Surgeon Sheds Light on Early-Stage Interventions in Lung Cancer

Daniela Molena, MD

Screening high-risk patients for lung cancer with low-dose computed tomography (CT) and the adoption of minimally invasive surgical approaches have reduced lung cancer mortality, explained Daniela Molena, MD, adding that outcomes could be improved further by increasing awareness for screening and addressing the stigma that surrounds the disease.

“When we think about lung cancer, we often think about smokers and a disease that's caused by patients' behavior. Therefore, very little money has been invested in trying to prevent and screen for this disease,” said Molena. “However, screening is very important. We're not advertising it enough. So many patients are at risk of lung cancer. [With screening], we could identify them at an early stage and save their lives.”

In an interview during the 2019 OncLive^® State of the Science Summit™ on Non—Small Cell Lung Cancer, Molena, director, Esophageal Surgery Program, Memorial Sloan Kettering Cancer Center, discussed the role of screening and the implementation of minimally invasive surgical techniques in early-stage lung cancer.

OncLive^®: Could you discuss the use of screening in lung cancer and highlight some of the surgical approaches that are available?

Molena: Lung cancer is one of the most malignant cancers that you can imagine. The mortality of lung cancer is higher than that of breast cancer, colorectal cancer, and prostate cancer combined. We have a lot of work to do to improve the prognosis of this disease, but now, we can use low-dose CT scans to screen for these patients. The National Lung Screening Trial (NLST) showed that the use of low-dose CT scan on high-risk patients can [reduce lung cancer mortality by 20%].

Because we have a tool to identify lung cancer at an early stage, we see much more early-stage lung cancers that we can treat surgically. We've made incredible progress over the past several years. The most important change was the introduction of minimally invasive surgery, which is much easier for patients to recover from. [This approach] has also reduced the morbidity of the procedure and increased patient satisfaction because there is less pain [involved]. Now, we're talking about going from 3 incisions, to 2 incisions, to even 1 incision.

The future will move toward more lung-sparing approaches. You can think about it relative to treatment in breast cancer. Initially, we thought more was better. We did many very expansive surgeries and resections, and then we realized that a smaller resection is equivalent in terms of survival. With lung cancer, [the scars] aren't as visible, but it's still very important, because quality of life and the ability to do the things that they want to do are the reasons [patients go through treatment]. Also, if lung cancer [recurs], there is only so much lung you can remove. We're going to see much more lung-sparing approaches, such as sublobar resections or [white-light] resections, when appropriate. As we move toward that kind of approach, then we have to use some of the technology we have available to identify which patients are candidates for those approaches versus lobectomy. We'll have to have a better assessment of the lymphatic drainage, the lymph node, and the original disease, and use our imaging modalities to guide us.

How is “high risk” being defined?

As in any clinical trial, the eligibility criteria should be very clear and somewhat restricted. [In the screening trials], patients had to have smoked 30 or more packs of cigarettes a year and be current smokers or have smoked within the past 15 years. Moreover, patients had to be between 50 and 55 years of age. These patients should definitely consider screening. That doesn't mean that other patients might not benefit from screening.

In the NLST, patients with a history of lung cancer were excluded from [enrollment]. Patients with lung cancer are those who are at risk. Often, we see patients who live through their lung cancer, and then years later, recur; that's not uncommon to see. [What about patients] with second-hand smoking exposure? That is impossible to quantify. Many people have lived in houses where there was a lot of smoking, and we have no idea what that might have done [to them] in terms of risk. In the future, we may broaden the at-risk population with a better understanding of who should be screened.

What efforts can be made to improve awareness?

We really need to do a better job of advertising the importance and availability of screening. Part of that can be accomplished by reducing the stigma that is associated with this disease. Patients are often scared to go for scans; they don't want to know [the results] because they feel guilty. They feel guilty about having caused this disease, so we have to work on trying to change that point of view. I start with my patient's family members. Every time I see a patient with lung cancer, I always ask their family members how much they have smoked or been exposed to it. Often enough, I find patients who are eligible for screening [that way].

What are some of the other challenges associated with lung cancer screening?

When you scan someone, [the patients] have to live with what you find. You're going to find things and you have to decide what's relevant and what's not. Sometimes, in the process of doing that, we may be too aggressive, and we can hurt patients by trying to figure out if they have cancer or not. We have to do a better job of interpreting the findings of the CT scan and compromise so that we're not overly aggressive.

There is a role for surveillance here as well. Not everything needs to be cut out, biopsied, or aggressively treated. At Memorial Sloan Kettering Cancer, we have a trial for ground glass opacity. Ground glass opacity is a big unknown in lung cancer; many patients have it, and many of them are very early-stage lung cancers. Some of them will never become a problem, so how do you decide which one is relevant and which one you want to treat aggressively?

One of my colleagues is creating a registry of patients with ground glass opacity, so we can follow them and have a better understanding of which patients we need to treat and which patients we can wait and watch. I hope that will give us a little more information about what to do in the future.

Does the awareness start at the primary care physician (PCP) level?

Absolutely. No one questions that women need mammograms. My primary care doctor talks about Pap smears, mammograms, and colonoscopy; they have all become part of routine practice. Your PCP will discuss that with patients when they visit with them. However, CT scans for smokers are not routine yet. It definitely has to start with the PCP being aware and able to talk about smoking in addition to other risk factors, such as asbestos and radon.

It's not just smoking by itself. Family history is important. There are never-smokers who have lung cancer. Once we move away from the ideology that smoking alone causes lung cancer, we'll do a better job [of increasing screening rates]. Time will help as well.

If a nodule is found, how do you determine if a patient is eligible for surgery?

If I see a nodule on a patient's CT scan, I tell them that is cancer until proven otherwise because early-stage cancer is curable. If you wait and see, you might get to the point where it's no longer resectable. [To determine if they are a candidate for surgery], I look at their functional status and see if they can tolerate general anesthesia.

The other aspect is the amount of lung we can remove. The majority of patients with lung cancer have smoked some in the past, and so, all of the remaining lung has been injured. We do have a way to measure their functions and see what they start with, so we can predict what their function would be after surgery. Sometimes, we have to compromise. We'll do a lobectomy because that's still standard of care; however, if someone has borderline pulmonary function numbers, we can maybe do a little less with the lobectomy if the lung cancer is small. Those are all considerations we make before we put [patients through surgical resection].

When it comes to surgery, minimally invasive surgery should be the standard of care. There is no reason why a patient should not be offered a minimally invasive approach. I don't believe there's any difference between video-assisted thoracoscopic surgery (VATS) and robotic surgery; they're both good options. If you need the robot to offer a minimally invasive approach to patients, use the robot. If you can use VATS, that's great. A minimally invasive approach helps patients experience less pain and fewer complications, which helps them recover faster. When we do lobectomies, patients come home the next day. It's amazing what we can do now. The outcome of this operation is amazing, and the complication rate is very low.

In the future, it's going to be very important to use a multidisciplinary approach. Right now, if patients have early-stage disease, they go to surgery. If it's advanced-stage disease, they go to the oncologist. However, I see a future where there is going to be a combination of treatments in the early-stage setting. Perhaps some patients won't need surgery if they respond really well to a certain treatment.

In the future, there’s also going to be more emphasis on patient perspective. Often, we make decisions based on the best care available, but we may not ask what the best treatment is for an individual patient. Patient input is very important. For example, you might have a better cure rate by removing a patient's entire lobe. However, if the patient is a marathon runner and their quality of life is much more important than cure, maybe a lung-sparing resection is better for that patient.