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1947
The American College of
Surgeons Commission on
Cancer and the American
Cancer Society
The National Cancer Data Base
Report on Lung Cancer
Willard A. Fry, M.o., F.A.c.s.~
Herman R. Menck, M.B.A.’
David P. Winchester, M.D., F.A.C.S>
’ Commission on Cancer, American College of Surgeons, Chicago, Illinois.
* Department of Surgery, Northwestern University Medical School, Chicago, Illinois, and
Department of Surgery, Evanston Hospital, Evanston, Illinois.
BACKGROUND. Previous Commission on Cancer data from the National Cancer
Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. The most current (1992) data for lung
cancer are described here.
METHODS. Four Calls for Data have yielded a total of 560,455 lung cancer cases
diagnosed in 1986-1987 and 599,597 cancer cases diagnosed in 1992, from hospital
cancer registries across the United States.
RESULTS. A total of 91,115 lung cancer cases diagnosed in 1986-1987 and 92,182
diagnosed in 1992 were reported from cancer registries across the United States.
Lung cancer occurs mainly in patients between the ages of 50 and 80 years. There
was an increasing relative frequency of adenocarcinoma, and of lung cancer in
women, and a noteworthy poor prognosis among African Americans. Lung cancer
patients were reported from all types and sizes of hospitals in America, from
smaller community hospitals to major teaching centers. Treatment by surgical
resection occurred more frequently in the major cancer centers. The overall prognosis for lung cancer remains extremely poor.
CONCLUSIONS. For a selective category of patients (Stage I), cancer-directed surgery
offers reasonable cure rates, but these data underline the need for earlier diagnosis
and improved treatment modalities in the overall management of lung cancer
patients. Cancer 1996; 721947-55. 0 I996 American Cancer Society.
KEYWORDS lung cancer, national survey, treatment, survival, National Cancer
Data Base.
L
Address for reprints: Herman R. Menck, M.B.A.,
American College of Surgeons, 55 East Erie
Street, Chicago, IL 60611.
Received August 21, 1995; revision received
January 15, 1996; accepted January 15, 1996.
0 1996 American Cancer Society
ung cancer is the second most common cancer among U.S. men
and women, accounting for 170,000 new cases in United States in
1995.’ It is also the most common cause of cancer death among both
sexes, with an estimated 157,400 lung cancer deaths in 1995. Lung
cancer occurs mainly between the ages of 50 and 80 years, and the
incidence of lung cancer continues to rise among U.S. women.’ Appropriate treatment for lung cancer continues to be under clinical
in~estigation.~-*
Previous National Cancer Data Base reports confirmed the marked increase in incidence among women and have
highlighted the extremely grim prognosis of this d i ~ e a s e . ~This
” ” report continues to monitor these trends.
1948
CANCER May 1,1996 / Volume 77 I Number 9
MATERIALS AND METHODS
The methods of the NCDB and the Commission on Cancer (COCI have been previously described.”-I3 These data
from NCDB participating hospitals make up a convenience sample voluntarily submitted by hospital cancer
registries. Eighty percent of the cases come from facilities
that are members of the Approvals Program of the Commission on Cancer. The types of medical facilities and
their annual cancer caseloads are further described below.
Data received included 91,115 lung cancer cases first
accessioned in 1986-87 from 513 hospitals and 92,182
cases in 1992 from 1,183 hospitals. These data represent
approximately 30% and 55% of all lung cancers in the
United States in 1986-87 and 1992, respectively. Among
the reported 1992 lung cancer cases, most patients (73%)
were diagnosed and treated at the reporting hospitals,
21% received all or part of their treatment at the reporting
hospital but were diagnosed elsewhere, and 5% were diagnosed at the reporting hospital but treated elsewhere.
Surgical procedures were coded following the Data
Acquisition Manual (DAM14).Stage was coded using the
fourth edition of the American Joint Committee on Cancer (AJCC) staging manual.’’ To maximize the number of
patients for whom stage was reported, “Combined AJCC
Stage Group” was used, which includes the pathological
(pAJCC) stage group when documented, augmented by
the clinical (cAJCC) stage group when pathologic stage is
not recorded. Approximately 20% of the 1992 cases were
reported without clinical or pathologic AJCC Stage Group.
