Lung cancer

Philip C Hoffman, Ann M Mauer, Everett E Vokes

Lung cancer remains a major worldwide health problem, accounting

for more than a sixth of cancer deaths. The proportion of cancers that
are adenocarcinomas is increasing in North America and to some degree in
Europe, leading to a changing clinical picture characterised by early
development of metastases. Newer diagnostic techniques have allowed for more
accurate tumour staging and treatment planning. In patients with non-small-cell
cancer, surgical resection offers substantial cure rates in early-stage cases.
Combined chemotherapy plus radiation therapy has clearly improved the
treatment results for patients with locally advanced cancers, and patients with
metastatic disease are now candidates for newer chemotherapy regimens
with more favourable results than in the past. Small-cell lung cancer
is highly responsive to chemotherapy, and recent advances in radiation therapy
have improved the prospects for long survival. New techniques for screening,
and innovative approaches to both local and systemic treatment offer hope for
substantial progress against this disease in the near future.

Lung cancer is the cause of 128% of cancer cases and 178% of cancer deaths
worldwide.1 In the UK in 1995, there were 36600 deaths from lung cancer.2 In
1999 in the USA, an estimated 158900 people will die from the disease. The
incidence of lung cancer is highest in the more developed countries of North
America and northern Europe; during the past few years, the incidence of lung
cancer in men in these countries has been declining slightly, but it continues to
rise in women. In these regions, more than 90% of cases in men and 80% of
cases in women are related to smoking. In China, where smoking rates are very
high, mortality from lung cancer has been rising sharply, and the rise is expected
to continue. 3 Clinical and pathological features Features visible on light
microscopy classify lung cancers into two major groups: small-cell and non-smallcell cancers. The latter include squamous-cell (epidermoid) carcinoma,
adenocarcinoma, and large-cell carcinoma; bronchoalveolar carcinoma is
generally subclassified under adenocarcinoma. This division is sufficient for most
clinical needs. The proportion of squamous-cell carcinomas has decreased from
about 40% of lung cancers to 2025% in North America in the past 1520 years.
In European countries, squamous-cell carcinoma is still the commonest cell type.
It is the classic lung cancer: central in location: endobronchial in nature,
sometimes with central cavitation; commonly associated with lobar collapse,
obstructive pneumonia, or haemoptysis; and shows late development of distant
metastases. The proportion of adenocarcinomas has risen from about 2025% of
lung cancers to about 40% in North America. Although adenocarcinoma is
increasing in prevalence among European women, it is not yet predominant in

Europe. 4 The reasons for this shift are not clear, although the rise in incidence of
lung cancer in women plays some part. Other possible factors include changes in
smoking habits and products (eg, low-tar cigarettes) or other environmental
exposures. Adenocarcinoma is characterised by the early development of
metastases, in many cases while the primary tumour is a symptomless
peripheral lesion. Malignant pleural effusion commonly accompanies
adenocarcinoma. Adenocarcinoma is not as strongly associated with smoking as
is squamous-cell carcinoma, to some extent because when lung cancer does
occur in non-smokers, it is typically adenocarcinoma; however, the association
with smoking is generally not disputed. Bronchoalveolar carcinomas, a subtype
of adenocarcinomas, may be unifocal or multifocal. The latter distribution can
resemble pneumonia, and patients may undergo several courses of antibiotics
for persistent infiltrates before the definitive diagnosis is made. Lymph-node and
distant metastases are less common than with other cell types; when metastases
occur, they may resemble more typical adenocarcinoma. About 10% of lung
cancers are large-cell carcinomas. These cancers are commonly large peripheral
masses, sometimes with cavitation. Small-cell carcinomas (about 20% of lung
cancers) have a rapid growth rate, and are characterised by early metastases.
Small-cell tumours are typically central in location, with extensive mediastinal
adenopathy. Bronchoscopy is typically positive, with submucosal spread in many
cases. The association with smoking is very strong.
Clinical features
Patients may present for medical attention because of symptoms related to the
primary tumour, mediastinal spread of tumour, distant metastatic spread, or
paraneoplastic syndrome. Symptoms related to the primary tumour include
cough, dyspnoea, haemoptysis, and postobstructive pneumonia. Chest pain
suggests parietal pleural involvement or other extension beyond the lung.
Superior sulcus tumours may produce shoulder pain, arm pain or brachial
plexopathy, or Horners syndrome. Symptoms related to mediastinal spread
include: hoarseness with left-sided lesions, caused by left recurrent laryngeal
nerve injury by the tumour or nodes; and obstruction of the superior vena cava
with right-sided tumours or associated lymphadenopathy. Elevation of the
hemidiaphragm may occur as a result of phrenic-nerve paralysis. Less common
features include dysphagia from oesophageal obstruction and pericardial
tamponade. Metastases from lung cancer are common; sites of spread include
the brain, pleural cavity, bone, liver, adrenal glands, contralateral lung, and skin.
Initial presentation with symptoms related to a metastatic focus is very common,
particularly in patients with adenocarcinoma.
Presentation with symptoms related to a paraneoplastic syndrome is much less
common, though some patients first seek attention because of pain in an arm or
leg from hypertrophic pulmonary osteoarthropathy, or from the symptoms of
hypercalcaemia with squamous-cell carcinoma. Although the syndrome of
inappropriate secretion of antidiuretic hormone is clinically evident in 1020% of
patients with small-cell carcinoma, it does not generally cause symptoms. When
Cushings syndrome is seen with small-cell cancer, the manifestations are

