Standardised packaging and tobacco-industry-funded research.

www.thelancet.com Vol 384 July 19, 2014 233 Authors’ reply We thank Gerard Hanna and colleagues for their interest in our study, and agree it raises questions about the best sequence of treatments for patients with operable non-small-cell lung cancer. We found no difference in the number of complete resections b e t w e e n p a t i e n t s r e c e i v i n g chemotherapy compared with those receiving immediate surgery. Equally, although the numbers of patients are small, we found no increase in the number of incomplete resections for patients receiving chemotherapy, although this fi nding was not clearly reported. Unfortunately, with the data we have collected, we cannot reliably dist inguish between disease progression and disease recurrence. As described in our paper, the data on recurrence were analysed using a landmark date of 6 months. This allows for all patients to have completed their treatment. However, if we look at the crude rates of local recurrence by treatment group within the 6 months following randomisation (when treatment for those receiving preoperative chemotherapy would be ongoing), there is no excess of events in the chemotherapy group (6%) compared with the surgery group (6%). This is despite 25% of all local recurrences (as fi rst events) being recorded during this period. It should be borne in mind that patients included here have been staged using older, less accurate methods than those used today. Patients seemingly progressing on preoperative chemotherapy might reflect the presence of metastatic disease at the time of randomisation. In the surgery-only group, these patients would likely have been categorised as having a recurrence when in reality they should also be regarded as having progressed. These fi ndings are based on limited data, but taken together they do not suggest an increase in the number of progressions in the chemotherapy group or operable tumours becoming inoperable during preoperative chemotherapy. Overall there is still an absolute survival improvement of 5% for patients receiving preoperative chemotherapy and this approach might allow chemosensitivity testing of the tumour to avoid ineffective treatment after surgery. There are different potential reasons for giving either preoperative or postoperative chemotherapy in this setting. Patients selected for preoperative chemotherapy are more likely to have a better prognosis than those selected for postoperative chemotherapy, because unfit patients and patients with incomplete resection would be excluded. Our research hopefully reassures those treating patients that preoperative chemotherapy is better than surgery alone with a benefi t size comparable to that of postoperative chemotherapy. Further investigations of these treatments might be warranted to explore whether certain patients benefi t more or less from either preoperative or postoperative chemotherapy or indeed, a combination of both.