Introduction
Lung cancer is the leading cause of cancer related deaths in the western world with non
small lung cancer (NSCLC) accounting for around 75-80% of cases and small cell lung cancer
(SCLC) accounting for the rest.1 In Australia there are approximately 8,200 cases of lung
cancer diagnosed every year.2 Lung cancer was the fifth most common cancer reported in
cancer registries in 1998, but it was the leading cause of death from cancer accounting for
20.1% of cancer deaths. In the year 2000, lung cancer was responsible for 22.8% of male
cancer deaths and 14.9% of female cancer deaths and 5.3% of total Australian deaths.3 The
correct and efficient diagnosis, staging and treatment of lung cancer is therefore essential and
any small improvement in the handling on NSCLC could have significant effects in both
decreasing costs to the Australian healthcare system and improving the length and quality of
life of patients.
Lung cancer usually arises in the bronchi in response to repetitive carcinogenic stimuli,
inflammation and irritation. Disruption of the cell development occurs in the mucosal lining
and progresses to elevate and erode the basel membrane. The tumour then spreads throughout
the lung and will eventually metastasise to the lymph nodes and to other parts of the body.4
There are four main histological classifications of lung cancer. There are three that are closely
related in their behaviour and management, these are squamous cell carcinomas,
adenocarcinomas and large cell carcinomas and these are usually grouped as NSCLC: these
will be the focus of this evaluation. In contrast SCLC has a distinct natural history and
management and will not be assessed here.5
The accurate staging of NSCLC
The management of NSCLC is directed by staging based on tumour size and location,
nodal involvement, and the presence or absence of distant metastasis. The aim of staging
NSCLC is to accurately identify the group of patients who will have the greatest survival
benefit from either surgical resection or radical radiotherapy and chemotherapy. 6 Currently, up
to 50% of operations in early stage lung cancer are futile due to the presence of locally
advanced tumours or distant metastasis.7 Therefore there is a real need to improve the number
of correctly staged NSCLC patients and in so doing reducing the number of futile operations
that occur.
Staging NSCLC at the time of diagnosis is done by the TNM classification system
which then both guides management and predicts outcome. The various T, N and M factors are
grouped in different stages (from 0 to IV) in which patients are ranked to produce a system
1Devaraj, A., G. J. Cook, et al. (2007). "PET/CT in non-small cell lung cancer staging-promises and problems."
Clinical Radiology 62(2), p. 97.
2 http://www.cancer.org.au//aboutcancer/cancertypes/lungcancemonsmaUcell.htm Lung Cancer Council. 3rd
September 2007.
3 Clinical Practice Guidelines for the Prevention, Diagnosis of Lung Cancer. National Health and Medical
Research Council (2004), p. 3.
4 Clinical practice guidelines, p. 3.
5Clinical Practice Guidelines for the Prevention, Diagnosis of Lung Cancer. National Health and Medical
Research Council (2004) , p. 3
6Clinical Practice Guidelines for the Prevention, Diagnosis of Lung Cancer. National Health and Medical
Research Council (2004), p. 53.
7 National Institute of Health and Clinical Effectiveness, “The Diagnosis and treatment of Lung Cancer; Methods, Evidence
and Guidance. National Collaboration Centre of Acute Care. 2005.