Anatomic site and histology were coded using the ICD0 2 CM manual.lfiSurvival rates were computed for cases
diagnosed in 1986-87 following traditional procedures
for relative ~urvival.’~
The purpose of this analysis is to describe group
trends across the years of this study and to formulate
hypotheses from associations indicated in the descriptive
analyses. The aggregate NCDB data are presented in several summary tables and figures.
RESULTS
The lung cancer cases were divided into small cell and
nonsmall cell tumors, and comparisons were made regarding patient and tumor characteristics between these
two histologic subgroups for the time periods 1986-87
and 1992. The median age of nonsmall cell patients reported was 66.2 years for 1986-87 and 67.4 years for 1992.
The median age reported for small cell tumor patients
was 65.2 years for 1986-87 and 66.4 years for 1992. The
percentage of reported lung cancers among females increased from 34.2% in 1986-87 to 37.5% in 1992 for nonsmall cell lung cancers and from 41.5% in 1986-87 to
45.3% in 1992 for small cell cases. The dominant ethnic
group reported was non-Hispanic white (85.8% for nonsmall cell lung cancer, 89.6% for small cell lung cancer
in 1992). This reflects the composition of cases from the
hospitals reporting these data.
There was little change over time in the anatomic
subsite distribution of the reported lung cancers, with the
primary tumor occurring most frequently in the upper
lung. The subsite distribution for nonsmall cell cancers
included main bronchus (6.4% in 1986-87,6.1% in 1992),
upper lobe (48.9% in 1986-87, 49.8% in 1992), middle
lobe (4.4% in 1986-87, 4.6% in 19921, lower lobe (21.4%
in 1986-87,22.5% in 19921, overlapping subsites (3.0% in
1986-87, 3.3% in 1992), and subsite unknown (15.9% in
1986-87, 13.7% in 1992). The subsite distribution for
small cell cancers included main bronchus (12.9% in
1986-87, 13.4% in 1992), upper lobe (39.8% in 1986-87,
40.5% in 19921, middle lobe (4.3% in 1986- 87, 4.7% in
1992),lower lobe (16.2%in 1986-87, 17.5%in 1992),overlapping subsites (3.9% in both 1986-87 and 1992), and
subsite unknown (23.0 in 1986-87, 20.1% in 1992).
In 1992, significant percentages of patients were
reported as unstaged, including 19.4% of nonsmall cell
tumor patients and 21.8% of small cell tumor patients.
For all lung cancers combined, adenocarcinoma was
reported with increasing frequency (27.7% in 1986/87
versus 30.8% in 1992) and squamous cell carcinoma
with decreasing frequency (37.6% in 1986/87 versus
32.4% in 1992). These data still indicate that squamous
cell carcinoma is more frequent in our data. Adenocarcinoma occurs with greater relative frequency in
women (33.5% in 1986-87, 34.9% in 1992) than in men
(24.7% in 1986-87 and 28.3% in 1992).
The cases were reported from various-sized hospitals
with a range of annual cancer case loads, including, in
1992, 0.9% from hospitals with fewer than 150 cases per
year, 20.5% from hospitals with 150-499 cases, 40.8%
from hospitals with 500-999 cases, 28.8% from hospitals
with 1,000 or more cases, and 8.9% from hospitals with
unknown case loads. There was little difference in the
distribution of reporting hospital size between 1986-87
and 1992.
In applying COC approval program categorization
for hospitals, most of the lung cancers were reported
from teaching hospitals (21.9% in 1986-87, 17.7% in
1992), community comprehensive cancer centers
(40.0% in 1986-87, 33.8% in 1992), community medical
centers (29.9% in both 1986-87 and 1992), and hospitals without approval status (5.8% in 1986-87, 15.9% in
1992), with fewer cases reported from NCI-designated
cancer centers (2.2% in 1986-87,2.5% in 1992. The data
suggest that there is a relatively even distribution of
lung cancer cases across institutions, from major designated cancer centers to teaching hospitals to smaller
community hospitals. This even distribution has implications for establishing new treatments and perhaps
clinical trial evaluations.
NCDB Report on Lung CancerlFry et al.