primarily metabolic (eg, hypokalaemic alkalosis) rather than of body habitus.

Various neurological syndromes may occur, including encephalomyelitis,
subacute sensory neuropathy, opsoclonus and myoclonus, cerebellar
degeneration, limbic encephalitis, and the Eaton-Lambert myasthenic syndrome
seen in small-cell carcinoma. Lung cancer commonly produces systemic effects
such as anorexia, weight loss, weakness, and profound fatigue. These effects are
not associated exclusively with lung cancer, but they are particularly noticeable
in this group of patients. Hypercoagulopathy, in the form of venous
thromboembolism, is also common, especially with adenocarcinoma. Lung
cancer can be associated with dermatomyositis and membranous
glomerulonephritis.
Diagnosis
As with any cancer, accurate tissue diagnosis is essential, with the main
differentiation being small-cell or non- small-cell carcinoma. In patients with
unresectable tumours, thoracotomy for tissue diagnosis is almost never
necessary. Sputum cytology may give a high yield for typically endobronchial
tumours (eg, small-cell and squamous-cell carcinoma) but the yield is poor for
adenocarcinomas. Overall, because of the changing histological patterns, the
yield is probably less than 50%. Fibreoptic bronchoscopy gives a very high rate of
diagnosis in excess of 90%, when tumour is visualized endobronchially. This
figure is derived from a combination of washings, brushings, and direct biopsy.
For tumours that are not visualised, the yield for washing and brushing is about
75% in central lesions and 55% in peripheral lesions. The yield in small-cell and
squamous- cell carcinoma is higher than that in adenocarcinoma and large-cell
carcinoma. Percutaneous fine-needle aspiration gives a high yield (more than
85%), with a high accuracy for histological subtype. This technique may be used
for diagnosis of peripheral tumours, or when bronchoscopy is inconclusive, and is
especially useful in patients who are not candidates for resection, to establish
cell type so that non-surgical treatment can be planned. The risk of
pneumothorax is about 2035%, although only 5% of patients need a chest tube.
Most patients with characteristic epidemiological and radiographic features and
clearly resectable lesions will proceed to thoracotomy without percutaneous
biopsy first, since clinical management is unlikely to be changed by the biopsy
(ie, if positive for cancer, resection will proceed; if negative for cancer,
exploration will probably still proceed, since there is a risk of a false-negative
result). Moreover, the likelihood of making a specific benign diagnosis by
percutaneous biopsy is low. In some patients tissue diagnosis is made by means
of mediastinoscopy, which also provides key staging information. Analysis of
pleural fluid or samples taken by needle aspiration or biopsy of apparent
metastatic foci such as liver, adrenal gland, or contralateral lung is also an
effective way to establish a histological or cytological diagnosis.
Staging of lung cancer
The main aim of staging is to identify candidates for surgical resection, since this
approach offers the highest potential for cure in lung cancer. Careful staging is

