Clinical Guidelines and Clinicians ’ Intentions in End - Of - Life Care

size-based criteria (visceral pleural invasion, hilar atelectasis, and obstructive pneumonitis), Jones et al (reference 16 in our article2) have clearly indicated that hilar atelectasis and obstructive pneumonitis rarely are the only criteria for staging non-small cell lung cancer as stage 1B. Hung et al raised the possibility that our finding that T2P tumors 3 cm in size is a poor independent prognostic factor for survival because these patients may have T2S tumor sizes much 3 cm. From our patient database, the mean tumor size for patients with T2P tumors 3 cm was 5.15 cm (median size, 4.5 cm; 95% confidence interval, 3 to 9 cm) and the mean tumor size of patients with T2S tumors 3 cm was 5.07 cm (median size, 4.5 cm; 95% confidence interval, 3.2 to 8.5 cm; p 0.4595 [nonparametric t test]). Thus, it is unlikely that the independent unfavorable prognostic significance of T2P tumors 3 cm in size in our study is due to larger tumor size. Another finding in our study1 was that patients with T2P tumors 3 cm in size had similar survival times to those with T2S tumors 3 cm and T2P tumors 3 cm in size was an independent favorable prognostic factor, thus raising another question about whether the designation T2P should even be applied to tumors 3 cm. As stated by Travis et al3 (page 1387) on behalf of the International Association for the Study of Lung Cancer (IASLC) International Staging Committee (ISC) “the question of the effect of tumor size on the impact of visceral pleural invasion remains to be determined in studies of larger numbers of cases such as the prospective IASLC database” and “Study of larger numbers of cases with careful documentation of visceral pleural invasion will hopefully provide an answer to the question whether size has any impact on the significance of this T factor . . . . . . Hopefully these issues will be resolved in the prospective IASLC lung cancer staging project”3 (page 1389). Thus, it is not only worthwhile to perform an analysis to determine the prognostic significance of the T2P designation according to the newly proposed T factor sizes 3 and 5 cm (T2a), 5 and 7 cm (T2b), and 7 cm (T3), but is also worthwhile to conduct such an analysis for tumor sizes 2 cm (T1a), 2 cm, and 3 cm (T1b).