The addition of chemotherapy to surgery, or surgery plus radiotherapy, improves survival for patients with operable non-small-cell lung cancer. This is the conclusion of an Article published Online First (www.thelancet.com) and in an upcoming edition of The Lancet, written by Sarah Burdett, Meta-analysis Group, Medical Research Council (MRC) Clinical Trials Unit, London, UK and Dr Jean-Pierre Pignon, Meta-Analysis Unit, Institut Gustave-Roussy, Villejuif, France, and colleagues from the NSCLC Meta-analysis Collaborative Group.
There have been many randomised controlled trials that have investigated the effect of adding chemotherapy (adjuvant chemotherapy) in operable non-small-cell lung cancer. In today's study, the authors did two comprehensive systematic reviews and meta-analyses to establish the effects of adding adjuvant chemotherapy to surgery, or to surgery plus radiotherapy.
The researchers went as far back as 1965 in their search for eligible studies. The first meta-analysis of surgery plus chemotherapy versus surgery alone was based on 34 trial comparisons and 8447 patients (3323 deaths). The data showed a benefit of adding chemotherapy with an absolute increase in survival of 4% at 5 years from 60% to 64. The second meta-analysis of surgery plus radiotherapy and chemotherapy versus surgery plus radiotherapy was based on 13 trial comparisons and 2660 patients (1909 deaths). This data also showed a benefit of adding chemotherapy to surgery plus radiotherapy, again with an absolute improvement in survival of 4% at 5 years from 29% to 33%.
The authors say: "In both meta-analyses we noted little variation in effect according to the type of chemotherapy, other trial characteristics, or patient subgroup."
They conclude: "The addition of adjuvant chemotherapy after surgery for patients with operable non-small-cell lung cancer improves survival, irrespective of whether chemotherapy was adjuvant to surgery alone or adjuvant to surgery plus radiotherapy... In the absence of comorbidities and contraindications to chemotherapy, adjuvant platinum-based chemotherapy should be considered for patients at high risk of recurrence—ie, those with stage IB, II, or III disease."
They add: "This meta-analysis was not designed to study the effect of postoperative radiotherapy, but has shown that the effect of chemotherapy is similar irrespective of what locoregional treatment is used: surgery alone or surgery plus postoperative radiotherapy. Randomised trials are needed to assess whether modern radiotherapy is effective as an adjuvant treatment."
In an accompanying Comment, Dr Gregory P Kalemkerian, University of Michigan, Ann Arbor, MI, USA, says: "Today's meta-analysis adds further support to the use of adjuvant chemotherapy in patients with resected NSCLC. Although the survival benefit seems small, worldwide adoption of adjuvant chemotherapy could save up to 10,000 lives every year."
He adds: "Adjuvant platinum-based chemotherapy can be recommended for patients who have complete resection of stage II–III NSCLC ,and have uncomplicated recovery with good performance status within 3 months of surgery. Treatment can be considered for patients with larger tumours (T2b, T3) without lymph node involvement."
However, Dr Kalemkerian also cautions that scarcity of data in patients with both early (stage IA) disease and in patients over 70 years at any stage means that adjuvant chemotherapy cannot be recommended in these groups until more evidence becomes available.
For Sarah Burdett, Meta-analysis Group, Medical Research Council (MRC) Clinical Trials Unit, London, UK, please contact MRC Press Office T) +44 (0) 20 7637 6011 E) press.office@headoffice.mrc.ac.uk
Dr Jean-Pierre Pignon, Meta-Analysis Unit, Institut Gustave-Roussy, Villejuif, France. T) +33 1 42 11 45 65 E) jean-pierre.pignon@igr.fr
Dr Gregory P Kalemkerian, University of Michigan, Ann Arbor, MI, USA. E) kalemker@umich.edu
For full Article and Comment, see: http://press.thelancet.com/nsclcmeta.pdf
Journal
The Lancet