Lung Cancer : Principles and Practice

Wayne State Univ., Detroit, MI. Covers natural history, biology, and treatment options for lung cancer, with contributions from clinicians in all relevant disciplines. Reflects changes that have occurred in field since first edition. Includes halftone illustrations and color plate. For researchers and practitioners. Previous edition: c1996. DNLM: Lung Neoplasms.

Lung cancer remains the leading cause of cancer-related death in men, and in women it has surpassed even breast cancer. The primary cause of lung cancer in up to 90 percent of patients is smoking, and it is estimated that bronchiogenic carcinoma will develop in 10 to 15 percent of all smokers. Environmental factors -- for example, passive smoke, occupational exposure to asbestos or chromium, and air pollution -- as well as genetic predisposition in a multistep carcinogenic process may both play a part. Nevertheless, cessation of cigarette smoking is the most effective, most easily achievable, and least expensive intervention in reducing the risk of lung cancer.

Despite marked progress in the treatment of lung cancer, most patients still die of their disease within several months to a few years. Some patients and physicians have a nihilistic perception of the treatment of lung cancer, and adequate treatment is often delayed or not even considered. However, even locally advanced disease can be cured in many patients with the appropriate multimodal therapy. Patients with a suspected or confirmed diagnosis of lung cancer are best evaluated by a team of lung-cancer specialists consisting of thoracic surgeons, medical oncologists, radiation therapists, pneumologists, radiologists, and pathologists.

Lung Cancer: Principles and Practice reflects this multidisciplinary approach to a common disease. Lung cancer should be suspected in any patient who presents with persistent cough or hemoptysis or with deep venous thrombosis, without other clinical explanations or constitutional symptoms. A simple chest radiograph may reveal a pulmonary mass, and subsequent computed tomography of the chest and upper abdomen will allow rapid assessment of any extension of the tumor into the mediastinum and of any metastases to the liver and adrenals. Tissue diagnosis should then be performed by the most appropriate means (e.g., transthoracic fine-needle biopsy, transbronchial biopsy, or mediastinoscopy). The advantages and appropriateness of each technique are discussed in detail in this book.

Once the histology and precise stage of the tumor are determined, the optimal treatment and sequence of interventions can be discussed. Approximately half the book is devoted to clinical management by surgery, radiation therapy, and chemotherapy. Small-cell lung cancer and non-small-cell lung cancer are discussed separately, and treatment recommendations are given according to stage and other prognostic factors. Approximately half the patients present with metastatic disease at diagnosis, and chemotherapy is usually indicated. The emerging role of chemotherapy not only in the treatment of small-cell lung cancer but also in the treatment of non-small-cell lung cancer is reflected by the inclusion in separate chapters of a discussion of the role of second-line chemotherapy and the treatment of elderly persons. An entire section of this textbook is devoted to additional, palliative treatments such as radiotherapy and brachytherapy, the use of expandable stents and laser surgery for airway obstruction, and the management of pleural effusion.

Most patients in whom treatment can be administered with curative intent present with locally advanced disease. In these patients, monotherapy (surgery alone) is rarely sufficient, and a multimodal approach to treatment should be considered. Although adjuvant chemotherapy has failed to offer a survival advantage, modern combination chemotherapy has shown promise as neoadjuvant therapy before surgery or radiation. The indications and limitations of adjuvant radiotherapy after complete resection of non-small-cell lung cancer are discussed, and current controversies are highlighted. The reader will find precise answers to most relevant clinical questions. Rare topics, such as the occurrence of multiple primary tumors and the difficulty and occasional impossibility of distinguishing them from metastases, are also addressed. The role of surgery in patients with stage T4 primary tumors with infiltration of the superior vena cava is critically reviewed.

An issue rarely discussed in clinical textbooks is cost effectiveness. Here, methods are briefly reviewed, and the cost effectiveness of some therapeutic interventions, in contrast to screening programs, is emphasized. Despite the proven cost effectiveness of palliative chemotherapy in comparison with the best supportive care, global budget restrictions may not allow this treatment to be offered to all patients. Given the growing importance of health care expenditures and limited resources, an even more extensive review of this subject would be welcome in a future edition.

The first section of this textbook is devoted to the biology and molecular genetics of lung cancer. Potential targets for future therapeutic interventions, such as ras and erbB2, epidermal growth-factor receptors, telomerase, and angiogenesis, are appropriately reviewed. The difficulties, challenges, limitations, and opportunities of studying lung cancer in experimental models are highlighted. This information, together with the sections on clinical issues, makes Lung Cancer: Principles and Practice a truly comprehensive and valuable textbook on a common and often ultimately fatal disease.

I reviewed this book over a three-month period. For every clinical question that came up at weekly multidisciplinary tumor-board meetings, I could easily find appropriate references, reviews, and management recommendations. The quality of this book lies in the fact that a vast amount of information is divided into 66 concise, practice-oriented chapters, most of which do not exceed 20 pages. This allows one to consult the book even in a busy clinic and to elaborate the answers to more difficult questions at the end of the day, within less than an hour. As with any multiauthored book, there is some unavoidable redundancy, but in the context of the multimodal treatment of lung cancer, it is even welcome. The limitations of standard therapy and the importance of continued basic and clinical research are pointed out. This comprehensive and useful textbook should be available to every physician involved in the care of patients with lung cancer.

Roger Stupp, M.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.