1949
TABLE 1
Percent of Nonsmall Cell Lung Cancers By Combined Stage (pAJCClcAJCC)and Selected Patient, Tumor, and
Reporting Hospital Characteristics, 1992
Stage group
Ratio" of
advanced 10
earlydisease
Cases
764
3578
10350
22124
19850
5726
62392
0
I
11
111
N
Total
2.2
0.4
0.4
0.4
0.5
0.7
0.5
18.1
15.5
18.5
23.4
27.4
26. I
23.6
6.4
4.9
6.8
7.2
7.4
6.6
7.0
28.3
31.8
31.3
31
31
31.3
31.1
45.0
47.3
43.0
37.9
33.8
35.3
37.8
100
100
100
I00
3.9
5.3
4.3
3.2
2.6
2.7
3.2
0.4
0.6
22.0
26.2
7.1
6.9
32.1
29.4
38.3
36.9
100
100
3.4
2.7
38981
23406
05
0.9
0.2
1.3
0.5
0.6
24.3
19.1
18.2
16.9
20.3
23.9
7.2
4.8
5.3
5.2
5.8
8.7
30.9
29.5
33.9
35.1
31.7
29.8
37.2
45.7
42.4
31.6
41.7
37.1
100
100
100
100
100
3
4
4.4
4.5
3.8
3.1
53601
1093
5341
17
856
1421
0.2
0.4
0.6
2.1
22.1
23.7
24.9
23.2
6.1
7.2
7.6
33.2
30.8
31.2
29.8
38.3
37.9
36.6
37.4
3.5
3.1
2.9
3.0
8469
4490(i
5377
3640
0.6
0.4
0.6
0.4
0.7
4.2
7.4
7.9
8.9
7.8
2.7
7
45.1
31.8
27.4
27.2
36.2
28.3
31.1
41.4
33.6
34.5
33.2
40.2
62.1
37.8
9.8
2.7
2.3
2.3
5.4
13.1
3.2
3922
31641
2881
14108
20H3
0.5
8.7
26.7
29.6
30.2
15.1
6.3
23.6
1.0
0.3
0.2
0.3
0.9
47.2
38
20.4
16.7
18.6
8.9
21.5
21.6
38. I
45
45.9
ion
7.7
5.3
4.4
21.5
29.1
33.5
32.8
30.2
100
100
100
100
1.1
1.6
3.9
4.9
4.1
2624
10549
22906
5180
21133
0.3
22.3
7.1
28.1
42.2
100
3.4
19670
0.5
0.1
0.8
26.2
15.7
25.5
8.5
4.9
5.9
37.8
33.3
24.9
27
45.9
100
100
100
2.7
5.3
2.8
20393
7372
14957
Age
<40
'10-49
50-59
60-69
i0--;9
80 -
Total
Sex
Male
Female
Ethnicity
Non-Hispanic white
llispsnic
Black
hnerican Indian
Asian
Ilnknown
I00
100
100
I00
Income
Low
Middle
High
U nknow
Anatomic subsite
Main bronchus
Upper lobe
Middle lobe
Lower lobe
Overlapping
Unknown
lotal
Grade
Grade 1
Grade 2
Grade 3
Grade 4
Unknown
f listology
Adenocarciiioma
Squamous cell
carcinoma
Large cell carcinoma
Other
0.6
6.6
II
41.9
100
100
I00
100
100
I00
100
100
100
100
100
..--I IJI
62392
41CC American Joint Cornrnillw on Cancer.
Hanu = Pane arouus I1 1 Ill 1 IVJSIaRe moup 0 tI
Nonsmall Cell Lung Cancer AJCC Stage Grouping
Young patients were reported with more advanced disease (40-49 years, 45.0% Stage 1v) than were older patients, for example, those aged 70-79 years (33.8% Stage
N ; Table 1). Hispanics (45.7%) and blacks (42.4%) were
reported with more Stage IV nonsmall cell lung cancer
than non-Hispanic whites (37.2%). No marked differ-
ences in stage distribution were reported by income, size,
or type of hospital.
