International Journal of Radiation Oncology*Biology*Physics
Clinical investigation: lungComorbidity and KPS are independent prognostic factors in stage I non-small-cell lung cancer
Introduction
Although the recommended treatment for Stage I non-small-cell lung cancer (NSCLC) is surgical resection, this approach is not possible in all patients. Comorbidity, functional status, pulmonary function, and age often determine the resectability in this group of patients. Unfortunately, the selection criteria of patients for surgical resection are not uniform. Therefore, the comparison of outcomes in different studies using the same treatment modality is difficult and can be misleading, because most of these studies lack any description of comorbidity and functional status.
Patients who are poor risk for surgery secondary to comorbid conditions, decreased pulmonary reserve, or functional status are often treated with definitive radiation. Despite having clinical stages similar to resected patients, these patients have a worse prognosis, limiting the ability to compare treatment modalities. Additionally, nonuniform surgical exclusion criteria limit the ability to compare radiation series, which are largely composed of inoperable patients. Noncancer-related deaths constitute varying percentages of all deaths in both surgical and radiotherapy (RT) series, reflecting differences in the patient populations in terms of functional and comorbidity status 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 (see Table 3, Table 4).
In this retrospective study, we used two different comorbidity scales for patients treated with surgery or RT for Stage I NSCLC at the Medical College of Wisconsin (MCW) to evaluate the effects of comorbidity on overall survival (OS) and its prognostic importance.
Section snippets
Surgical group
The records of 113 consecutive patients with clinical Stage I NSCLC who had undergone surgery at MCW affiliated hospitals between June 1990 and November 1998 were reviewed (Table 1). Seventy-eight patients were treated at the Zablocki Veterans Affairs (VA) Hospital and 35 patients at a MCW affiliated community hospital. Most patients were men (87%). The median age was 66 years (range 46–80).
All patients were evaluated with a complete history and physical examination, chest X-ray, CT of the
Surgical group
Fifty-six percent (63 of 113) of clinical Stage I patients treated surgically were dead at the time of analysis. Twenty-eight of these 63 had died of disease recurrence and 35 patients of noncancer-related causes. The OS was 56% at 3 years and 44% at 5 years (Fig. 1). OS was not significantly different for patients with clinical or pathologic Stage T1 tumors compared with those with Stage T2. However, the presence of positive mediastinal or hilar lymph nodes on pathologic examination was
Discussion
Overall 5-year survival rates for surgical treatment of stage I NSCLC (pathologic) ranging from 43% to 84% have been reported in the literature (Table 3)3, 4, 5, 6, 7, 8, 9. Differences in tumor-related factors (T stage, tumor size, histologic features, grade) and surgical approach (pneumonectomy, lobectomy, segmentectomy, wedge resection) partially account for this wide range. It is also likely that patient selection based on comorbid conditions, performance status, age, and pulmonary function
Conclusions
The presence of significant comorbidity and KPS are important prognostic factors in Stage I NSCLC, independent of other factors. The evaluation of the effect of tumor or treatment-related prognostic factors on OS in the absence of comorbidity assessment or KPS may influence the accuracy of prognostic estimates and interpretation of results. Furthermore, it makes comparison of different studies difficult as patient selection for surgical resection is influenced by comorbidity and KPS. We
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Dr. Bousamra’s current address is University of Louisville, Suite 1200, Rudd Heart and Lung Institute, 201 Abraham Flexner Way, Louisville, Ky 40201.