Survival after resection for primary lung cancer: a
population based study of 3211 resected patients
T-E Strand, H Rostad, B Møller, J Norstein
............................................................... ............................................................... .
See end of article for
Dr T-E Strand, Cancer
Registry of Norway,
Montebello, N-0310 Oslo,
30 November 2005
Accepted 15 March 2006
Published Online First
5 April 2006
Thorax 2006;61:710–715. doi: 10.1136/thx.2005.056481
Background: Very few population based results have been presented for survival after resection for lung
cancer. The purpose of this study was to present long term survival after resection and to quantify
prognostic factors for survival.
Methods: All lung cancer patients diagnosed in Norway in 1993–2002 were reported to the Cancer
Registry of Norway (n=19 582). A total of 3211 patients underwent surgical resection and were included
for analysis. Supplementary information from hospitals (including co-morbidity data) was collected for
patients diagnosed in 1993–8. Five year observed and relative survival was analysed for patients
diagnosed and operated in 1993–9. Factors believed to influence survival were analysed by a Cox
proportional hazard regression model.
Results: Five year relative survival in the period 1993–9 was 46.4% (n=2144): 58.4% for stage I disease
(n=1375), 28.4% for stage II (n=532), 15.1% for IIIa (n=133), 24.1% for IIIb (n=63), and 21.1% for
stage IV disease (n=41). The high survival in stage IIIb and IV was due to the contribution of multiple
tumours. Cox regression analysis identified male sex, higher age, procedures other than upper and middle
lobectomy, histologies such as adenocarcinoma and large cell carcinoma, surgery on the right side,
infiltration of resection margins, and larger tumour size as non-favourable prognostic factors.
Conclusions: Survival was favourable for resected patients in a population based group including
subgroups such as elderly patients, those with advanced stage, small cell lung cancer, tumours with nodal
invasion, and patients with multiple tumours. These results question the validity of the current TNM system
for lung cancer with regard to tumour size and categorization of multiple tumours.
diagnosis and treatment.1–3Patients are often in an advanced
stage of disease and resection rates are therefore low.
Improvements of surgical outcomes have been sparse, but
evidence of lower postoperative mortality and slightly
increased survival has been reported.4 5Previous reports
often originate from single institutions, and there are few
population based reports on survival, especially relative
The population based cancer registries create a unique
platform for studies of risk factors for survival. Traditionally,
these registries have recorded the incidence of various
cancers and research has been concentrated on aetiological
factors and time trends in incidence. Now the registries are
moving toward a trend where evaluation of treatment plays a
more central role. This paper adds to a series of publications
based on the evaluation of lung cancer treatment in
Norway.11 12The purpose of this study was to present relative
and observed survival in different subgroups after resection
and to quantify prognostic factors in a defined population.
he increasing incidence and poor survival of patients
with lung cancer, including women and young people,
necessitates a reappraisal of the current strategy for
All newly diagnosed cases of cancer are required by
Norwegian law to be reported without patient consent to
the Cancer Registry of Norway. Since 1953, the Registry has
collected information on all cancer patients in the population
from clinical and pathology reports. The Registry also
routinely receives death certificates from the Cause of
Death Registry of Statistics Norway. For patients whose
clinical or pathology reports were not satisfactory, supple-
mentary reports from the hospital records were requested.
Electronic summary discharge files from hospitals have been
available from 1998 and were used for quality assurance.
reported on clinical reports as ‘‘yes’’ or ‘‘no’’. Supplemental
information regarding preoperative and postoperative radio-
therapy was obtained from verification systems of the linear
accelerators located at the six different oncology units in
Norway (including two satellite units). For all patients
diagnosed from 1993 to 1998, supplementary information
was requested, including details of co-morbidity.
Data on all lung cancer patients diagnosed during the
period 1993–2002 were analysed retrospectively. Cases
diagnosed at necropsy or notified with death certificate only
were excluded (n=704). Of the remaining 19 582 cases,
surgical treatment was performed in 3211 patients and these
were studied in detail. Twenty patients underwent surgery
twice in the period for synchronous or metachronous
tumours. Observation was terminated on 31 December
2004. Patients who had emigrated (n=13) were followed
up to the date of emigration or to the date of the last
consultation after emigration, if known.
Information on treatment, including the date of operation
and type of resection performed, was derived from clinical or
pathology reports. Supplementary information including
operative reports was retrieved from hospitals when the
information was found to be incomplete. The survival time
was calculated from the date of operation to the last follow
All cases were restaged at the Cancer Registry according to
pathology TNM (pTNM) by an experienced thoracic surgeon
(HR).13For synchronous tumours with different histopathol-
ogy, the T stage of the most advanced lesion determined the T
category according to the current TNM system. Only the first
tumour was included in analyses in patients with metachro-
nous tumours. The tumour size (largest diameter) as
or chemotherapy was
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