Novel Surgical Strategies at the Forefront in Lung Cancer

Matthew Steliga, MD

Although the mediastinal nodal staging system has not changed in the field of non—small cell lung cancer (NSCLC), it’s important to pathologically stage the mediastinum prior to the development of a treatment plan, said Matthew Steliga, MD.

“It's important, not only to rule out false-positives, where nodes could have increased in size or uptake for benign reasons, but it is also critical to stage the mediastinum even if it looks negative in certain high-risk patients,” added Steliga, associate professor of surgery, surgical oncologist, Winthrop P. Rockefeller Cancer Institute, University of Arkansas.

Beyond staging, researchers have been channeling their efforts into making surgical procedures safer and more effective. One way to do this is through the implementation of prehabilitation programs, which are designed to help patients quit smoking and exercise more to ultimately get them in better shape for surgery.

“Yes, we might delay surgery by 4 to 6 weeks, but if they can get through it safer with fewer complications, and have a better outcome in the long-run, then it's certainly worth it,” said Steliga.

Another important aspect is enhanced recovery after surgery (ERAS), which focuses on assisting patients through the perioperative period to ensure quicker and safer recoveries.

In an interview during the 2019 OncLive^® State of the Science Summit™ on Non—Small Cell Lung Cancer, Steliga discussed key surgical updates in lung cancer and the shifting role of surgery with the emergence of novel therapies.

OncLive: What are some recent developments in the surgical care of NSCLC?

Steliga: First, there have been some changes made to the staging system with the eighth edition of the American Joint Committee on Cancer Staging Manual with further subcategorization.

Furthermore, although mediastinal nodal staging has not changed, it's important for us to pathologically stage the mediastinum before any kind of treatment plan is developed. We need to stage the mediastinum even if it looks negative in certain high-risk patients. These patients include those who have occult mediastinal lymph nodal disease; it may be those with larger or more central tumors. Any patient who has an N1 lymph node that looks positive may have occult N2 disease as well, which would upstage them. Increased standard uptake values on the PET scan would clearly make them at higher risk of occult nodal disease, too.

Therefore, it's important to stage the mediastinum in most patients, either with endobronchial ultrasound or mediastinoscopy, so that we can accurately get a stage and develop the best treatment plan for them.

Other important developments that we are working on in the world of surgery include making surgery safer, more efficient, and easier on the patients. We have both prehabilitation programs and ERAS for that. Prehabilitation includes efforts such as getting patients to quit smoking and getting them to exercise, even if it’s just a daily walking regimen. Increasing their activity and quitting smoking can put them in much better shape for surgery.

Then, with ERAS, we're looking at everything in the perioperative period. How do we decrease opioid use? [We want to do this] not only to decrease opioid addiction, but to decrease complications from opioids. We use multimodality pain control with many different medications to try to manage pain better with opioid alternatives; this can help patients recover a little quicker, get them through their hospital stay, decrease length of time in the hospital, and reduce cost complications.

How have the approvals of novel systemic therapies impacted the role of surgery?

As many of our medical therapies are getting better, we're seeing some dramatic responses in some of our patients. We have to evaluate everyone on a case-by-case basis, but there have been cases where we have had a patient with a clearly unresectable disease upfront, and then after significant treatment response, had tumor shrinkage. Their situation improved enough where we could [go on to] surgery. It is possible—not always, but sometimes—for patients to be downstaged, where their cancer can significantly respond to treatment and we can then re-evaluate whether or not they are a candidate for surgery. It’s important to have ongoing discussions in a multidisciplinary fashion to follow patients as they go through treatment.

Is there any ongoing research at your institution that you would like to highlight?

In our group, we're doing a lot of work with tobacco cessation. We know that smoking increases risk, and we know that quitting can decrease that risk. However, getting people to quit smoking is a difficult obstacle to overcome. We've done a lot of work with integrating tobacco cessation into our clinical workflow—where every patient gets counseled, gets approved pharmacotherapy, ongoing counseling, and then [followed up via telephone]. Through this effort, we have had many people quit smoking who had been unable to quit after decades of trying. We think it's important to quit smoking even after a diagnosis of cancer. Although they already have cancer, continuing to smoke can increase complications from surgery, chemotherapy, or radiation. Furthermore, once cured, people who continue to smoke can increase their risk for second primary tumors.