CORRESPONDENCE
Are We Losing Out in the Care of Non-Small Cell Lung Cancer Patients? To the Editor: Lung cancer is difficult to cure because it is usually already advanced when discovered. Non-small cell lung cancer discovered early responds to resective operation, but more advanced disease usually requires multimodality therapy. Radiotherapy and operation are the two modalities that are by themselves curative. Each has its strong points. Operation is best in early disease confined to the lung. Radiotherapy, on the other hand, is best for microscopic and macroscopic spread. The area of the spread, if not sterilized, is shrunken so that it can be more easily removed. Thus, radiotherapy and operation in that order complement each other. Trials, 30 years ago, of preoperative irradiation failed to show a survival advantage over operation alone, and its theoretical advantage has not been seriously considered in more modern times. One would think that communication and collaboration between the purveyors of the two curative modalities would occur on a frequent basis, and that radiotherapists and surgeons would be best of friends. This is far from the case. Why can’t the radiotherapist let surgeons know about modern treatmenttreatment optimally consisting of continuous-course small fractions to therapeutic dose levels using molded fields and computerized dosimetry? Why can’t they explain how much better this is than 30 years ago? Why can’t the surgeons acknowledge their gains in preoperative and postoperative care and intraoperative techniques (use of staplers, for example)? Why can‘t we learn to operate after radiotherapy with a reasonable morbidity and mortality? Why can’t the radiotherapist chide the surgeon about sending him or her patients to treat with gross disease left behind? Is this the surgeon who denies that debulking is good therapy but who is applying glorified “dubulking“ in most advanced lung cases, as up to one half of recurrences are local ones? Is this the same surgeon who refers all patients for postoperative radiotherapy where he or she has left gross disease behind or believes he or she might have left any local spread behind? Is this the surgeon who, when reporting results, fails to acknowledge the place postoperative radiotherapy might have played? Why don’t the radiotherapists more often ask the surgeon at least occasionally to refer a virgin (surgically unmolested) case for therapy? Perhaps they are too polite. Or perhaps they realize that they will one day treat the patient regardless of when the surgeon operates. In superior sulcus tumors, why do surgeons shackle the radiotherapist to split-course therapy with operation sandwiched between courses? At least one radiotherapist [l] recommends initial thoracotomy in all possible resectable cases of superior sulcus tumor and then referral for continuous course postoperative radiotherapy. Why can’t the surgeons and radiologists start to speak to each other and work together as a team to re-run the 20- to 30-year-old preoperative radiotherapy trials? During the seemingly interminable time it takes to organize and carry out such trials, should the many locally advanced patients not in the trials be given the benefit of the combined team approach? Perhaps the resident who has never operated on a previously irradiated patient can get to know the satisfaction of resecting a previously unresectable patient who now has a better chance for a cure. Isn’t it time for the surgeon to update his or her thinking and learn to operate after modern therapeutic dose radiotherapy? The chemotherapists are urging such a preoperative chemotherapy approach. Some authors, namely Kirschner [2], Neptune [3], Stem 141, and Patterson and associates 151, have written to a
0 1991 by The Society of Thoracic Surgeons
certain extent on this topic. Why haven’t they been more often heeded and copied? Is it because surgeons are happy just to operate first even if the chance for cure is minimal? I know a pulmonologist who claims to be “surgically minded’ and who refers a patient to operation even if he or she only has a ”1 in 1000” chance because that is the patient’s “only chance.” Wouldn’t he be better off referring to an enlightened radiotherapist who, after therapeutic dose radiotherapy, in turn might refer that patient to an enlightened, modern surgeon who then might, sure enough, resect with a better chance for a cure? Today, a patient is diagnosed medically without being seen by the surgeon, is staged without the surgeon, and is referred without a surgical consult to radiotherapy for “some palliation.” Is this happening because our medical colleagues have given up on us? Given up on our “operate now at all costs” approach? Isn’t there a better chance of our being involved in the decision making, direct patient