What is the role of chemotherapy before surgery in the treatment of operable stage I NSCLC?
Author(s):
- Associate Professor Christos Karapetis — Author
- Cancer Council Australia Lung Cancer Guidelines Working Party — Co-author
Guidelines commissioned by
Last modified:
3 May 2018 00:32:15
What is the role of chemotherapy before surgery in the treatment of operable stage I NSCLC?
Pre-operative neoadjuvant chemotherapy for stage IA
The pre-operative adjuvant therapy approach is predicated on clinical staging, which is principally based on radiological findings, rather than histological evaluation (aside from diagnostic biopsies). The majority of studies evaluating neoadjuvant (or pre-operative) chemotherapy for early stage NSCLC either excluded patients with clinical stage IA disease, or if included they represented a small percentage of the patients. Most studies do not segregate the stage I categories, and often pool stage I and II together in the study analyses. This makes subgroup evaluation of stage IA difficult or impossible. In studies where stage IA disease has been evaluated as a separate subgroup, the results have been variable. There is no confirmed survival benefit.
Pre-operative neoadjuvant chemotherapy for stage IB
The benefit of chemotherapy before surgery is not well established in stage IB NSCLC. The French Thoracic Cooperative Group performed a trial of neoadjuvant cisplatin based chemotherapy in operable stage I,II and III NSCLC. A survival benefit was demonstrated in the pooled stage I and II subgroup.[1] One hundred and thirty one (131) of the total of 355 patients in this study had stage I disease. The Big Lung Trial (BLT/LU22) did not demonstrate a survival benefit for neoadjuvant chemotherapy in the overall study population, which included stage I, II and III NSCLC.[2] An associated systematic review did reveal a benefit.[3] A meta-analysis of 13 randomised controlled trials also showed a benefit, but this was particularly evident for patients with stage III NSCLC, whilst the findings for stage I and II were inconclusive.[4] A previous systematic review produced similar conclusions.[5] The Spanish Lung Cancer Group conducted a trial comparing surgery alone to neoadjuvant chemotherapy or post-operative chemotherapy (Carboplatin + Paclitaxel x three cycles). No benefit was seen with chemotherapy in stage I patients, regardless of whether the chemotherapy was administered before or after the surgery.[6] A meta-analysis comparing post-operative and pre-operative chemotherapy did not find a difference in outcome according to the timing of the chemotherapy around surgery.[7]
Brouchet et al[8] reported that pre-operative chemotherapy did not increase post-operative complications. In a phase II study from Japan, there were more complications post surgery if neoadjuvant chemotherapy is combined with radiotherapy and the dose of radiotherapy was greater than 45Gy.[9]
Evidence summary and recommendations
| Evidence summary | Level | References |
|---|---|---|
| There is insufficient data to support the use of chemotherapy before surgery for stage IA NSCLC.
Last reviewed December 2015 |
I, II | [7], [6], [1] |
Evidence-based recommendation
|
Grade |
|---|---|
 Last reviewed December 2015 |
B |
| Evidence summary | Level | References |
|---|---|---|
| There is insufficient data to support the administration of chemotherapy before surgery for stage IB NSCLC.
Last reviewed December 2015 |
I, II | [7], [6], [1] |
| Evidence-based recommendation
|
Grade |
|---|---|
Last reviewed December 2015 |
B |
References
- ↑ 1.0 1.1 1.2 .
- ↑ .
- ↑ .
- ↑ .
- ↑ Burdett S, Stewart LA, Rydzewska L. A systematic review and meta-analysis of the literature: chemotherapy and surgery versus surgery alone in non-small cell lung cancer. J Thorac Oncol 2006 Sep;1(7):611-21 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17409927.
- ↑ 6.0 6.1 6.2 .
- ↑ 7.0 7.1 7.2 Lim E, Harris G, Patel A, Adachi I, Edmonds L, Song F. Preoperative versus postoperative chemotherapy in patients with resectable non-small cell lung cancer: systematic review and indirect comparison meta-analysis of randomized trials. J Thorac Oncol 2009 Nov;4(11):1380-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19861907.
- ↑ .
- ↑ .
Appendices