An expected correlation was reported between advanced stage and higher histologic grade. The ratio of
advanced disease (Stages 11,111, IV) to early-stage disease
(Stages 0, I) varied widely by anatomic subsite, from ii
high of 9.8 for the main bronchus to 2.3 for the middle
1950
CANCER May 1,1996 I Volume 77 I Number 9
TABLE 2
Percent of Small Cell Lung Cancers by Combined Stage (pAJCClcAJCC)and Selected Patient, Tumor, and
Reporting Hospital Characteristics, 1992
Stage group
Ratio' of
advanced to
0
I
11
111
1v
Total
early disease
Cases
0.0
0.2
0.3
0.2
0.3
0.3
0.2
4.5
6.6
7.7
8.3
9.8
10
8.7
I .5
2.8
4.1
4.1
3.7
2
3.8
30.3
36.1
31.3
29.7
30.1
28.8
30.4
63.6
54.4
56.7
57.6
56.1
58.8
56.9
I00
21
13.8
11.6
10.7
8.9
8.7
10.2
66
607
2089
4417
3540
787
1 1506
0.3
0.2
8.6
8.e
3.8
3.7
28.3
32.9
59
54.4
I00
100
10.3
10.1
6326
5179
0.2
1.2
0
0
0.9
0.4
8.8
6.4
7.4
9.:
7.:
3.8
4.1
3.6
0
3.5
1.6
30.4
28.1
31.9
23. I
29.2
28.9
56.8
60.2
57.1
69.2
56.6
61.4
100
100
100
100
100
100
10.1
12.2
12.5
12
8.4
11.3
10289
171
674
13
113
246
0.1
9.9
8.4
7.8
10.2
3
4
3.8
2.7
29.7
30.4
29.6
32.fi
57.3
57
58.4
53.6
100
100
100
100
9
10.6
11.1
a
1533
a440
850
675
11.2
9.5
8.7
8.1
7.3
6
4
3.6
3.7
3.8
22.4
28
30.6
32.3
30.3
60.3
58.4
57
55.5
57.2
100
100
100
100
100
7.9
9.4
i 0.3
10.9
10.6
116
2495
4808
3045
1042
20.6
5.9
5.4
4.4
3.8
3.6
26.5
30.4
28.8
31.9
28.4
47.1
49.1
58.2
55.4
59.3
100
100
100
100
100
3.9
5.6
34
112
777
6384
4199
Age
.:40
40-49
50-59
M-69
i0-79
80 4
Total
100
100
100
100
:00
100
Sex
Male
Female
Ethnicity
Yon-Hispanic white
Hispanic
Slack
American Indian
.Asian
Unknown
Income
l.ow
Middle
High
Unknown
Hospital caseload
< i50 cases
150-499 cases
500-.999 cases
1000; cases
Ilnknown size
G:ade
Grade 1
Grade 2
tirade 3
Grade 4
Unknown
0.2
0.5
0.9
0.0
0.1
0.1
0.3
0.8
0
0
0.3
0.1
0.5
- 7
I.,
15.2
8.4
8.8
8.2
10.6
10.3
10.5
AJCC: American Joint Committee on Cancer.
Ratio - Slage groJps I1 111 t WiStage group 0 t I
+
and lower lobes, and by histology, from a high of 5.3 for
large cell carcinoma to 2.7 for squamous cell carcinoma.
Small Cell Lung Cancer AJCC Stage Grouping
The ratio of advanced disease (Stages 11, 111, IV) to earlystage disease (Stages 0, I) was much higher (10.2) for all
small cell lung cancers, compared with 3.2 for nonsmall
cell lung cancers (Table 2). For small cell lung cancer,
worse stage prognosis increased with younger age, lower
income, higher hospital case load, and higher histologic
grade. More advanced disease was also reported for Hispanics, blacks, and those whose tumor was located in the
main bronchus.
Surgery for Nonsmall Cell Lung Cancer
The pattern of surgery for nonsmall cell lung cancers by
diagnosis year and by covariables of interest is shown in
Table 3. There was a predominance of lobectomy (17.1%)
over pneumonectomy (4.0%) and a decreasing incidence
of pneumonectomy with increasing age (6.7% for ages
40-44 years, 2.8% for ages 79-79 years). l h e r e was little
change in surgical patterns between reporting periods.
Patients from high-income neighborhoods more frequently underwent resection (segmental, lobectomy,
pneumonectomy 30.8%) than were those from low-income neighborhoods (21.1%). Non-Hispanic whites were
reported with higher percentages of surgical resection
NCDB Report on Lung CancerlFry et al.