also warranted to identify candidates for new aggressive multimodal treatments

for locally advanced disease. The staging assessment covers three major issues:
distant metastases; the state of the chest and mediastinum; and the condition of
the patient. In the assessment for metastatic spread, the history and physical
examination are the most helpful, perhaps upplemented by liver-function studies
and measurement of serum lactate dehydrogenase concentration. The upper
abdomen is now routinely included in computed tomography (CT) of the chest, to
image the adrenal lands and most of the liver. Radionuclide bone scanning and
CT or magnetic resonance imaging (MRI) of the brain are commonly done, but
their yield in patients without symptoms is very low; many authorities
ecommend against their routine use in early-stage patients, in whom their value
is unproven. In stage III patients, however, most clinicians would advocate these
procedures.
In the assessment of the chest, bronchoscopy is always done preoperatively if
resection is planned, to assess proximal bronchial disease, and to rule out
additional lesions. CT is done to assess invasion by the tumour of djacent
structures, and to look for hilar and mediastinal adenopathy. CT has 88%
accuracy and negative predictive value of more than 90% in the mediastinum. In
the aortopulmonary window, however, the accuracy is only 80% and the
negative predictive value is 83%. The accuracy is 95% for adenocarcinoma, but
71% forsquamous carcinoma.5
As a general rule, enlarged mediastinal nodes on CT alone do not mean that a
patient is unsuitable for surgery, because false-positive results occur quite
commonly (postobstructive infection can lead to inflammatory
lymphadenopathy). Positron-emission tomography (PET) is highly sensitive and
specific for mediastinal staging. 6 With the routine use of combined modality
therapy in stage III disease, mediastinoscopy (cervical or left parasternal) is
required to document initially unresectable disease, by proving the involvement
of N2 (ipsilateral mediastinal) or N3 (contralateral mediastinal) tolerate various
therapies. Pulmonary-function studies are routinely done before planned
resection, with most surgeons aiming for a forced expiratory volume in 1s (FEV1)
of about 1 L after planned resection. If the tumour is centrally located, especially
if there is associated atelectasis, a quantitative split ventilation/perfusion scan
may be needed for better assessment of the contribution to the FEV1 by each
lung. The diffusion capacity of carbon monoxide (corrected for haemoglobin) is a
good predictor of morbidity and mortality from thoracotomy; a value below 60%
of predicted is associated with a mortality rate as high as 25% due to respiratory
complications.10 The main prognostic factors in patients with lung cancer are
tumour stage and performance status. Other factors that may be important
include degree of weight loss, sex (women fare better), serum concentration of
lactate dehydrogenase, and the presence of bone and liver metastases.
The staging schema for lung cancer (panel 1) uses the TNM (tumour, node,
metastases) system, and is routinely used in staging of non-small-cell cancer.
Although the definition of the T, N, and M groups has not changed in recent
years, there has been a new stage grouping (panel 2), reflecting more precise

evaluation of prognosis innodes.7 Newer staging modalities for the chest include
video-assisted thoracoscopy (for assessment of the pleura andmediastinum,
biopsy of peripheral lesions, and biopsy of suspicious contralateral lesions), and
transbronchial needle biopsy of mediastinal nodes. 8,9 The medical assessment
of the patient involves review of some objective information, combined with a
judgment about the patients performance status and ability tovarious subgroups
(American Joint Committee on Cancer/Union Internationale contre le Cancer). 11
The TNM staging is less useful prognostically in patients with small-cell lung
cancer than in those with non-small-cell lung cancer. Patients are classified into
those with limited-stage disease (about 33% of patients) with tumour confined
to one hemithorax, including ipsilateral mediastinal and supraclavicular node
groups, all of which can be encompassed in a radiotherapy port; and those with
extensive-stage disease (the remaining 67% of patients), with tumour outside
the limited-stage boundaries and with distant metastases in most cases. Staging
procedures for patients with small-cell cancer are similar to those above, but
may include a bone-marrow examination. Bone-marrow involvement occurs in
about 20% of patients, although bone marrow as the only site of metastatic
disease is very rare. Very few patients withsmall-cell lung cancer are found to
have stage I or II disease. Patients with small-cell lung cancer who have a
malignant pleural effusion are judged unsuitable for combined
chemoradiotherapy, the usual treatment for patients with tumour more clearly
limited to the chest and mediastinum.
Treatment of non-small-cell lung cancer Stage I (T1N0, T2N0) cancers are treated
whenever possible by surgical resection. 5-year survival is in the range of 40
67%, with the better results in patients with T1N0 staging. 11,12 Many presumed
recurrences are second primary cancers. No role for adjuvant therapy has been
established, although a trial comparing adjuvant chemotherapy with observation
alone is underway for patients with T2N0 cancers. In this group chemoprevention
trials are of great interest, in an effort to prevent the development of second
primary tumours. 13 Primary radiotherapy may be considered for patients
withstage I cancer who refuse or are medically unfit for surgery; it has a 25%
cure rate in otherwise operable patients. 14 There has been some interest in
hyperfractionated accelerated radiotherapy as a method to improve local control.
15 Stage II (T1N1, T2N1, T3N0) cancers are routinelytreated by surgical
resection. The prognosis is worse than with stage I cancers, with 5-year survival
rates in the range 2555%, and results at the lower end of this range if the
histology is non-squamous. 11,16 In a randomised study of patients with
squamous-cell cancer, adjuvant radiotherapy lowered local recurrence rates
significantly but did not affect survival. 17 A meta-analysis of randomised trials
of postoperative radiotherapy in early-stage non-small-cell lung cancer found
that such treatment may adversely affect survival in patients with stage I and II
disease. 18 Thus, postoperative radiotherapy is not indicated in these patients. A
randomised trial by the Lung Cancer Study Group compared early-generation
chemotherapy (cyclophosphamide, doxorubicin, cisplatin) with immunotherapy in
patients with stage II/III resected adenocarcinoma or large-cell carcinoma. There
was an 8- month difference in median survival in favour of the chemotherapy

