• Horace M DeLisser, Carla C Keirns, Esther A Clinton, and Mitchell L Margolis.
• Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania 19104-4539, USA. delisser@mail.med.upenn.edu
• J Natl Med Assoc. 2009 Aug 1;101(8):765-71.

BackgroundThe belief that exposure of lung cancer to air during surgery causes tumor spread is prevalent but poorly understood.PurposeThe purpose of the study was to summarize the published literature on the potential historical origins of this belief, study the recurrence rates of surgically treated stage I nonsmall cell lung cancer, research the mechanisms by which surgery might promote tumor growth and metastasis, and examine the social and cultural implications of this belief.Data SourcesVarious databases, reference lists, and expert contacts were the sources of data.FindingsAlthough the origin of this belief is obscure, its emergence may have been due to early debates within the medical community about the risks of lung biopsies, the significant surgical morbidity initially associated with thoracic surgery, and the difficulty early on of staging lung cancer patients before surgery. Approximately one-third of patients undergoing curative surgery for stage I lung cancer experience a recurrence of the tumor. Most recurrences are detected in the first 24 months after resection and likely reflect the presence of undetected, occult metastases at the time of surgery. Mechanisms by which surgery could promote tumor growth and worsen prognosis include direct seeding of tumor at local sites, tumor manipulation, stimulation of subclinical tumor by postsurgical inflammation, and accelerated metastatic tumor growth due to loss of inhibitory factors derived from the primary tumor. These beliefs are more likely to be prevalent, and resistant to change, in minority and disadvantaged groups.ConclusionsThese findings provide the basis for an approach to patients who fear the spread of their cancer by surgery.

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