1951
TABLE 3
Percent of Nonsmall Cell Lung Cancer I:ases By Surgery and Selected Patient, Tumor, and Reporting Hospital Characteristic
Diagnosis year
1986-87
1992
Total
pAICClcAICC'
Stage 0
Stage I
Stage II
Stage ill
Stage IV
IJnkiown
Total
None
Partial wedge
segmentalresection
Lobectomyl
bUoectomy
Pneumonectomy
Other
Unknown
Total
Cases
66.i
69.i
6a.i
3.3
3.7
3.5
16.2
17.9
17.1
4.1
3.9
4.0
5.5
3.5
4.5
4.2
1.2
2.6
100
100
100
73394
75950
149344
56.3
31.5
33.9
78.1
89.3
75.7
69.7
7.2
II
3.6
2.3
1
2.8
3.7
17.7
50.5
44
11.3
2.3
11.6
17.9
8.9
4.8
16.7
5.4
0.8
2.2
3.9
8.5
1.5
1.5
2.6
100
100
100
6.1
3.2
3.5
1.4
0.2
0.3
0.4
0.5
4.5
1.2
293
14380
4255
18977
23137
14908
75950
59.5
65.2
65.6
66.7
71.4
85.2
5.9
3.2
3.4
3.8
4.1
2.8
20.7
18
19.4
20.3
17.7
7.6
5.9
6.7
5.7
4.5
2.8
0.9
7.2
5.8
4.7
3.7
2.8
2
0.8
69.0
76.4
76.8
82.4
73.7
62.2
3.9
2.R
2.8
2.2
3.6
2.3
18.7
13.5
12.4
12.1
16.6
14.6
4.0
2.5
3.1
2.2
3.3
3.3
3.3
4.2
3.8
1.1
2.3
11.5
1.1
0.7
1.2
0
0.4
6.2
74.2
69.5
64.8
69.9
3.2
3.7
4.8
3.3
14.4
18.1
22
17.5
3.5
3.9
4
4.Y
3.6
3.5
3.5
3.8
1.1
1.3
0.9
0.7
56
66
70.4
71.4
77.9
71.8
5.2
4.3
3.4
3.8
4.1
3.4
23.9
19.6
17.9
17
11.3
16.8
6
4.3
3.9
3.5
3.6
3.9
5.2
4.8
3.3
2.9
3.1
3.3
3.7
0.9
1.1
1.4
0
100
100
100
100
Age'
c 40
40-49
50-59
60-69
70-79
ao
Ethniciry"
Non-Hispanic white
Hispanic
Black
American Indian
Asian
Unknown
Incomed
Low
Middle
High
llnknown
Type of hospital (approval category)>
NU-designated cetiter
Teaching hospital
Commutiity-comprehension
Community
Other approved
Nonapproved
1.1
1.2
1.1
1.3
1.4
0.8
100
100
100
100
100
I00
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
963
4187
12066
26465
24487
7782
65022
1345
6747
91
1024
1721
10135
55090
6344
4381
2067
13730
25306
22814
195
11838
AICC: American Joint Chmittee on Cancer; NCI: Naliunli Cancer Instirule.
Surgical procedures were coded following the DAM, including no cancer-directed surgery: 0-8;surgery unknown: 9; partiallwedgelsegmenrdresection: 20-29; lobecionlvlbilobectomy;30-49 pneurnonectomy:
50-79: and other (local rmcrion, distanr siw, and surge7 KOS): 10-19.80-99.
' 1992.
(26.6%) than were Hispanics (18.8%) or blacks (18.3%).
There was also a higher incidence of resection in the
NCI-Designated Cancer Centers and teaching hospitals
as opposed to smaller community hospitals, and also for
tumors located in the lobes, for tumors of lower histologic
grade, and for adenocarcinomas.
Multimodality Treatment for Nonsmall Cell lung Cancer
Over time there has been a decreasing use of radiotherapy
alone (33.7% in 1992 versus 39.6% in 1986-87) and an increasing utilization of chemotherapy (6.8% in 1992 versus
5.3% in 1986-87) and combined chemotherapy and radiation (10.7%in 1992 versus 7.6% in 1986-87; Table 4).
Non-Hispanic whites (20.1%)and those of higher income (23.2%)were more likely to have received surgery
alone than Hispanics (14.9%) and blacks (13.7%) and
those of low income (16.4%). Patients seen at hospitals
with small case loads ( ~ 1 5 cases
0
per year) were more
frequently reported to receive no treatment (34.6%)than
those seen at hospitals with case loads of 500-999 cases
per year (19.2%) or those with 1,000 or more cases per
year (17.0%).
