usually defined by the median among controls). We examined the interaction between GSTP1 polymorphisms and cumulative exposure to smoking and their association with lung cancer risk.

METHODS

Data are from a large hospital-based case-control study of persons treated for primary lung cancer at the Massachusetts General Hospital since 1992. Controls were drawn from friends and nonrelated family members. We genotyped 1,042 cases and 1,161 controls for GSTP1 using polymerase chain reaction-restriction fragment length polymorphism techniques.

FINDINGS

The GSTP1 GG genotype approximately doubled the lung cancer risk associated with pack-years. This interaction was stronger among current smokers. At 26 pack-years (median among controls with a smoking history), the adjusted odds ratio for the association between pack-years and lung cancer risk was 13 (95% confidence interval = 6.5-25) among current smokers with the GSTP1 GG genotype compared with 6.1 (95% confidence interval = 4.9-7.5) among those with the GSTP1 AA genotype.

CONCLUSIONS

GSTP1 GG increases the lung cancer risk associated with pack-years of smoking.

Attributable and absolute risk of lung cancer death by smoking status: findings from the Japan Collaborative Cohort Study

Estimating the proportion of lung cancer deaths that can be avoided is important in assessing the potential impact of antismoking efforts on the reduction of lung cancer deaths. We calculated the population attributable risk (PAR) and absolute risk of lung cancer death according to smoking status based on the Japan Collaborative Cohort (JACC) Study. The analytic cohort included 45,010 males and 55,724 females aged 40-79 years. Cox proportional hazards model was used to determine age-adjusted relative risks and PAR according to smoking status. We also computed lung cancer mortality according to age and smoking status. In males, 52.2% and 14.8% of lung cancer deaths were attributable to current and former cigarette smoking, respectively. In females, the corresponding figures were 11.8% and 2.8%. Among current male smokers, the relative risk was strongly correlated with the intensity and duration of cigarette smoking. In contrast, the PAR was associated with an intermediate level of smoking except for the years of smoking: the largest PARs were observed in those with 20-29 cigarettes per day, 40-59 pack-years and 20-22 years old at starting smoking. Absolute risks were estimated to increase with age and duration of smoking and not to decrease even after cessation. These findings suggest that avoidable lung cancer deaths are primarily among light to moderate smokers who are considered amenable to population-based antismoking strategies. For all current smokers, immediate cessation is encouraged because it offers the only realistic way to avoid a substantial increase in lung cancer mortality brought about by further continuation of smoking.

Lung cancer screening by spiral CT. What is the optimal target population for screening trials?

The purpose of this document is to provide recommendations for the selection of the optimal target population for lung cancer screening trials with Spiral Computer Tomography based on an analysis of risk factors and high-risk populations. Our recommendations are to include current or ex-smokers (<5 years) with a smoking history of at least 30 years and an average consumption of at least 20 cigarettes a day. When these selection criteria are applied there is no need for a lower age cut-off. Elderly people can be included as long as their life expectancy is more than 10 years. Participants should be fit enough to undergo thoracic surgery. They may have a history of previous cancer, provided that the cancer has been curatively treated at least 5 years ago without evidence of relapse, except for breast cancer, melanoma and hypernephroma. People with an inability to lie flat, who are unable to hold their breath for 20 s, with a body weight above 140 kg, a chest CT scan within 1 year before enrolment or a previous pneumonectomy should not be invited. The inadequacy of the unit 'Pack-Years' (PY) to estimate the individual lung cancer risk is recognised, and future initiatives to develop an appropriate lung cancer risk model are encouraged.

A review of chronic inhalation studies with mainstream cigarette smoke, in hamsters, dogs, and nonhuman primates

This paper is the continuation of previously published work, a review limited to studies on rats and mice. This paper makes an identical evaluation as before, but, restricting the species being evaluated to representative studies of smoke-exposed hamsters, dogs (both by tracheostomy and by direct inhalation), and nonhuman primates. As was seen previously, no statistically significant increase in the incidence of malignant tumors of the respiratory tract was found in any of the 3 species, even though very long exposures and high doses of smoke were used. All 5 of the species of laboratory animals commonly used to evaluate carcinogenic potential produce results with mainstream cigarette smoke that are at variance with the epidemiological evidence in smokers.

