Induction chemotherapy for locally advanced non-small cell lung cancer

The poor survival of patients with stage III non-small cell lung cancer has led to a reevaluation of the role of systemic chemotherapy administered before operation. The results of 15 phase-II pilot trials of induction chemotherapy (5 with chemotherapy alone; 4 with chemotherapy and radiotherapy; and 6 with chemotherapy and concurrent radiotherapy) are reviewed in this article, and recommendations for future randomized studies are made. For most trials, only patients in stage IIIa were eligible, but five trials included both IIIa and IIIb patients. The studies employed a variety of chemotherapy and radiotherapy induction protocols, but no superiority could be demonstrated for the administration of chemotherapy and radiotherapy over chemotherapy alone. Response was observed in more than 50% of patients overall, although the complete clinical remission rate was always less than 15%, and the pathologic complete response rate was usually less than 10%. After induction therapy, approximately 70% of patients were eligible for a thoracotomy, and complete resection was possible in 60% of patients. The median survival ranged from 8 to 32 months, with a median of approximately 1 1/2 years. Two-year to 3-year survival ranged from 25% to 30%. The studies reviewed showed that induction therapy followed by surgical resection is feasible and is not associated with unacceptable toxicity. The apparent survival benefit conferred by such combined modality treatment may be due to patient selection, and until randomized trials are undertaken, induction therapy and surgical intervention for locally advanced non-small lung cancer must be viewed as experimental.