1952
CANCER May 1, 1996 / Volume 77 / Number 9
TABLE 4
Percent of Nonsmall Cell Lung Cancers by Treatment Combination and Selected Patient, Tumor, and Reporting Hospital Characteristic
Diagnosis year
1987
1992
Total
pAJCC/cAJCCa
Stage 0
Stage I
Stage I1
Stage 111
Stage N
Unknown
Total
Agea
< 40
40-49
50-59
60-69
70-79
80t
Ethnicity'
Non-Hispanic
white
Hispanic
Black
American
Indian
Asian
Unknown
Incornea
Low
Middle
High
Unknown
Hospital caseloada
< 150 cases
150-499 cases
500-999 cases
1OOOt cases
Unknown size
Total
Surgery
Radiation
Chemotherapy
Surgery &
radiation
Radiation &
chemotherapy
Other
None
Total
Cases
18.4
19.3
18.9
39.6
33.7
36.6
5.3
6.8
6.1
8.6
6.7
7.7
7.6
10.7
9.2
2.2
3
2.6
18.2
19.7
18.9
100
100
100
75360
77452
152812
32.8
62
35.6
7.7
2.8
13.5
19.3
21.6
18.8
19.5
41.8
41.4
30.4
33.7
5.2
1.3
2.2
6.9
11
6.9
6.8
6.2
4.3
24.3
9.2
4.7
4
6.7
3.6
1.7
3.8
15.2
15.6
8.2
10.7
4.6
1.5
6
4.4
2.7
2.2
3.0
25.9
10.3
8.6
14.8
21.8
34.8
19.7
100
100
100
100
100
100
100
305
14717
4368
19404
23598
15060
77452
23.3
16.7
18.8
21.4
20.4
10.8
16.3
22.8
28.8
32.4
38.1
40.2
14
10
8.4
7.7
5.6
2.5
6
9.4
9
7.7
5.6
2.4
19.8
22
17.4
12.1
6.5
2.1
10.8
7.6
5.4
3.2
1.4
0.3
9.8
11.4
12.3
15.6
22.5
41.7
100
100
100
100
100
100
981
4258
12323
26905
25011
7974
20.1
14.9
13.7
33.4
32.1
37.6
6.7
9.6
7.1
6.8
5.1
5.9
10.6
11.5
12.3
3
2.8
2.5
19.4
24
21
100
100
100
66429
1353
6765
11
15.4
19.8
50.5
31.8
34.3
11
9.5
5.1
6.6
6.4
7.8
5.5
14.5
7
0
4
3.7
15.4
18.4
22.3
100
100
100
91
1024
1790
16.4
19.4
23.2
19.1
37.9
33.9
25.2
33.7
6.5
6.6
8.8
6.8
6.3
6.8
6.6
6.6
9.9
10.6
12.5
11.7
1.9
3
4.6
3.7
21
19.6
19.1
18.3
100
100
100
100
10302
56260
6462
4428
13.2
17.2
18.8
20.8
22.2
19.3
28.6
32.5
35.2
34
29.7
33.7
6.7
7.4
6.1
7.1
7.6
6.8
4.6
5.8
7
7.1
7
6.7
9.8
10
10.9
10.9
11.2
10.7
2.6
2.7
2.8
3.2
4.1
3
34.6
24.4
19.2
17
18.3
19.7
100
100
100
100
100
100
697
15796
31540
22493
6926
77452
AJCC American Joint Committee on Cancer.
a
1992.
Multimodality Treatment for Small Cell Lung Cancer
Very few patients underwent surgical treatment for small
cell lung cancer (Table 5). Radiotherapy used alone for
small cell lung cancer is not particularly common. The
bulk of patients receive chemotherapy or combined chemotherapy and radiation treatment for most stage levels.
Major differences in patterns of treatment for small cell
lung cancer between age groups, sexes, ethnic groups,
and hospitals of different sizes and types were not noted.
Patients of low income and those seen at hospitals with
small case loads were less likely to have received combined radiation and chemotherapy.
Nonsmall Cell Lung Cancer Survival
Five-year relative survival for nonsmall cell lung cancer
varied by stage from 42% (Stage I), to 22% (Stage 111, to
5% and 3%for Stages I11 and IV,respectively (Fig. 1).Fiveyear survival for Grade 1 tumors was somewhat better, at
28%, than that for Grade 2 (19%), Grade 3 (12%), and
Grade 4 (10%) tumors. Five-year survival was uniformly
poor for all age, sex, income, and ethnic groups (approximately 14%,all stages combined).
