新肺癌分期系統可改善NSCLC病患之照護


  July 23, 2009 — 專家表示,近十年來首度出現的一項新版的肺癌分期系統,可以改善非小細胞肺癌(nonsmall-cell lung cancer,NSCLC)病患的照護。
  
  耶魯大學醫學院、耶魯癌症中心胸腔腫瘤計畫小組,在7月的胸腔(Chest)期刊提出新版TNM系統NSCLC分期方法。
  
  原本的TNM分期系統是在1970年代初期提出,是根據來自一個醫學機構(德州大學安德森癌症中心)2,155名病患的有限資料庫。曾在1997年改版,依舊根據該資料庫,此次納入5,319名個案。
  
  這個最新的版本在1990年開始十年的全球協力合作。由國際肺癌研究協會(IASLC)主辦,Eli Lilly藥廠提供不設限的資金,建立了一個最新的資料庫。總共比較了20個國家、45個來源的81,015名案例(58%來自歐洲、21%來自北美、14%來自亞洲、7%來自澳洲)。
  
  作者指出,這些努力促成這個在各類癌症中相當獨特的分期系統。
  
  【新版運用了更多資料】
  主要作者、耶魯大學胸腔外科主任Frank Detterbeck醫師表示,原本的系統和資料庫是我們今日所知的癌症分期的有力基礎。
  
  他在聲明中表示,不過,該分期系統有其限制。因為資料庫小而有限,由機構主導而非基於證據。
  
  他指出,新版的IASLC分期系統變得更有科學基礎,運用相關資料進行肺癌分期。
  
  資深作者、耶魯癌症中心肺科學教授、胸腔腫瘤計畫共同主任Lynn Tanoue醫師表示,病患癌症分期之準確定義的重要性未能被重視。
  
  這對病患獲得最佳治療相當有決定性。新的分期系統讓我們更精準定義病患的預後,以及加強我們和國際同儕分享資料的能力。
  
  舉例來說,NSCLC且擴散到肋膜腔的病患,我們一般將肋膜擴散的病患視為預後不佳,只適合安寧療護。不過,新版的分期系統顯示,肋膜擴散而有切除之病患的預後相對較佳,表示有一些病患無須如此悲觀。
  
  【舊系統運作良好】
  喬治華盛頓大學醫學院的Gene Colice醫師在編輯評論中寫道,NSCLC的TNM分期方法在肺癌學界運用得不錯。它在一般預測結果和比較治療效果上滿有用的。
  
  這個最新版的TNM方法,將可讓我們更有效率地照護肺癌病患。
  
  Colice醫師指出,這個最新版的TNM方法,是由一大群醫師所貢獻的極大努力,將可讓我們更有效率地照護肺癌病患,因為更細微的分期更可以反映出預後。
  
  他指出,新版的方法應視為醫師處置NSCLC時的標準。
  
  美國胸腔醫師學院(ACCP)前任總裁Michael Alberts醫師回應這些觀點,因為新版指引,肺癌的診斷和治療可以有顯著的進步。舊系統運作良好。不過,新系統也令人引頸期盼,將納入第3版的ACCP肺癌指引內。
  
  【並非用來篩選治療】
  雖然分期系統提供有關癌症範圍和相對預後的資料,它並非用來提供治療建議。
  
  Detterbeck醫師表示,這個分期系統是用來命名以及定義預後的工具;不應過份簡化為用來篩選治療的工具。
  
  Colice醫師指出,TNM分期系統是根據解剖特徵和存活者的觀察經驗。為了使這個系統進步,須注意肺癌生物學,提供瞭解預後和治療反應的新方法。
  
  Detterbeck醫師等人宣告沒有相關財務關係。編輯、Colice醫師報告為Teva、GlaxoSmithKline、Pfizer、Boehringer Ingelheim、Lilly、MedImmune、Forest以及Almirall等藥廠進行研究。
  

New Lung Cancer Staging System Should Improve Care for NSCLC Patients

By Zosia Chustecka
Medscape Medical News

July 23, 2009 — An update to the lung cancer staging system — the first in 10 years — should improve care for patients with nonsmall-cell lung cancer (NSCLC), say experts in the field.

