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Surgery is the most effective treatment modality for resectable non-small cell lung carcinoma, but overall five year survival rates remain low. For decades trials failed to provide evidence that adjuvant chemotherapy has added value over surgery alone. In recent years, postoperative cisplatin and vinorelbine showed a sustained survival benefit of up to 15%, and some centres now use such platinum based chemotherapy regimens as standard practicepractice.
The recent multicentre trial of preoperative adjuvant chemotherapy was designed and started before this evidence was available. The trial randomised more than 500 people with non-small cell lung carcinoma (61% with clinical stage I, 31% with stage II, and 7% with stage III) to receive surgery alone or surgery combined with three cycles of platinum based chemotherapy administered preoperatively. Chemotherapy proved to be feasible, had a good response rate, and resulted in downstaging of almost a third of people who received it, but it did not improve overall survival. However, when this trial was added to a previous meta-analysis, the results suggested a 12% survival benefit compared with surgery alone, which is equivalent to a 5% improvement in survival at five years of follow-up. Postoperative complications were not increased in the chemotherapy group, and quality of life did not seem to be impaired.
The biggest problems with postoperative chemotherapy had been low tolerance and low compliance. However, the authors of a linked editorial (doi: 10.1016/S0140-6736(07)60715-6) say that more than 80% of patients in their centre complete the four cycles of postoperative chemotherapy that is now standard practice. They think that although preoperative chemotherapy may have potential benefit, surgery should not be delayed, and they are not convinced that the current trial, although important, calls for a change in this practice.