Five-year survival was analyzed by type of surgery by
stage. For each stage, an advantage was reported for those
who were selected for lobectomy/bilobectomy and partial
NCDB Report on Lung Cancer/Fry et al.
1953
TABLE 5
Percent of Small Cell Lung Cancer Cases By Treatment Combination and Selected Patient, Tumor, and Reporting Hospital Characteristic
~~~~
Diagnosis year
1986-87
1992
Total
pAJCClcAJCC'
Stage 0
Stage I
Stage I1
Stage 111
Stage IV
Unknowii
Total
Incomea
Low
Middle
High
Unknown
Hospital caseload"
< 150 cases
150-499 cases
500-999 cases
1000t cases
Unknown size
Total
~
Surgery
Radiation
Chemotherapy
Radiation &
chemotherapy
Other
None
Total
Cases
1.7
1.2
1.5
9.4
7
8.2
35.4
39.3
37.3
33.7
34
33.8
5.4
3.5
4.5
14.4
15.2
14.8
100
100
100
15755
14722
30477
3.6
5.8
4.4
0.6
0.6
1.1
1.2
7.1
5.3
4.8
E.2
8.2
E'. 1
35.7
32.9
30.5
35.4
43.9
37.3
39.3
32.1
35.4
37.2
44.6
28.9
31.9
34
3.6
8.7
12.3
2.6
2.9
2.7
3.5
17.9
11.7
10.9
10.6
15.5
20.9
15.2
100
100
100
28
996
433
3497
6552
3216
14722
1.1
1.1
1.9
&I
41.6
39.2
36.7
38.2
30.8
34.1
36
36.8
2.1
3.1
3.7
3.6
16.3
15.4
100
37.3
40.7
38.6
39.6
38.3
39.3
27.1
30.3
35.5
34.9
33.4
34
1.2
3.1
3.3
3.8
4.0
3.5
28.9
18
14.1
14
15.1
15.2
1
I
i1.7
5.9
1
0.6
1.6
1.1
1.1
0.9
1.2
11.8
6.4
?.3
6.6
8.3
7
100
100
100
100
1868
10928
1063
863
100
100
100
16
14.3
166
3130
6089
4056
1281
14722
100
100
100
100
100
100
'AICC: American Joint Committee on Cancer.
1992.
Perc en1
Percent
A J C C Stag
AJCC Stag
-+
--
I
--*--II
80
60
--t
II
111
IV
I
100
61
33
25
21
1Q
II
100
60
29
18
17
15
/I1
100
35
11
7
6
5
IV
100
27
6
4
2
2
Years
FIGURE 1. Five-year relative survival from nonsmall cell lung cancer.
FIGURE 2. Five-year relative survival from small cell lung cancer.
wedgelsegmental resection. For example, for Stage I, 5year survival differed by type of surgery, from lobectomy/
bilobectomy (55%),to partial wedgelsegmental resection
(49%), to pneumonectomy (44'%), to other noncancerdirected surgery or no surgery at all (16%). For Stage 11,
5-year survival varied from lobectomylbilobectomy
(32%), to partial wedge/segmental resection (28%), to
pneumonectomy (25%), to other or none (9%).
Five-year survival was also analyzed by treatment
combination. Better survival was reported for patients
with resectable tumors. Comparing treatments of surgery
only versus radiotherapy only yielded survival results for
Stage I of 55% (surgery only) versus 9% (radiotherapy
only), for Stage I1 33% versus 7%, for Stage I11 23% versus
3%), and for Stage IV 14% versus 4%.
