The lung cancer sessions at the American Society of Clinical Oncology (ASCO) meeting in 2003 highlighted the role of multi-modality management in early-stage and locally advanced NSCLC, and questioned whether NSCLC is a systemic disease. It may well be, as now there does appear to be a role for systemic therapy both in surgically resected disease and in potentially resectable disease.

In the past 30 to 40 years, several studies have been performed that have evaluated adjuvant treatments following surgical resection for early-stage NSCLC.

The five-year survival rates for patients with clinical stages IA, IB, IIA, IIB, and IIIA are 61%, 38%, 34%, 24%, and 9% respectively, following surgical resection.

The survival rates for the above stages post-surgery (pathologic stage) are 67%, 57%, 55%, 39%, and 25% respectively.2 Furthermore, two-thirds of the recurrences occur systemically, while local recurrence accounts for the remaining third.

While progress has not been substantial, much has been learned about the biology of the disease. The presence of micrometastatic disease at the time of resection is the likely reason for the recurrence, despite complete removal of all macroscopic disease.

Micrometastases have been detected by methods such as immunohistochemistry and polymerase chain reaction (PCR) in patients with radiologically localized lung cancer.3 The outcome for such patients can only be improved by eradication of micro- metastatic disease in addition to optimal surgical resection. This provides the rationale for the use of adjuvant therapy for patients with early-stage NSCLC following surgical resection.

The International Adjuvant Lung Trial The data from the International Adjuvant Lung Trial (IALT) were presented at the plenary session of the 39th Annual Meeting of ASCO, by Dr LeChevalier.4 Patients with completely resected NSCLC were randomized to receive three to four cycles of cisplatin-based therapy versus observation alone.The cisplatin doses prescribed were 80mg/m2 every three weeks for four cycles, 100mg/m2 every four weeks for three or four cycles or 120mg/m2 every four weeks for three cycles.The second agent consisted of either etoposide 100mg/m2 for three days, or vinblastine 4mg/m2/week, or vinorelbine 30mg/m2/ week or vindesine 3mg/m2/week. The accrual goal was 3,300 patients with an interim analysis planned after 320 and 640 deaths.The primary objective was to detect an increase in survival from 50% to 55% with adjuvant chemotherapy for patients with completely resected stages I, II, and IIIA NSCLC.