group, but too few stage II patients were included for benefit in that subgroup to
be certain.19 Another randomised study, in patients with resected stage II and
IIIA cancers, showed that the addition of chemotherapy conferred no benefit over
radiotherapy alone.20 At present, the role of postoperative chemotherapy is not
established in stage IIpatients, though many investigators believe the
documented benefits in stage IIIdisease will probably be applicable to earlier
stages. Stage IIInon-small-cell lung cancer is defined as locally or regionally
advanced disease. That implies either large primary tumours classified as T3 or
T4, or mediastinal or supraclavicular lymphadenopathy (N2 or N3). Stage IIIB
includes T4 primaries and N3 regional lymphadenopathy, which usually imply
unresectable disease, whereas stage IIIA disease is judged marginally resectable
in many cases. Since clinically detectable distant metastases are absent, some
patients with stage IIIdisease are treated with curative intent. Traditionally this
has consisted of surgery or radiotherapy or a combination (stage IIIA) or
radiotherapy alone (stage IIIB). The subgroup of patients with invasion of parietal
pleura or chest wall or with superior sulcus tumours (but with negative lymph
nodes) have been treated surgically, sometimes combined withradiotherapy, and
the results are similar to those of patients with resected stage II disease. This
finding led to the inclusion of such patients with T3N0 tumours in stage II in the
new staging schema. 11 When stage IIIB non-small-cell lung cancer is treated
with the aim of cure by radiotherapy alone, most patients will show early
progession of systemic disease due to the presence of (undiagnosed)
micrometastatic disease at the time of initial diagnosis. Many will also show
progression within the original tumour sites; thus, radiotherapy alone, in most
cases, is unable to eradicate all known disease within the chest. Median survival
times in patients treated with radiotherapy alone average 10 months or less, and
5- year survival rates are between 5% and 10%. To improve on these survival
data, multimodality therapy has been investigated. These studies have focused
on the use of two to three cycles of induction chemotherapy administered before
standard radiotherapy; simultaneous admin-istration of chemotherapy and
radiation; or the use of intensified radiotherapy schedules aim at increasing at
least local and regional control. The use of induction chemotherapy is the most
strongly supported by randomised trials and meta-analyses. 21,22 After two
cycles of cisplatin plus vinblastine, median survival times are longer than with
radiotherapy alone. 23,24 In one study, median survival increased from 10
months to 14 months by the addition of chemotherapy, and 5-year survival rates
increased from 7% to 17%. 24 In a large meta-analysis of trials comparing
radiotherapy alone or with chemotherapy, the hazard ratio was 087 for the
combined treatment, indicating a 13% reduction in risk of death, and an absolute
survival benefit of 4% at 2 years. 22 Thus, induction chemotherapy can be
considered one current standard treatment option for unresectable stage III
disease. The simultaneous administration of cisplatin and radiotherapy was
supported by one randomised trial. 25 However, these data have not been
confirmed by other investigators. Combination chemotherapy with radiotherapy
seems more promising. The concurrent use of radiotherapy with cisplatin and
etoposide or the three-drug regimen of mitomycin, vinblastine, and
cisplatinseems to convey a survival advantage similar or superior to that