The new revision of the tumor-node-metastases (TNM) method for staging NSCLC is described in the July issue of Chest by a group from the Yale Cancer Center Thoracic Oncology Program at the Yale University School of Medicine in New Haven, Connecticut.

The original TNM staging system, adopted in the early 1970s, was based on a limited database of 2155 patients from 1 medical institution (the University of Texas MD Anderson Cancer Center in Houston). It was revised in 1997, still based on that 1 database, which by then consisted of 5319 cases.

This latest revision is the culmination of 10 years of work and an international effort that began in 1999. Under the auspices of the International Association for the Study of Lung Cancer (IASLC), with funding from an unrestricted grant from Eli Lilly, a new dataset was established. In its final form, it comprised 81,015 cases from 45 sources in 20 countries (58% from Europe, 21% from North America, 14% from Asia, and 7% from Australia).

"An effort of this magnitude as a basis for a staging system is quite unique among types of cancer," note the authors.

New Revision More Data-Driven

"The original system and database laid the strong foundation for lung cancer staging as we know it today," said lead author Frank Detterbeck MD, FCCP, chief of thoracic surgery at Yale University.

"However, the staging system had limitations. [Because of] the small and very narrow database, the staging system was guided by intuition rather than by evidence," he said in a statement.

"The revised IASLC staging system marks a shift to a more scientifically based, data-driven approach to lung cancer staging," he added.

"The importance of an accurate definition of a patient's cancer stage cannot be overemphasized," added senior author Lynn Tanoue, MD, FCCP, codirector of the Thoracic Oncology Program and professor of pulmonology at the Yale Cancer Center.

"It is crucial in determining the best treatment for a patient," she continued. "The new stage-classification system allows us to more precisely define a patient's prognosis and enhances our ability to share results with colleagues internationally."

One example is the case of NSCLC patients whose disease has spread to the pleural cavity. "We typically view patients with pleural dissemination as having such a poor prognosis that only palliative care is appropriate," the authors write. However, the revised staging system showed that resected patients with pleural dissemination have a relatively good prognosis, which suggests that "there may be a subgroup in [which] such a pessimistic attitude is not appropriate," they add.

Old System Served Community Well

"The TNM method for staging of NSCLC has served the lung cancer community well," writes Gene Colice MD, FCCP, from the George Washington University School of Medicine, in Washington, DC, in an accompanying editorial. "It is a useful common denominator for generally predicting outcomes and comparing treatment effects."

This newest revision of the TNM method?.?.?. will allow us to care for the lung cancer patient even more effectively.

"This newest revision of the TNM method, which reflects an enormous effort by a dedicated group of physicians, will allow us to care for the lung cancer patient even more effectively, because the refinements in staging classifications better reflect prognosis," Dr. Colice notes.

"This revised approach should be accepted as the standard for clinicians managing NSCLC," he adds.

These sentiments were echoed by Michael Alberts, MD, FCCP, past president of the American College of Chest Physicians (ACCP). "There have been significant advances in the diagnosis and therapy for lung cancer since the last revision," he said in a statement. "The old system served us well. However, the new system has been eagerly awaited and will be used in the third edition of the ACCP Lung Cancer Guidelines."

Not To Be Used for Selecting Treatment

Although the staging system provides information on the extent of the cancer and the corresponding prognosis, it does not provide recommendations on treatment.

"The stage-classification system is designed to be a nomenclature tool and a tool to define prognosis; it is an inappropriate oversimplification to use it as an algorithm to select treatment," said Dr. Detterbeck.

Dr. Colice notes that the TNM staging system is based on anatomical features and empirical observations of survival. To advance beyond this system, attention needs to be focused on the biology of lung cancer, where insights can provide new ways of understanding prognosis and treatment responses, he writes.

Dr. Detterbeck and coauthors have disclosed no relevant financial relationships. Editorialist Dr. Colice reports having carried out work for Teva, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Lilly, MedImmune, Forest, and Almirall.

Chest. 2009;136:6-8 and 260-271.

    
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