These data are less favorable than data from other
1954
CANCER May 1,1996 / Volume 77 / Number 9
reports showing a 5-year survival for TlNoMosquamous
cell carcinoma of approximately 80%.” However, because
Stage I cancers in the NCDB data were not subgrouped
by precise node sampling, such as was done by the Lung
Cancer Study Group, such stratified analysis could not be
performed. These NSCLC survival data are similar to
those from the SEER Program, which reported similar
5-year relative survival rates, including localized disease
49.4%, regional 16.0%, distant 1.6%, unstaged 8.3%, and
all 15.2%.’*
Small Cell Lung Cancer Survival
Five-year relative survival for small cell lung cancer varied
by stage from 19% (Stage I), to 15% (Stage 11), to 5% and
2% for Stages 111 and IV,respectively (Fig. 2). The 5-year
survival was uniformly poor for all age, sex, income, and
ethnic groups (6%), and treatment did not markedly effect
survival. These SCLC survival data are similar to those
from the SEER Program, which reported similar 5-year
relative survival rates, including localized disease 17.1%,
regional 8.7%, distant 1.6, unstaged 5.8%, and all 5.0%.18
DISCUSSION
These data suggest that our hospital cancer registries are
capable of pooling significant amounts of data on cancer
patients, which will have continuing significance for evaluation of treatment and planning of new treatment strategies. The overall unfavorable survival rates not only for
small cell lung cancer but also nonsmall cell lung cancer
are well known.’ There has not been a significant improvement with time, and controversy continues regarding what forms of additional therapy are appropriate. Statistically significant treatment modifications will best be
made through large cooperative group studies. The current NCDB data suggest that there is a need for more
clinical investigation of multimodality therapy for the
treatment of lung cancer. These data suggest that more
therapeutic approaches are available at major cancer centers and teaching hospitals than at community cancer
centers.
The data show that lung cancer patients are treated
not only in major cancer centers but also in large and
small community hospitals, suggesting that increased
clinical trial activity would be meaningful in community
hospitals, provided that an adequate clinical trial organization is present. The data suggest that patient accrual
to clinical trials will be limited if more community cancer
center participation is not achieved.
Because of the large number of patients afflicted with
lung cancer and the current mediocre survival results,
these data underscore the continuing need for earlier diagnosis, better staging, and improved treatment modalities. Strategies involving coordinated efforts by hospitals
with established cancer programs should be important
in the years to come.
APPENDIX: STAGING OF CANCER OF THE LUNG (Definition of TNM)
Primary tumor 0
Tx
TO
Tis
T1
T2
T3
T4
Primary tumor cannot be assessed, or tumor proven by the presence of
malignant cells in sputum or bronchial washings but not visualized
by imaging or bronchoscopy
No evidence of primary tumor
Carcinoma in situ
Tumor 3 cm or less in greatest dimension, surrounded by lung or
visceral pleura, without bronchoscopic evidence of invasion more
proximal than the lobar bronchus ( i t , not in the main bronchus)a
Tumor with any of the following features of size or extent: more than 3
cm in greatest dimension; involving main bronchus, 2 cm or more
distal to the carina; invading the visceral pleura; associated with
atelectasis or obstructive pneumonitis that extends to the hilar
region but does not involve the entire lung
Tumor of any size that directly invades any of the following: chest wall
[includingsuperior sulcus tumors), diaphragm, mediastinal pleura,
or parietal pericardium; or tumor in the main bronchus less than 2
cm distal to the carina but without involvement of the carina; or
associated atelectasis or obstructive pneumonitis of the entire lung
Tumor of any size that invades any of the following: mediastinum,
heart, great vessels, trachea, esophagus, vertebral body, carina; or
tumor with a malignant effusionb
Regional lymph nodes (N)
~~
NX
NO
N1
N2
N3
~~
~
~~
~
Regional lymph nodes cannot be assessed
No regional lymph node metastasis
Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph
nodes, including direct extension
Metastasis in ipsilateral mediastinal and/or subcarinal lymph nod+)
Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or
contralateral scalene, or supraclavicularlymph nodes(s)
Distant metastasis (M)
Mx
MO
M1
Presence of distant metastasis cannot be assessed
No distant metastasis
Distant metastasis
Stage grouping
Stage
T
N
M
Occult
Tx
0
Tis
I
T1
NO
NO
NO
NO
N1
N1
N2
N2
NO
N1
N2
N3
AnY N
Any N
MO
MO
MO
MO
MO
IIIB
T2
T1
T2
TI
T2
T3
T3
T3
hYT
N
AnY T
I1
IIIA
T4
MO
MO
MO
MO
MO
MO
MO
MO
M1
The uncommon superficial tumor of any Size with its invasive component limited to the bronchial
wall, which may extend proximal to the main bronchus, is also classified as T1.
Most pleural effusions associated with lungcancer are due to rumor. However,there ate a few patients
in whom multiple cytopathologic examinations of pleural fluid are negative for tumor. In these cases,
fluid is non-bloody and is not exudate. When these elements and clinical judgemenl dictate that rhe
effusion is not related to the tumor, the effusion should be excluded as a staging element and the
patient should be staged as T1, T2, or T3.
a
NCDB Report on Lung CancerIFry et al.
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