Telomerase activity and expression of human telomerase RNA component and human telomerase reverse transcriptase in lung carcinomas

The aim of this study was to evaluate the usefulness of determination of telomerase activity and expression of human telomerase RNA component (hTERC) and human telomerase reverse transcriptase (hTERT) for the diagnosis of lung carcinomas. The tissues studied consisted of 115 carcinomas and adjacent nonneoplastic lung, which were removed surgically without previous chemotherapy or radiotherapy. Telomerase activity was determined using a semiquantitative polymerase chain reaction-based telomeric repeat amplification protocol (TRAP) assay. The results obtained were classified into high and low telomerase groups. Localization of expression was examined by using in situ hybridization and immunohistochemistry. The correlation between telomerase activity in lung carcinoma and clinicopathologic features, including prognosis, was investigated. Telomerase activity in lung carcinomas was detected in 107 of 115 (93%) lung carcinomas, but not in any adjacent noncancerous tissues, and was significantly higher in small cell carcinoma than in any other histologic type. This activity also was significantly higher in poorly differentiated than in well-differentiated squamous cell carcinomas and adenocarcinomas. The overall survival rate (P =.020) was significantly lower in the high telomerase group. Messenger RNAs for hTERC and hTERT were mainly detected in the cytoplasm of cancer cells by in situ hybridization, and TERT protein was localized in the nuclei of these cells by immunohistochemical staining. Determinations of telomerase activity by in situ hybridization, immunohistochemistry, and TRAP assay are useful for evaluating the diagnosis and prognosis of lung carcinomas.

Early glandular neoplasia of the lung

Although bronchogenic carcinomas progress through a very well defined sequence of metaplasia, dysplasia and carcinoma in situ, very little is known about the early progression of glandular neoplasms of the lung. In particular, the early precursor lesion from which fully malignant adenocarcinomas arise has effectively eluded recognition, at least until recently. Several lines of evidence now implicate atypical adenomatous hyperplasia (AAH) as an initial morphologic stage in multistep lung tumorigenesis. Despite its small size, AAH can be appreciated at the light microscopic level and characterized at the molecular genetic level. Indeed, the genetic characterization of AAH promises to further our understanding of lung cancer development and might facilitate the design of novel strategies for early detection of lung cancer.

K-ras mutations in 239PuO2 canine lung neoplasms

Single-strand conformational polymorphism (SSCP) analysis and direct sequencing methods were used to examine lung tumors derived from a cohort of beagle dogs with inhalational exposures to 239PuO2. These exposures were done at Pacific Northwest Laboratories where 18-month-old beagle dogs were given 239PuO2 by single-dose inhalation and allowed to live out their life-spans. Formalin-fixed paraffin-embedded blocks of tissues from 25 dogs exposed to 239PuO2 by aerosol inhalation which later developed lung tumors were available for this study. Two of 25 tumors had mutations within exon 1 of K-ras detected by SSCP analysis. Both mutations were GGT to GAT transitions at codon 12 confirmed by direct sequencing experiments. One was an adenocarcinoma from the medium-high exposure group and the other was a broncheolo-alveolar carcinoma from the medium-low exposure group. The rate of K-ras mutations in plutonium-induced lung tumors described herein (8%) was greater than previously described in canine plutonium-induced lung tumors (0%), but was less than that which we have described in spontaneous canine lung cancer (16%), less than that reported for human spontaneous non-small cell lung cancer (13-36%) and less than that described in rats with spontaneous lung cancer (40%) or lung tumors following 239Pu inhalation exposure (46%).

A review of chronic inhalation studies with mainstream cigarette smoke in rats and mice

In this paper, I review the results of a representative selection of chronic inhalation studies with rats and mice exposed to mainstream cigarette smoke and describe the inhalation exposures and the histopathological changes reported by various authors. Many of the studies used nose-only exposure systems, whereas others simply used large whole-body chambers. Smoke-induced epithelial hypertrophy, hyperplasia, and squamous metaplasia were reported in the conducting airways in most of the studies, along with increased numbers of intra-alveolar macrophages that were occasionally associated with alveolar metaplasia. Lung adenomas and adenocarcinomas were reported in only a few of the studies. No statistically significant increase in the incidence of malignant lung tumors was seen in either species as a result of smoke exposure, a finding that does not agree with the results of epidemiological studies in humans. Possible reasons for this lack of correlation are given.

