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Ann Thorac Surg 2000;69:249-250
© 2000 The Society of Thoracic Surgeons

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Invited Commentaries

^a Division of Hematology and Oncology, Loyola University Medical Center, 2160 S First Ave, Maywood, IL, USA 60153

e-mail: kalbain{at}wpo.it.luc.edu

Invited commentary

Population-based studies in the United States have shown that there is an increase in lung cancer in both smoking and non-smoking women. A higher prevalence of smoking accounts for part of the increased lung cancer incidence in women, but not all of it. There is molecular epidemiologic evidence that, dose for dose, women may be more susceptible to the carcinogens in tobacco smoke than men, and women also develop lung cancer at an earlier age than men. Currently it is not known why there is an increasing incidence of lung cancer in women who have never smoked. Furthermore, adenocarcinoma and possibly bronchiolalveolar cell carcinoma may account for more of the lung cancers in women, particularly in the non-smoking population compared to patients with lung cancer who are current or former smokers. Finally, there is debate whether lung cancer in women has a different intrinsic biologic behavior and natural history than in men stage-for-stage, or if various reports of better survival for women with lung cancer than men may be a result of earlier stage of presentation and a different mix of histologic subtypes. How the prior smoking history impacts on the natural history and response to treatment of lung cancer once diagnosed is not resolved.

This well-conducted, single institution retrospective analysis adds to the information already known about lung cancer in women. It represents one of the largest analyses of sex differences in lung cancer in a group of patients with surgically resectable disease that was carefully staged. The findings validate many other reports of lung cancer in women (versus men) regarding younger age of onset, less smoking, and more adenocarcinoma. Somewhat surprising was the observation that in stage I disease, patients with adenocarcinoma perhaps did better (p = 0.16). However, as the authors point out, the findings regarding survival differences were less conclusive. Women fared better than men in the univariate analysis, but the multivariate model only suggested an improved outcome for women that was not statistically significant. Most likely this was because of the tendency for women to present with an earlier stage of disease and with adenocarcinoma. It would be interesting to conduct a multivariate analysis in the subset with stage I disease. Variations in treatment (operative over the long time period of accrual of this cohort) of the patients with more advanced-stage disease would not confound the results in stage I lung cancer, since surgery was the only treatment given to these patients over time.

These results together with the large body of evidence already reported provide justification for the stratification of large phase III trials in lung cancer by sex. However, to date there are no data to support offering different treatments in lung cancer based on sex alone. The large chemoprevention and smoking cessation initiatives, currently planned by the cooperative groups as well as ongoing treatment trials in early stage disease, will need to enroll sufficient numbers of women to address treatment outcome endpoints in both men and women. Furthermore, the time is ripe to conduct large molecular epidemiologic studies of the differences in lung cancer between men and women and between smoking versus never-smoked cohorts. These studies should include analyses of markers of the interactions of environmental and genetic risk factors for lung cancer (DNA adduct studies), genetic alterations in tumor tissue, and the possible role of steroid hormones.

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