Dear Editor,

We read with interest the editorial by Birring and Peake on early diagnosis and screening of lung cancer [1]. The diagnosis of lung cancer is often delayed by the patient themselves, although some doctors are still guilty of adopting the laissez-faire approach towards small, particularly calcified lesions. As clinicians, we are increasingly seeing referrals of incidental small lung nodules on computed tomography (CT).

The authors clearly pointed out that even 10mm tumours with 109 cells can already represent a late stage in lung cancer. In this modern era, we believe all lung lesions should be investigated and histological diagnosis obtained. Patients with a lesion too small to undergo image-guided fine needle aspiration (FNA), typically smaller than 8mm in our institute, would be fully counselled and be offered video-assisted thoracic surgery (VATS) biopsy with intra-operative frozen section followed by oncological lung resection if indicated. We have had successes with resection of tiny 1mm lung cancer nodules using the above algorithm when assisted by immediate pre-operative CT localization of the lesion with pig-tail hooked wire by radiologist [2]. Whether these tiny lesions should have a separate cancer stage, namely pre-stage Ia or Ia1, and result in better survival following resection will be a matter for future debate and research. The optimum strategy for the management of small lesions whether incidentally or during screening certainly needs to be determined.

Yours sincerely,
Dr. Calvin S.H. Ng, Senior resident
Prof. Anthony P.C. Yim, Professor & Chief of Cardiothoracic Surgery

References

1. Birring SS, Peake MD. Symptoms and the early diagnosis of lung cancer. Thorax 2005; 60:268-9.

2. Ciriaco P, Negri G, Puglisi A, Nicoletti R, Del Maschio A, Zannini P. Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization. Eur J Cardiothorac Surg 2004;25:429-33.

Dear Editor,

Re: Symptoms and the early diagnosis of lung cancer

Five year survival of patients with Lung Cancer in the United Kingdom is disappointing and the comparisons made by Birring et al. [1] and others with some internationally published data have been consistently unfavourable [2]. Doctors and government bodies in the United Kingdom have searched for differences in patients, disease or treatment which might explain the shortfalls in survival and improve the care of our patients [2,3]. There has been little focus in the literature on the data. Review of the SEER website 5 year survival figure referenced by Birring et al. and others throws some light on the survival differences. In their latest survival data SEER report 64,035 cases of non small cell lung cancer, 11,306 cases of small cell lung cancer and 75,341 of lung and bronchus cancer [4]. It can only be assumed that cases without proven histology are not included in the much quoted SEER lung and bronchus cancer survival figures. Survival figures for lung cancer in the United Kingdom do include around 25% of cases without histology [5]. Survival of patients diagnosed as having lung cancer without proven histology is around a quarter of those with proven histology. Cancer registry data suggest leaving these patients out of the survival calculation will add around 4% to survival at 5 years [5]. SEER data cannot therefore be used to compare overall survival in the United Kingdom with that of the United States.

Wendy JA Anderson
Claire Butler
Karen Darragh
Graeme P Currie

References

1. Birring S S, Peake M D. Five year survival of patients with Lung Cancer in the United Kingdom. Thorax 2005;60 268-269.

2. Sikora K. Cancer survival in Britain. Bmj 1999;319:461-2.

3. Improving Outcomes in Lung Cancer: The Manual. Department of Health, 1998.

4. SEER. www.seer.cancer.gov.

5. Fitzpatrick D, Gavin A, Middleton R, Catney D. Cancer in Northern Ireland 1993-2001. A Comprehensive report. Northern Ireland Cancer Registry. Queens University Belfast, 2004.