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Overestimating the Influence of the 1999 WHO Classification of Lung Tumors on Survival in Bronchioloalveloar Carcinoma

Center for Cancer Research, Cancer Therapeutics Branch, National Cancer Institute, Bethesda, MD

To the Editor:

The recent article by Zell et al¹ in the November 20, 2005, issue of the Journal of Clinical Oncology reported an epidemiological study of the impact of the 1999 WHO Classification of lung tumors on change in survival in bronchioloalveolar carcinoma. They demonstrated that the period of the diagnosis (before or after 1999) is an independent prognostic factor in bronchioloalveolar carcinoma population, and attributed the improved survival in the latter period to the revised classification.

While their findings are plausible, there are many other factors besides application of the revised classification that could have contributed to the disparity in survival. In the same time period analyzed by Zell et al,¹ there has been a dramatic increase in the accuracy of staging secondary to the increased use of positron emission tomography scanning as well as increased sensitivity in computed tomography scans.^2-4 New therapeutics became available through clinical trials and/or United States Food and Drug Administration approval over the same time period for second- and third-line treatment, such as docetaxel, pemetrexed, as well as epidermal growth factor receptor tyrosine kinase inhibitors. Moreover, they did not show how many patients were diagnosed with the revised classification in the latter period, and level of compliance with the new criteria is not clear. This is important because the hypothesis of Zell et al¹ was based on an assumption that all patients were diagnosed with the revised classification in the latter period.

Finally, we believe that basing clinical outcomes on the Surveillance, Epidemiology, and End Results database may be confounded because it only includes data for first-line therapies. Updating the Surveillance, Epidemiology, and End Results data collection to incorporate more detailed clinical variables such as the use of second- and third-line therapies, as well as new imaging modalities such as positron emission tomography scans, would allow more accurate analysis of the impact of these variables on survival.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Zell JA, Ou SH, Ziogas A, et al: Epidemiology of bronchioloalveolar carcinoma: Improvement in survival after release of the 1999 WHO classification of lung tumors. J Clin Oncol 23:8396-8405, 2005[Abstract/Free Full Text]

2. Pozo-Rodriguez F, Martin de Nicolas JL, Sanchez-Nistal MA, et al: Accuracy of helical computed tomography and [18F] fluorodeoxyglucose positron emission tomography for identifying lymph node mediastinal metastases in potentially resectable non–small-cell lung cancer. J Clin Oncol 23:8348-8356, 2005[Abstract/Free Full Text]

3. Kalff V, Hicks RJ, MacManus MP, et al: Clinical impact of (18)F fluorodeoxyglucose positron emission tomography in patients with non-small-cell lung cancer: A prospective study. J Clin Oncol 19:111-118, 2001[Abstract/Free Full Text]

4. Brink I, Schumacher T, Mix M, et al: Impact of [18F]FDG-PET on the primary staging of small-cell lung cancer. Eur J Nucl Med Mol Imaging 31:1614-1620, 2004[CrossRef][Medline]

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• In Reply:
  Jason A. Zell, Sai-Hong Ignatius Ou, Argyrios Ziogas, and Hoda Anton-Culver
  JCO 2006 24: 1963-1964 [Full Text]

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