contact and rapport, and guided optimistic approach when we work as a team with our b u d d i e s t h e radiotherapists? Perhaps the team approach might help educate our pessimistic colleagues and allow some of the locally advanced non-small cell lung cancer patients a better chance for cure. Incidentally, some radiotherapists include in their radiotherapy for cure category disease confined to the hemithorax including ipsilateral supraclavicular or contralateral hilar nodes! Imagine the surgeon operating on such a patient for curative resection of residual disease after a good response to radiotherapy! It might happen. I think surgeons would welcome the chance to regain a place in the care of cancer patients and help save some of the large group of locally advanced patients who are now falling between the cracks. A small increase in cure of such salvage cases would make a real dent in the present miserable outcome in advanced non-small cell lung cancer. Isn’t it strange how rare present-day trials are that combine in logical sequence the two modalities that, by themselves, are curative? They have been replaced by trials of modalities that, by themselves, are noticurativechemotherapy and immunotherapy. Someday after better drugs are found, they may have earned a place in non-small cell lung cancer therapy, but not yet. Are we up to this challenge? 1 believe we are, but it takes a rearrangement of our motivation and thinking to collaborate with the radiotherapists-our great and good buddies. john S. Chattihers, MD Mercy Hospital 4077 Fifth Ave
Sun Diego, CA 92103
References 1. Cox JD. In: Shields TW, ed. General thoracic surgery. Vol 2. Third Ed. Philadelphia, London: Lea & Febiger, 1989:1150-9. 2. Kirschner PA. Lung cancer. N Y State J Med 1981;3:339-42. 3. Neptune WB. Primary lung cancer surgery in stage I1 and stage 111. Arch Surg 1988;123:58>5. 4. Stern H. Discussion of [3]. Arch Surg 1988;123:585. 5. Patterson GA, Ilves R. Ginsberg IS, et al. The value of adjuvant radiotherapy in pulmonary and chest wall resection for bronchogenic carcinoma. Ann Thorac Surg 1982;34:692-7.
Tetralogy of Fallot To the Editor: Snir and his colleagues [ l ] are to be congratulated on their truly spectacular results for the so-called absent pulmonary valve syndrome in tetralogy of Fallot. I am intrigued, however, by their Ann Thorac Surg 1991;52:1368-71
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0003-4975/91/$3.50
Are We Losing Out in the Care of Non-Small Cell Lung Cancer Patients? To the Editor: Lung cancer is difficult to cure because it is usually already advanced when discovered. Non-small cell lung cancer discovered early responds to resective operation, but more advanced disease usually requires multimodality therapy. Radiotherapy and operation are the two modalities that are by themselves curative. Each has its strong points. Operation is best in early disease confined to the lung. Radiotherapy, on the other hand, is best for microscopic and macroscopic spread. The area of the spread, if not sterilized, is shrunken so that it can be more easily removed. Thus, radiotherapy and operation in that order complement each other. Trials, 30 years ago, of preoperative irradiation failed to show a survival advantage over operation alone, and its theoretical advantage has not been seriously considered in more modern times. One would think that communication and collaboration between the purveyors of the two curative modalities would occur on a frequent basis, and that radiotherapists and surgeons would be best of friends. This is far from the case. Why can’t the radiotherapist let surgeons know about modern treatmenttreatment optimally consisting of continuous-course small fractions to therapeutic dose levels using molded fields and computerized dosimetry? Why can’t they explain how much better this is than 30 years ago? Why can’t the surgeons acknowledge their gains in preoperative and postoperative care and intraoperative techniques (use of staplers, for example)? Why can‘t we learn to operate after radiotherapy with a reasonable morbidity and mortality? Why can’t the radiotherapist chide the surgeon about sending him or her patients to treat with gross disease left behind? Is this the surgeon who denies that debulking is good therapy but who is applying glorified “dubulking“ in most advanced lung cases, as up to one half of recurrences are local ones? Is this the same surgeon who refers all patients for postoperative radiotherapy where he or she has left gross disease behind or believes he or she might have left any local spread behind? Is this the surgeon who, when reporting results, fails to acknowledge the place postoperative radiotherapy might have played? Why don’t the radiotherapists more often ask the surgeon at least occasionally to refer a