Ann Thorac Surg 1998;66:1143-1144
© 1998 The Society of Thoracic Surgeons
Original articles: general thoracic
Kathy S. Albain, MDa
a Division of Hematology/Oncology, Cardinal Bernardin Cancer Center, Loyola University Medical Center, 2160 S First Ave, Bldg 112, Rm 109, Maywood, IL 60153-5599, USA
 |
Invited commentary
|
|---|
 Top
 Invited commentary
|
|---|
This analysis of 208 patients contributes to a large literature of prognostic factors and the role of female sex in lung cancer outcome. These previous reports emphasized the importance of a sufficient sample size, the number of predictive factors studied, and use of multivariate models. The most important predictors of favorable survival were stage of disease (separately within small cell and non–small cell), performance status, serum lactic dehydrogenase (LDH) level, and serum albumen level. Female sex was variably reported as a favorable indicator of outcome. Ouellette and associates observed no survival difference between men and women, which changed in favor of women once adjusted for stage. But no information was provided regarding other important known predictors such as LDH level or performance status, nor were treatment details given by stage. Conclusions were drawn from a heterogeneous cohort that combined all histologies and stages. Each critical stage/histology subset was too small to explore the possible independent contribution of female sex to a favorable outcome in a multivariate analysis.
Before this report, large cooperative group data bases were analyzed regarding the independent contribution of female sex to outcome. Appropriately, these studies were separated by small cell and non–small cell histologies. For example, in small cell lung cancer, the Southwest Oncology Group analyzed 2,580 patients; the Toronto Group, 614; the Cancer and Leukemia Group B, 1,521; and the Danish Group, 874. Cox multivariate models in these studies did support an independent favorable predictor status for female sex, especially in limited stage disease. However, when included, a normal LDH level consistently was the most important predictor, and in recursive partitioning models, female sex was only sporadically important. Thus, the biology of small cell lung cancer may be different in female patients, because when available, the LDH variable replaced female sex as a critical factor. In contrast to small cell cancer, less to no significance for female sex was found in large data base analyses of metastatic non–small cell lung cancer. These studies were conducted in the 1980s and early 1990s, before the availability of third-generation regimens that recently have had a favorable impact on survival and before the consistent use of concurrent chemoradiotherapy in limited small cell and stage III non–small cell lung cancer. New analyses of current large data bases are needed to readdress the issue regarding outcome in female versus male patients.
Therefore, this article does not stand alone to either confirm or refute the independent favorable prognostic role of female sex because of a small sample size with a population heterogeneous for stage and histology. However, its major contribution perhaps is this one finding in a consecutively accrued, single-institution cohort: similar clinical presentations and extent of workup were observed for men versus women. With the dramatic rise of lung cancer deaths in women, more studies must be done to confirm these results and to collect data regarding time to diagnosis in men versus women and its potential impact on differential outcome between the sexes. If women with lung cancer indeed have a more favorable prognostic profile at diagnosis, studies must be conducted on the contribution of the hormonal milieu to the molecular biology and molecular epidemiology of lung cancer in men versus women and in women smokers versus nonsmokers.
