FORT LAUDERDALE, FloridaThe National Comprehensive
Cancer Network (NCCN) 2001 guideline for non-small-cell lung cancer (NSCLC) now
calls for a "multidisciplinary evaluation" of patients with NSCLC as
the standard of care.
"Many NSCLC patients need to see several
specialists," said Mark G. Kris, MD, of Memorial Sloan-Kettering Cancer
Center. "It may be an oncologist and surgeon or medical oncologist and
radiation oncologistbut getting the input of multiple specialists and giving
multiple therapies probably will enhance the outcome," he said.
Dr. Kris and David S. Ettinger, MD, of Johns Hopkins Oncology
Center, presented the updated NSCLC guideline during the Sixth Annual NCCN
Conference: Practice Guidelines and Outcomes Data in Oncology.
Dr. Ettinger addressed the issue of positron emission
tomography (PET) scansa new option in this year’s guideline. "We do
know that PET is more sensitive and more specific then the CT scan and the
chest x-ray. The bigger issue down the pike, now that we have spiral CTs,
concerns small lesions: Do you really need a PET scan for a peripheral lesion
that’s less than 1 cm? So I think this area of the PET scan is in
evolution," Dr. Ettinger said.
The panel recommended PET scans as optional because the PET
scanner is too early in its development to be recommend as part of the routine
evaluation of NSCLC.
"Many institutions do not have a PET scanner, and the
medical literature on it is not substantial," Dr. Kris said. "The
literature that has been published suggests that PET would be useful to help
identify patients who would not benefit from a difficult procedure like a major
The 2001 guideline recommends mediastinoscopy, the gold
standard in evaluating mediastinal node involvement, for clinical stages I-III
disease, but considers it optional in peripheral T1-2 stage I disease. "In
T2 disease, mediastinoscopy of a peripheral lesion may be warranted. In a small
T1 lesion, many thoracic surgeons say that it won’t be helpful, since, if
done, the lymph nodes would be negative," Dr. Ettinger said.
The panel also recommended that no fewer than four N2 lymph
node stations be sampled during surgical staging. "Just remember, in
surgical resection, the most important thing is to do adequate surgery. It’s
important to get a good handle on at least four lymph nodes to understand lymph
node involvement," Dr. Ettinger said.
The panel noted that a randomized trial of mediastinal lymph
node sampling vs complete lymphadenectomy during pulmonary resection in
patients with N0 or N1 NSCLC is currently being conducted by the American
College of Surgeons Oncology Group.
Based on the results of an Intergroup cooperative study
reported in the New England Journal of Medicine in 1999, there was no consensus
about how to treat surgically resected N1 or N2 disease with negative margins.
However, the guideline states that radiation therapy is considered optional
(category 3, major disagreement among panel members) in N1 disease, and that
radiotherapy or combination chemotherapy plus radiotherapy are considered
optional (category 2B, nonuniform consensus) for N2 disease.
"These recommendations reflect the relative lack of data
that we have in this field. I think that this will change over the next 2 to 5
years," Dr. Kris said.
For metastatic disease, the first-line chemotherapy recommended
continues to be a platinum-based regimen. The 2001 guideline has added a second
line of chemotherapy; however, there’s no recommendation for third-line
According to Dr. Kris, trends that could affect future NSCLC
guidelines include the use of CT scans for screening high-risk individuals.
"We’re seeing smaller tumors. So I think over the next 2 to 5 years,
there is going to be a rethinking of how we manage cases. It may be that a 7 mm
tumor in the right lower lobe is not going to be treated by a right lower
lobectomy," he said.
A second emerging issue is the importance of physician training
and experience in thoracic surgery. "A well-publicized trial shows
striking differences in mortality between operations done by trained thoracic
surgeons vs those without specific thoracic surgery training," Dr. Kris