Cancer and women

Women have special physiologic considerations that may increase their risk of being diagnosed with certain cancers; however, the most important aspect to remember is that women are diagnosed with and die from many of the same malignancies as men. Health care providers need to be vigilant in evaluating women because one of the best ways to increase the chance of survival is early detection.

Lobectomy combined with volume reduction for patients with lung cancer and advanced emphysema

OBJECTIVE

Early-stage lung cancer is best treated by anatomic pulmonary resection. Patients with lung cancer and severe emphysema are often denied resection or are offered only limited, nonanatomic resections when established pulmonary function criteria for lobectomy are not met. Recently, with the introduction of the volume reduction operation, selected patients with disabling emphysema have undergone excision of approximately 30% of the most destroyed lung tissue and have subsequently demonstrated subjective and objective improvement in pulmonary function. Using these principles, we elected to combine anatomic lobectomy with volume reduction in a select group of patients with both emphysema and lung cancer who would not otherwise be candidates for pulmonary resection.

METHODS

Five patients with severe emphysema and suspected or proven lung cancers, who were poor candidates for anatomic lobectomy by traditional criteria but were good candidates for volume reduction, underwent lobectomy combined with volume reduction of one or more additional lobes.

RESULTS

All five patients having lung volume reduction and anatomic lobectomy for early-stage primary lung cancer did well postoperatively. Furthermore, each patient has demonstrated subjective and objective improvement in respiratory function on serial postoperative studies.

CONCLUSIONS

Selected patients with disabling emphysema and suitable anatomy for volume reduction, who have a lung cancer situated in destroyed lung tissue, may benefit from combined lobectomy and volume reduction. The introduction of the volume reduction operation has added a new factor in the algorithm for the evaluation and treatment of lung cancer in selected patients with advanced emphysema.

Health of older women

Older persons are the fastest growing segment of the American population, and older women significantly outnumber men. The health status of older women is influenced by disease and psychosocial factors. Comprehensive geriatric assessment is a tool which takes into account the many aspects of health and provides a framework for developing individualized goals of care. Cardiovascular disease, osteoporosis, hormonal treatment, urinary incontinence, mental health, sexuality, substance abuse, cancer and exercise are discussed.

Advanced non-small cell lung cancer chemotherapy: a randomized trial of two active regimens (MVP and PE)

The treatment of advanced or metastatic NSCLC remains a controversial issue and cisplatin-based combination chemotherapy is by far the most common treatment. Two of these cisplatin-based standard combinations, MVP and PE, were compared in this study in order to evaluate their response rates and survival times. Eighty-five previously untreated NSCLC patients were randomly selected to receive either MVP or PE and 72 of these patients were eligible for evaluation for response rate and survival. Response rates for MVP were: CR 11%, PR 35%, SD 19% and PD 35% and for PE: CR 0%, PR 26%, SD 22% and PD 52%. The median survival time was 9.7 months for MVP and 6.9 months for PE. Both schedules were well tolerated. The administration of MVP in advanced NSCLC resulted in superior response rates and survival times over those produced by PE.

Transcutaneous abdominal ultrasonography in the staging of lung cancer

BACKGROUND

There is limited information available regarding the relationship between clinical indicators of widespread disease in patients with lung cancer and the findings of transcutaneous ultrasonography.

METHODS

A retrospective survey was made of 279 consecutive patients with lung cancer. By reviewing the patients' records the clinical findings were divided into symptoms, signs, and laboratory tests indicative of metastatic disease. All patients had been examined by abdominal ultrasonography.

RESULTS

The patients included 19% with small cell carcinoma. The frequency of abdominal metastases by ultrasonography in those with small cell carcinoma was 40%, in the other patients it was 8%. Regardless of histological group, all the 40 patients with abdominal metastases by ultrasonography had at least one clinical category indicative of widespread disease and 38 (95%) had two or all three clinical categories positive. Fifty nine patients had no clinical indicators of metastases and none of these had abdominal metastases by ultrasonography.

