可以看一下这篇文章，
Letter to Editor: The Contribution of Cytotoxic Chemotherapy to the Management of Cancer
Morgan的文章有这么几个问题：
（1） 2%生存率的提高是比较经过化疗和未经过化疗的癌症病人。但是他们未区分病情严重情况，未化疗的那一组包括本来就未经医生推荐化疗的早期病人。
(2) 五年生存率并不能完全衡量化疗效果。比如一些乳癌患者经过化疗，5年后的生存率仍然超过对比组。另外一些如晚期结肠癌和肺癌，化疗对平均寿命的增加（可能小于5年）未考虑。
（3）比较有意思的一个情况是，摩根的研究未包括一些已知的治愈率高的癌症，如白血病，某些淋巴癌。另外数据的选择也有些问题。
没法贴PDF文件。大致贴一下text，格式有点乱。
The Contribution of Cytotoxic Chemotherapy to the Management of Cancer
Sir We read with interest the paper by Morgan et al. [1], which
claimed to assess the contribution of curative or adjuvant cytotoxic
chemotherapy to survival in adults with cancer. We are concerned that
their approach underestimates the contribution of chemotherapy to the care
of cancer patients. By using all newly diagnosed adult patients as
a denominator, despite the fact that chemotherapy is not indicated for
many of these patients, the magnitude of the benefit in many sub-groups is
obscured.
Furthermore, the authors use a time-point of 5 years to assess effect on
survival. This will underestimate the efficacy of chemotherapy because of
late relapses. In breast cancer, the leading cause of cancer death in women,
survival curves show ongoing relapses beyond 5 years. Adjuvant
chemotherapy produces an absolute survival benefit at 10 years in women
less than 50 years with node-negative and node-positive disease of 7% and
11%, respectively, whereas the benefit at 5 years is 3% and 6.8% [2].
Quality-adjusted Times Without Symptoms of disease and Toxicity of
treatment (Q-TWIST) analysis has shown additional benefits beyond just
survival, with adjuvant treatment of breast cancer prolonging qualityadjusted
survival, partly by delaying symptomatic disease relapse [3].
The paper also contains several inaccuracies and omissions. The authors
omitted leukaemias, which they curiously justify in part by citing the fact
that it is usually treated by clinical haematologists rather than medical
oncologists. They also wrongly state that only intermediate and high-grade
non-Hodgkin’s lymphoma of large-B cell type can be cured with
chemotherapy, and ignore T-cell lymphomas and the highly curable
Burkitt’s lymphoma. They neglect to mention the significant survival
benefit achievable with high-dose chemotherapy and autologous stem-cell
transplantation to treat newly-diagnosed multiple myeloma [4]. In ovarian
cancer, they quote a survival benefit from chemotherapy of 11% at 5 years,
based on a single randomised-controlled trial (RCT), in which chemotherapy
was given in both arms [5]; however, subsequent trials have
reported higher 5-year survival rates. In cancers such as myeloma and
ovarian cancer, in which chemotherapy has been used long before our
current era of well-designed RCTs, the lack of RCT comparing
chemotherapy to best supportive care should not be misconstrued to
dismiss or minimise any survival benefit. In head and neck cancer, the
authors erroneously claim the benefit from chemotherapy given concomitantly
with radiotherapy in a meta-analysis to be 4%, when 8% was in fact
reported [6].
The authors do not address the important benefits from chemotherapy to
treat advanced cancer. Many patients with cancers such as lung and colon
present or relapse with advanced incurable disease. For these conditions,
chemotherapy significantly improves median survival rates, and may also
improve quality of life by reducing symptoms and complications of cancer.
Advanced cancer consumes a significant component of the healthcare
dollar, and chemotherapy can be a cost-effective treatment. For example,
lung cancer with more than two-thirds of patients presenting with
advanced disease, accounted for 5.6% of total healthcare system costs in
Australia in 1993–1994 [7]. The use of chemotherapy rather than bestsupportive
care alone is cost-effective, as it reduces costs of treatment of
complications of lung cancer and requirement for palliative radiotherapy to
control pain [8,9].
Although we fully agree that there is a need for evidence-based
assessment of all treatments, the contribution of this type of analysis, with
pooling of all cancer patients, is questionable and potentially misleading. It
is time to focus on future improvement by providing optimal evidencebased
multi-disciplinary care to our patients.
L. MILESHKIN
D. RISCHIN
H. M. PRINCE
J. ZALCBERG
Division of Haematology and Medical Oncology,
Peter MacCallum Cancer Centre,
Melbourne, Australia
References
1 Morgan G, Ward R, Barton M. The contribution of cytotoxic
chemotherapy to 5-year survival in adult malignancies. Clin Oncol
2004;16:549–560.
2 Early Breast Cancer Trialists’ Collaborative Group. Polychemotherapy
for early breast cancer: an overview of the randomised trials. Lancet
1998;352:930–942.
3 Cole BF, Gelber RD, Gelber S, Coates AS, Goldhirsch A. Polychemotherapy
for early breast cancer: an overview of the randomised clinical
trials with quality-adjusted survival analysis. Lancet 2001;358:277–286.
4 Harousseau JL, Shaughnessy Jr, J, Richardson P. Multiple myeloma.
Hematology (Am Soc Hematol Educ Program) 2004;237–256.
5 Tattersall MH, Swanson CE, Solomon HJ. Long-term survival with
advanced ovarian cancer: analysis of 5-year survivors in the Australian
trial comparing combination versus sequential chlorambucil and
cisplatin therapy. Gynaecol Oncol 1992;47:292–297.
6 Pignon JP. Chemotherapy added to locoregional treatment for head and
neck squamous-cell carcinoma: three meta-analyses of updated individual
data. MACH-HC Collaborative Group. Meta-analysis of
chemotherapy on head and neck cancer. Lancet 2000;355:949–955.
7 The Cancer Council Australia. Clinical practice guidelines for the
prevention, diagnosis and management of lung cancer. National Health
and Medical Research Council; 2004.
8 Berthelot JM, Will BP, Evans WK, Coyle D, Earle CC, Bordeleau L.
Decision framework for chemotherapeutic interventions for metastatic
non-small-cell lung cancer. J Natl Cancer Inst 2000;92:1321–1329.
9 Szczepura A. Healthcare outcomes: gemcitabine cost-effectiveness in the
treatment of non-small cell lung cancer. Lung Cancer 2002;38(Suppl 2):
21–28.
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