Ann Thorac Surg 1997;64:1407-1408
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
David J. Girling, FRCP
Medical Research Council Cancer Trials Office 5 Shaftesbury Rd Cambridge CB2 2BW, United Kingdom
See also page 1402.
Sawyer and associates rightly point out that the role of postoperative thoracic radiotherapy (TRT) in non–small cell lung cancer remains controversial. Their most valuable contribution has been to identify stage IIIA patients at high, intermediate, or low risk of local recurrence and of death. However, their conclusion that TRT is of benefit in patients with stage IIIA disease and high or intermediate risk of local recurrence or death is based on nonrandomized, retrospective analyses of the effects of TRT in these groups. Such analyses are likely to be biased as a result of patient selection. A likely additional source of bias in the present study is treatment with chemotherapy: a substantial proportion of patients who received TRT, but very few in the operation-only group, also received postoperative chemotherapy. The suggestion has previously been made that even if TRT is beneficial for patients with N2 disease it might be harmful to those with N1 or N0 disease; indeed, there is some evidence from randomized trials in favor of this suggestion. Sawyer and associates might therefore like to consider extending their investigations to patients with stage II, N1 disease, but confining any treatment comparisons to patients who did not receive other, possibly confounding, treatments.
The most reliable way of assessing the role of TRT is by large, randomized, controlled trials with intakes stratified for pretreatment variables likely to influence outcome. A metaanalysis of updated individual patient data, currently being undertaken, has to date identified ten eligible trials involving modern radiotherapy techniques. Between them, these trials account for more than 2,000 patients, but patients' nodal status was not always specified or pathologically defined. This metaanalysis will undoubtedly help to clarify the clinical situations in which TRT should be offered to patients, but further randomized trials involving thorough pathologic staging would also be of great value. Any groups contemplating such trials should consider stratifying their intakes in accordance with the risk groups identified in the present study.
Related Article
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Effectiveness of Postoperative Irradiation in Stage IIIA Non–Small Cell Lung Cancer According to Regression Tree Analyses of Recurrence Risks
- Timothy E. Sawyer, James A. Bonner, Perry M. Gould, Robert L. Foote, Claude Deschamps, Victor F. Trastek, Peter C. Pairolero, Mark S. Allen, Carla M. Lange, and Hongzhe Li
Ann. Thorac. Surg. 1997 64: 1402-1407.
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