CONCLUSIONS

The results of this study indicate that abdominal metastases are found in lung cancer patients with clinical findings indicative of widespread disease. No abdominal metastases were found in patients with a negative clinical evaluation. The results indicate that transcutaneous ultrasonography of the abdomen is not necessary in the initial staging if the clinical evaluation is unremarkable.

Screening for lung cancer. Another look; a different view

PURPOSE

There is widespread acceptance that screening for lung cancer is not indicated, to our knowledge, because no randomized trial has demonstrated a reduction in mortality as a result of screening. The objectives of this work are to review prospective studies on lung cancer screening and to analyze the extent to which known biases may have influenced observed results.

BACKGROUND

Four randomized controlled trials have been conducted. The Memorial-Sloan Kettering and Johns Hopkins Lung Projects compared annual chest radiographs (CXRs) in a control group with CXRs and sputum cytologic findings in an experimental group. Although both studies failed to demonstrate any difference in outcome by the addition of cytologic study to CXR, long-term survival in both studies was approximately three times that predicted by other data. Accordingly, these results are at least consistent with the hypothesis that the screening CXRs may have improved survival. Two randomized trials, the Mayo Lung Project and the Czechoslovak study, compared regular and frequent rescreening CXRs in an experimental group with sporadic and/or infrequent rescreening in a control group.

RESULTS

Both the Mayo and Czech studies demonstrated a striking advantage for screening with respect to stage distribution, resectability, survival, and fatality. Nevertheless, mortality was somewhat higher in the screened groups in both studies. Survival and fatality comparisons in randomized trials can be confounded by overdiagnosis bias, lead-time bias, and length bias, while mortality is not subject to these biases. Accordingly, it is believed that a mortality reduction represents the strongest evidence for screening efficacy. Mortality is directly proportional to cumulative incidence. In both the Mayo and Czech studies, incidence of lung cancer was higher in the screened group. The higher cumulative incidence (which in the Mayo Lung Project was statistically significant) made possible the discordant findings of superior survival/fatality and inferior mortality in the screened populations. Overdiagnosis has been widely accepted to account for the "missing cases" in the control populations in the Mayo and Czech studies. However, epidemiologic and autopsy evidence as well as an outcome analysis of unresected early-stage screen-detected lung cancer demonstrates that screening does not lead to the overdiagnosis of lung cancer. Similarly, lead-time bias and length bias cannot account for the outcome differences in the Mayo Lung Project or Czech study. If survival and fatality comparisons (which suggest a striking benefit from screening) are not biased, then mortality comparisons (which suggest no benefit) cannot accurately reflect lung cancer death rates in these trials. Population heterogeneity may provide an explanation for how outcome differences may have been misrepresented by mortality comparisons in these two trials, as well as other large population-based randomized studies.

CONCLUSIONS

Periodic screening CXRs lead to clinically meaningful improvements in stage distribution, resectability, survival, and fatality in lung cancer. Mortality reductions have not been demonstrated, but mortality did not accurately reflect lung cancer death rates in the Mayo Lung Project and Czechoslovak study. Accordingly, reconsideration of the desirability of periodic CXR screening may be appropriate for individuals at high risk of lung cancer.

Small cell carcinoma of the lung: an "updated" overview

OBJECTIVES

To review the current status and recent advances, and ongoing research efforts related to the diagnosis, staging, and treatment of small cell lung cancer (SCLC).

DATA SOURCES

Review articles, book chapters, research studies, and abstracts relating to SCLC.

CONCLUSIONS

SCLC is the most aggressive type of lung cancer with many patients having widespread disease at the time of diagnosis. It is the most treatment responsive lung cancer to both chemotherapy and radiotherapy, with aggressive chemotherapy the cornerstone of treatment. Yet, the survival rate is limited. Several new drugs have been found to be active and it is hoped that they will lead to improved results.

IMPLICATIONS FOR NURSING PRACTICE

An understanding of the prognostic factors, staging, treatment modalities, and new therapies for SCLC will help nurses assist patients to make educated decisions about the potential risks and benefits of their therapeutic options.