achieved with induction chemotherapy. 26 Finally, a European trial investigated

the CHART regimen (continuous hyperfractionated accelerated radiotherapy). 15
In this intensive programme patients receive radiotherapy three times daily for
12 consecutive days. This approach resulted in a survival advantage compared
with standard radiotherapy alone. However, more than 33% of the patients had
early-stage disease (stages I or II) and another 38% had stage IIIA disease; most
had squamous- cell histology. Therefore, confirmatory trials of this approach are
still necessary. Interest has lately focused on the integration into stage III
treatment of drugs that have already been established in stage IV disease.
Current investigations of vinorelbine, paclitaxel, gemcitabine, and docetaxel with
concomitant radiotherapy seem particularly promising. 27 For patients with
marginally resectable stage III disease (stage IIIA), standard treatment
recommendations are less clear. 28 Some small randomised trials have
suggested a survival advantage with induction chemotherapy added to surgery
and radiotherapy, but confirmation in larger trials is needed. A large national trial
in the USA is investigatingthe contribution of surgical resection in these patients;
all receive concomitant radiotherapy and cisplatin plus etoposide, followed either
by additional concomitant chemoradiotherapy or surgical resection. On the basis
of evidence from the addition of chemotherapy in stage IIIB disease and the
suggested benefit in stage IIIA disease, a reasonable approach may be to offer
chemotherapy before surgery to selected patients after careful discussion of
potential risks and benefits. 4050% of patients with non-small-cell lung cancer
present with metastatic disease (stage IV). For those patients with a good
performance status, the palliative useof chemotherapy is no longer controversial
in North America. 29 Several randomised trials and meta-analyses have
supported the use of chemotherapy as standard treatment for patients with
advanced non-small-cell lung cancer who maintain a good performance status.
Many randomised trials compared chemotherapy with best supportive care and
showed overall trends toward improved survival in patients who received
chemotherapy. Meta-analyses confirmed the benefit of cisplatin-based
chemotherapy over best supportive care; chemotherapy confers a benefit in
median survival of 10 weeks and an improvement in 1-year survival of 10%, 22
as well as an improvement in quality of life. 30 The cost of chemotherapy
administration in patients with advanced non-small-cell lung cancer compares
with that of other accepted medical interventions, and may actually be less than
that of best supportive care. 31 The chemotherapy regimens of the 1980s and
early 1990s combined the drugs listed in panel 3. As single agents, these drugs
typically produced responses, defined as significant tumour shrinkage, in at least
15% of patients. Several newer agents with better single-agent activity have
resulted in longer median survival times. New regimens combining these agents
with cisplatin orcarboplatin were developed and investigated in phase II trials.
The new combination regimens offer better side-effect profiles, higher response
rates, and better survival. Randomised phase III trials have compared several of
these new regimens with the previous standard regimens (table). The newer
regimens seem to provide higher response rates and longer survival than singleagent cisplatin or the previous cisplatin-based combinations. 3238

