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Patterns of failure after treatment for carcinoma of the lung were analyzed by the major WHO cell types. Only diagnoses of the review panel of the Veterans Administration Lung Group were used. First sites of progression were analyzed for 185 patients in a clinical trial, and cause of death was evaluated in 300 consecutive autopsies from VALG studies. Clinical progression was similar for all cell types--20% failed locally and 30% developed metastases. Carcinomatosis or brain metastasis caused death in only 27% of patients with squamous, in over half with large cell and adenocarcinoma, and in 70% of patients with small cell carcinoma. Complications of the local tumor (infection, hemorrhage, and respiratory failure) caused death in 50% of patients with squamous, in 1/3 with large cell and adenocacrinoma, and in 21% of those with small cell carcinoma. These clinical and autopsy data suggest the need for aggressive treatment of the local tumor in all cell types, and systemic therapy for small cell carcinoma. Both local and systemic approaches are needed for large cell and adenocarcinoma.

This paper discusses the results of the treatment of 345 patients entered in the Veterans Administration Lung Group Protocol 13L. The study was activated March 1972, and closed for the patient accesion March 1975. All patients had a histological diagnosis of primary lung cancer considered clinically non-resectable or inoperable. Patients were equally randomized into two groups, radiotherapy alone or radiotherapy with chemotherapy. The analysis of the data included: treatment regimen, radiation dose, initial performance status, performance status change, cell type, duration of survival, quality of survival and age. The strongest influence on median survival was the level of radiation dose. The small cell carcinoma patients treated with radiotherapy and chemotherapy showed significant improvement in the median survival (38.2 weeks) over the patients treated with radiotherapy alone (20.6 weeks). The patients treated with radiotherapy and chemotherapy also showed improvement in performance status more frequently than the patients treated with radiotherapy alone. Other parameters of the analysis will be presented.

One hundred sixty-seven patients with extensive well-differentiated and 120 patients with extensive poorly differentiated squamous cell carcinoma of the lung received chemotherapy as part of a randomized study by the Veterans Administration Lung Group. Chemotherapy was administration at random using one of the following four regimens: (1) cyclophosphamide alone; (2) cyclophosphamide plus 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU); (3) doxorubicin (adriamycin) plus cyclophosphamide; and (4) doxorubicin plus CCNU. With data on survival as the criteria for evaluation, it has been shown that combined chemotherapy using doxorubicin plus cyclophosphamide achieves greater median survival for patients with squamous cell cancer of the lung than single-drug chemotherapy using cyclophosphamide, under the conditions of this study; however, prolongation of life is still minimal, and better treatment is required. About 20 percent of the patients receiving any of the four regimens developed serious toxic effects from therapy with the drugs.