Treatment principles in advanced non-small-cell lung cancer

Non-small-cell lung cancer (NSCLC) accounts for more than three quarters of all lung tumours and is the leading cause of deaths due to cancer in Australia. More than half of the patients with NSCLC present with advanced disease. Radiation therapy has been the mainstay of active treatment for these patients. There is increasing evidence supporting the benefit of chemotherapy as an addition to radiation therapy in locally advanced non-metastatic disease. The use of cisplatin-based chemotherapy prior to radiation therapy would appear to be a new standard of care in patients with stage III B NSCLC. In advanced (metastic) disease, palliation of symptoms remains the major goal of current treatment programmes. This can be achieved with the best supportive care, radiotherapy, and, in selected patients, platinum-based chemotherapy. Clinical trials to test new treatments, with survival, quality of life and cost-benefit as endpoints, are essential. The present study discusses the current status of conventional and newer treatment methods in locally advanced and metastatic disease.

Primary lung cancer in Mexico city: a report of 1019 cases

A retrospective study was performed in patients diagnosed with primary lung cancer, and admitted to the Instituto Nacional de Enfermedades Respiratorias between 1984 to 1992. One thousand and nineteen patients were studied, 636 males and 383 females. We found a higher incidence in the group among 61-70 years of age in both sexes. The highest percentage of tumors were from the adenocarcinoma variety, followed by the epidermoid carcinoma, while the small-cell carcinoma presented a lower incidence. Smoking has been associated with the development of lung cancer. Many of our patients were smokers. The highest frequency was in smokers with a smoking habit of more than 30 years and a rate of more than 10 cigarettes per day. However, an important part of the patients with cancer did not have a smoking habit, which led us to believe that there are other etiological possibility factors (genetic or environmental) that could be involved. Most of the cases of cancer were staged as stage IIIb and stage IV and the patients had an ECOG of 1-2. The main symptoms were coughing, sputum, dyspnea and thoracic pain. This data shows an increasing frequency of lung cancer in Mexico city as well as other countries, it also shows that it is going to be a serious health problem in the future. We consider that in order to improve the prognosis, it is necessary to increase the educational and orientation campaigns among the adult population with or without a smoking history.

Unsuspected lung cancer found in work-up for lung reduction operation

BACKGROUND

Lung reduction surgery is gaining acceptance in the treatment of patients suffering from severe diffuse emphysema. At the University of Pittsburgh 210 patients have been evaluated and 128 patients have undergone lung reduction operations.

METHODS

Ten patients, representing 7.8% of the operated group, have had asymptomatic cancerous or neoplastic lesions diagnosed on preoperative evaluation or pathologic analysis of resected tissue.

RESULTS

Six primary lung cancers (three squamous, three adenocarcinoma) and four other neoplastic lesions (squamous dysplasia, chemodectoma, and two carcinoid tumorlets) have been identified. All patients were heavy smokers, and all had markedly impaired pulmonary function. Patients whose lesions were identified on preoperative testing underwent thoracoscopic wedge excision of the tumor alone.

CONCLUSIONS

Our experience suggests that patients with impaired pulmonary function (chronic obstructive pulmonary disease) presenting for lung reduction operations are at a high risk of harboring an unsuspected neoplastic lesion. Complete preoperative evaluation of radiographic studies and preoperative bronchoscopic examination are mandatory.

[Spatial distribution of cancer incidence by anatomic site in Quebec]

Knowledge of the spatial distribution of diseases provides useful information in etiologic research and in implementation of preventive activities in community health. Spatial autocorrelation analysis is one of the various methods that enables to determine spatial clustering of diseases. This method has not been applied to lung, stomach and colon cancer in Québec. These cancers are frequent and are associated with environmental factors. The objectives of the study are to determine spatial distribution of incidence rates of these cancer sites by sex and to help generate etiologic hypotheses. Community health departments (CHDs) of residence are considered as risk markers since their population and environment may be related to the selected cancer sites. Data were obtained from Québec Cancer Registry. Rates were standardized by the direct method. Autocorrelation analysis was done through BW coefficient and Moran's coefficient I for correlograms. Results of standardized rates were compared to those of non standardized rates. Rates yielded the same results for the BW coefficient. Conversely, results were quite different for the correlograms. This implies that results from standardized rates should be kept since the age structure of CHD populations are different. Important variation in the level of spatial autocorrelation was found among the six sex-specific cancer sites. For male lung cancer and male stomach cancer first-order neighbouring CHDs showed similar incidence rates according to a geographic gradient. Female lung cancer exhibited spatial autocorrelation. Absence of spatial autocorrelation for colon cancer suggests that CHD is not the appropriate scale for study of this cancer and allows use of conventional epidemiologic methods. These results are discussed in relation to current etiologic hypotheses.(ABSTRACT TRUNCATED AT 250 WORDS)