virgin (surgically unmolested) case for therapy? Perhaps they are too polite. Or perhaps they realize that they will one day treat the patient regardless of when the surgeon operates. In superior sulcus tumors, why do surgeons shackle the radiotherapist to split-course therapy with operation sandwiched between courses? At least one radiotherapist [l] recommends initial thoracotomy in all possible resectable cases of superior sulcus tumor and then referral for continuous course postoperative radiotherapy. Why can’t the surgeons and radiologists start to speak to each other and work together as a team to re-run the 20- to 30-year-old preoperative radiotherapy trials? During the seemingly interminable time it takes to organize and carry out such trials, should the many locally advanced patients not in the trials be given the benefit of the combined team approach? Perhaps the resident who has never operated on a previously irradiated patient can get to know the satisfaction of resecting a previously unresectable patient who now has a better chance for a cure. Isn’t it time for the surgeon to update his or her thinking and learn to operate after modern therapeutic dose radiotherapy? The chemotherapists are urging such a preoperative chemotherapy approach. Some authors, namely Kirschner [2], Neptune [3], Stem 141, and Patterson and associates 151, have written to a
0 1991 by The Society of Thoracic Surgeons
certain extent on this topic. Why haven’t they been more often heeded and copied? Is it because surgeons are happy just to operate first even if the chance for cure is minimal? I know a pulmonologist who claims to be “surgically minded’ and who refers a patient to operation even if he or she only has a ”1 in 1000” chance because that is the patient’s “only chance.” Wouldn’t he be better off referring to an enlightened radiotherapist who, after therapeutic dose radiotherapy, in turn might refer that patient to an enlightened, modern surgeon who then might, sure enough, resect with a better chance for a cure? Today, a patient is diagnosed medically without being seen by the surgeon, is staged without the surgeon, and is referred without a surgical consult to radiotherapy for “some palliation.” Is this happening because our medical colleagues have given up on us? Given up on our “operate now at all costs” approach? Isn’t there a better chance of our being involved in the decision making, direct patient contact and rapport, and guided optimistic approach when we work as a team with our b u d d i e s t h e radiotherapists? Perhaps the team approach might help educate our pessimistic colleagues and allow some of the locally advanced non-small cell lung cancer patients a better chance for cure. Incidentally, some radiotherapists include in their radiotherapy for cure category disease confined to the hemithorax including ipsilateral supraclavicular or contralateral hilar nodes! Imagine the surgeon operating on such a patient for curative resection of residual disease after a good response to radiotherapy! It might happen. I think surgeons would welcome the chance to regain a place in the care of cancer patients and help save some of the large group of locally advanced patients who are now falling between the cracks. A small increase in cure of such salvage cases would make a real dent in the present miserable outcome in advanced non-small cell lung cancer. Isn’t it strange how rare present-day trials are that combine in logical sequence the two modalities that, by themselves, are curative? They have been replaced by trials of modalities that, by themselves, are noticurativechemotherapy and immunotherapy. Someday after better drugs are found, they may have earned a place in non-small cell lung cancer therapy, but not yet. Are we up to this challenge? 1 believe we are, but it takes a rearrangement of our motivation and thinking to collaborate with the radiotherapists-our great and good buddies. john S. Chattihers, MD Mercy Hospital 4077 Fifth Ave
Sun Diego, CA 92103
References 1. Cox JD. In: Shields TW, ed. General thoracic surgery. Vol 2. Third Ed. Philadelphia, London: Lea & Febiger, 1989:1150-9. 2. Kirschner PA. Lung cancer. N Y State J Med 1981;3:339-42. 3. Neptune WB. Primary lung cancer surgery in stage I1 and stage 111. Arch Surg 1988;123:58>5. 4. Stern H. Discussion of [3]. Arch Surg 1988;123:585. 5. Patterson GA, Ilves R. Ginsberg IS, et al. The value of adjuvant radiotherapy in pulmonary and chest wall resection for bronchogenic carcinoma. Ann Thorac Surg 1982;34:692-7.
Tetralogy of Fallot To the Editor: Snir and his colleagues [ l ] are to be congratulated on their truly spectacular results for the so-called absent pulmonary valve syndrome in tetralogy of Fallot. I am intrigued, however, by their Ann Thorac Surg 1991;52:1368-71
-
0003-4975/91/$3.50
