Chemo survival

Clinical Oncology (2004) 16: 549e560

doi:10.1016/j.clon.2004.06.007

Overview:

The Contribution of Cytotoxic Chemotherapy to 5-year Survival in Adult Malignancies

Graeme Morgan*, Robyn Wardy, Michael Bartonz

*Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore

Hospital, Sydney, NSW; yDepartment of Medical Oncology,

St Vincent’s Hospital, Sydney, NSW; zCollaboration for Cancer

Outcomes Research and Evaluation, Liverpool Health Service, Sydney, NSW, Australia

ABSTRACT:

Aims: The debate on the funding and availability of cytotoxic drugs raises questions about the contribution of curative or adjuvant

cytotoxic chemotherapy to survival in adult cancer patients.

Materials and methods: We undertook a literature search for randomised clinical trials reporting a 5-year survival benefit attributable

solely to cytotoxic chemotherapy in adult malignancies. The total number of newly diagnosed cancer patients for 22 major adult

malignancies was determined from cancer registry data in Australia and from the Surveillance Epidemiology and End Results data in the

USA for 1998. For each malignancy, the absolute number to benefit was the product of (a) the total number of persons with that

malignancy; (b) the proportion or subgroup(s) of that malignancy showing a benefit; and (c) the percentage increase in 5-year survival due

solely to cytotoxic chemotherapy. The overall contribution was the sum total of the absolute numbers showing a 5-year survival benefit

expressed as a percentage of the total number for the 22 malignancies.

Results: The overall contribution of curative and adjuvant cytotoxic chemotherapy to 5-year survival in adults was estimated to be 2.3% in

Australia and 2.1% in the USA.

Conclusion: As the 5-year relative survival rate for cancer in Australia is now over 60%, it is clear that cytotoxic chemotherapy only makes

a minor contribution to cancer survival. To justify the continued funding and availability of drugs used in cytotoxic chemotherapy,

a rigorous evaluation of the cost-effectiveness and impact on quality of life is urgently required. Morgan, G. et al. (2004). Clinical Oncology

16, 549e560

Key words: Chemotherapy, combined modality treatment, palliation, quality of life, radiotherapy, survival

Received: 18 August 2003 Revised: 20 April 2004 Accepted: 3 June 2004

Introduction

In adults, cytotoxic chemotherapy became established in the

1970s as a curative treatment in advanced Hodgkin’s disease

[1], non-Hodgkin’s lymphoma [2], teratoma of testis [3] and

as an adjuvant treatment for early breast cancer [4].

The initial results suggested the potential use of cytotoxic

chemotherapy as a definitive treatment or as an adjuvant

therapy in asymptomatic patients with the aim of improving

survival. However, as stated by Braverman [5] and others

[6e8], the early gains in a few tumour sites have not been

seen in the more common cancers. For most patients, the use

of cytotoxic chemotherapy is for the palliation of symptoms

and to improve quality of life [9], with prolongation of

survival being a less important outcome.

Some practitioners still remain optimistic that cytotoxic

chemotherapy will significantly improve cancer survival

[10]. However, despite the use of new and expensive single

and combination drugs to improve response rates and other

agents to allow for dose escalation, there has been no

change in some of the regimens used, and there has been

little impact from the use of newer regimens. Examples are

non-Hodgkin’s lymphoma [11] and ovarian cancer [12], in

which cyclophosphamide, adriamycin, vincristine and

prednisolone (CHOP) and platinum, respectively, (introduced

over 20 years ago) are still the ‘gold standard’

treatment. Similarly, in lung cancer, the median survival

has increased by only 2 months during the same time period

[13,14], and an overall survival benefit of less than 5% has

been achieved in the adjuvant treatment of breast, colon,

and head and neck cancers [15e17].

The recent debate on funding of new cytotoxic drugs

[18e20] has highlighted the lack of agreement between

medical oncologists and funding bodies on the current and

Author for correspondence: Dr Graeme W. Morgan, Director, Radiation

Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital,

Sydney NSW 2065, Australia. Tel: D61-2-9926-5010; Fax: D61-2-9906-

4150. E-mail: gmorgan1@bigpond.net.au

Clinical Oncology (2004) 16: 549e560

doi:10.1016/j.clon.2004.06.007