Chest X-ray screening improves outcome in lung cancer. A reappraisal of randomized trials on lung cancer screening

It is believed that population-based screening for cancer should be advocated only when screening reduces disease-specific mortality. Four randomized controlled studies on lung cancer screening have been conducted in male cigarette smokers, and none has demonstrated reduced mortality. Accordingly, no organization that formulates screening policy advocates any specific early detection strategies for lung cancer. Yet, despite this public policy against screening, there is considerable evidence that chest x-ray screening is associated with earlier detection and improved survival. Two randomized trials, the Memorial Sloan-Kettering and Johns Hopkins Lung Projects, were specifically designed to evaluate the effectiveness of sputum cytologic study. Both evaluated the efficacy of the addition of sputum cytologic studies to annual chest radiographs, and both demonstrated that cytologic study did not favorably influence outcome. All individuals in experimental and control groups in both studies had annual chest radiographs. Because survival rates observed in both studies were about three times higher than predicted, based either on the National Cancer Institute's Surveillance Epidemiology and End Results database or based on the American Cancer Society's annual Cancer Statistics, raises the possibility that the periodic chest radiographs performed in all patients in both studies contributed to an improved outcome. In the Mayo Lung Project and in the Czechoslovak study on lung cancer screening, the experimental groups underwent a program of relatively intensive and regular rescreening with chest radiographs and sputum cytologic study, while the control groups underwent either less-frequent rescreening or no rescreening. In both studies, the screened groups achieved meaningful improvements in stage distribution, resectability, and survival. However, increases in cumulative incidence of lung cancer in the experimental group in both studies (which in the Mayo Lung Project reached statistical significance) prevented significant improvements in survival from translating into corresponding reductions in mortality. The possibility that screening may be associated with lung cancer "overdiagnosis" has been widely postulated to account for higher survival and incidence rates and equivalent mortality rates. However, analysis of autopsy information and of disease outcome in individuals with screen-detected early stage lung cancer who do not undergo surgical resection strongly supports the conclusion that screening does not lead to overdiagnosis of lung cancer. Similarly, lead-time and length bias do not adequately account for the differences in cumulative incidence observed in the Mayo and Czech studies.(ABSTRACT TRUNCATED AT 400 WORDS)

Patterns of cigarette sales and lung cancer mortality in some central and eastern European countries, 1960-1989

BACKGROUND

Remarkable increases in lung cancer risk recently have been observed in the Central and Eastern European (CEE) area. This study examines the patterns of lung cancer mortality rates and cigarette sales in 1960-1989 in seven CEE countries with a total population of 97.5 million and 43,000 deaths from lung cancer in the last year under study.

METHODS

Trends in cigarette sales and mortality rates from lung cancer in seven CEE countries were compared for the years 1960-1989.

RESULTS

Among males, recent lung cancer death rates were the highest in Europe, and trends by country largely reflected the varied prevalence and duration of smoking in previous decades. For females, lung cancer mortality rates were much lower, although there were exponential rate increases. In the more recent birth cohorts, there were some declines in mortality rates among males, but not among females.

CONCLUSIONS

The rising cigarette consumption through the 1960s, 1970s, and, in some countries, the 1980s is accompanied in most of the countries by rising lung cancer mortality rates for young adults. This increasing cigarette consumption will determine future trends in lung cancer, which will increase well beyond the turn of the century and will continue longer for females than for males. This outlook underlines the urgent need for comprehensive lung cancer prevention with the concerted control of smoking as a priority. The role of cofactors and their interaction with smoking deserve further exploration.