To date, no particular chemotherapy regimen has been identified as superior in

terms of efficacy.
In patients for whom cisplatin-based chemotherapy fails, two agents, docetaxel
39 and gemcitabine, 40 have shown activity with response rates of 1520%.
Whether the use of any agent as second-line therapy produces a significant
survival benefit is not yet clear. We emphasisethat, although current evidence
supports the use of chemotherapy in patients with metastatic non-small-cell lung
cancer, the median survival times of these patients remain unsatisfactory, and
further clinical research is essential. Several new agents, including inhibitors of
angiogenesis, and molecular approaches are under investigation. An important
component of the care of patients with non-small-cell lung cancer is the
management of disease- related symptoms. Palliative radiotherapy may be used
for the control of pain related to bone metastases or haemoptysis or obstructive
symptoms. Additionally, surgical intervention or laser therapy may benefit
patients with bronchial obstruction. Treatment of small-cell lung cancer
Chemotherapy is the mainstay of treatment for small-cell lung cancer, and
adjuvant radiotherapy is commonly used in patients with limited disease.
Surgical resection is reserved for patients with pathologically documented stage I
or II disease, or as part of a combined-modality clinical trial. Active drugs include
cisplatin, carboplatin, etoposide, cyclophosphamide, doxorubicin, vincristine,
lomustine, and ifosfamide. Newer drugs of interest include altretamine,
paclitaxel, docetaxel, topotecan (which has shown benefit in the second-line
setting), gemcitabine, and irinotecan. Commonly used combinations include
cisplatin plus etoposide, cyclophosphamide, doxorubicin, and vincristine, and
cyclophosphamide, doxorubicin, and etoposide. Response rates to combination
chemotherapy are high, up to 7580% in extensive disease and up to 8595% in
limited disease, with complete tumour responses in 2025% and 5060%,
respectively. Median survival is 710 months for extensive disease and 1420
months for limited disease. 2- year survival of 2030% is seen in limited disease,
but rarely in extensive disease. Long-term survival is seen in 510% of patients
with limited-stage disease. The duration of chemotherapy is typically six cycles
(18 weeks), and some trials have even shown good results with only four cycles;
maintenance therapy has not proven effective in prolonging remission duration
or survival. 41 Thoracic radiotherapy has become standard practice in patients
with limited disease. A major randomised study showed that the combinedmortality group had a median survival of 15 months, and 2-year survival of 28%,
compared with 116 months and 12% for thechemotherapy-only group. A metaanalysis of 2103 patients in 13 trials confirmed a 14% reduction in mortality and
5% increase in 3-year survival. 43 In another trial, patients who received twicedaily radiotherapy had 2-year and 5-year survival of 47% and 26%, respectively,
compared with 41% and 16%, respectively, for patients who received once-daily
therapy. 44 The timing of thoracic radiotherapy seems to be critical to survival
and the rate of relapses in the central nervous system. Patients who received
early radiotherapy (ie, at 3 weeks instead of at 15 weeks) had a 5-month
improvement in median survival and a 9% increase in 5-year survival. 45 The
mechanism was thought to relate to early killing by radiation of drug- resistant

clones developing in the chest. The role of prophylactic cranial irradiation in the
treatment of small-cell lung cancer has been controversial.There is little question
that it can substantially reduce the risk of brain recurrence, from about 25% to
5%, but the effect on survival has been debated. The benefits seem tobe
confined to patients with systemic complete remission. In a randomised study,
the likelihood of brain recurrence as first site of failure was 19% for patients who
received prophylactic cranial irradiation and 45% for those who did not. The
overall rates of brain metastases were 40% and 67%. 46 The overall median
survival was not affected; moreover, this study did not show some of the serious
delayed neuropsychological sequelae that have been reported in the past in
patients receiving prophylactic cranial irradiation, 47,48 though the follow-up
may have been too short. The same group of investigators reported on a metaanalysis in patients in complete remission given prophylactic cranial irradiation.
The relative risk of death compared with controls was 084, corresponding to a
reduction in mortality of 16% in favour of the irradiated group, and an increase in
the 3-year survival from 153% to 207%. 49 In view of this analysis, and because
of the disappointing long-term control achievable by therapeutic radiotherapy for
overt brain metastases, many clinicians suggest prophylactic cranial irradiation
for patients with limited-stage cancer in complete remission. To keep toxic effects
to a minimum, it should probably be administeredin fractions of 200300 cGy
over 23 weeks, and should be separated from chemotherapy.
The future
Therapy for lung cancer has made progress in recent years. Chemotherapy is
now firmly established as a useful therapeutic modality for both small-cell and
advanced non-small-cell lung cancer (stages III and IV). Nevertheless, most
patients will die of disease progression, and current treatments, in particular
concomitant chemoradiotherapy for stage IIIdisease, are very toxic. Therefore,
the investigation of novel agents remains a high priority. Current interest is
focused on agents that may suppress tumour angiogenesis and drugs
manipulating the tumour-cell microenvironment, for example, matrix
metalloproteinase inhibitors. Our increased understanding of the molecular
biology of lung cancer may allow agents with selective activity against malignant
cells to be identified. Early trials investigating the local or regional delivery of
gene products (eg, p53) are also in progress. 50 Improved outcomes should
come with refinements in surgical and radiotherapy techniques, with refinements
in surgical and radiotherapy techniques, such as greater use of conformal
radiotherapy, and better selection of patients for resection or radiotherapy based
on prognostic markers. Finally, renewed interest and progress of screening
techniques offer the hope that a higher proportion of cases will be diagnosed at
an early stage. Therapeutic interventions should be offered to the overwhelming
majority of patients with lung cancer. Treatment goals of palliation versus
possible long-term benefit (or cure) should be reviewed with the patient. The
therapeutic nihilism that has characterised the attitude of many health-care
providers for lung cancer should be consigned to the past.