Surgery Remains Imperative in Lung Cancer Treatment

Eric Lambright, MD

Even with the impressive addition of novel agents—both targeted approaches and immunotherapies—surgery continues to have a significant role in the treatment plan of patients with lung cancer.

“Surgery trends to be one of the tools necessary to solve the problem of lung cancer,” said Eric Lambright, MD. “If we can minimize the side effects of operative care then that provides advantages for the patients. Some people believe it decreases risks a little bit, so that ultimately provides people with an advantage.”

OncLive: Can you provide an overview of your lecture on surgery in lung cancer?

Have there been any recent advancements in this field related to surgery?

What ongoing clinical trials in this space are being conducted?

What surgical challenges are we currently facing that you would like to see addressed in the next 5 to 10 years?

How do you determine who gets surgery over another type of therapy?

In an interview during the 2017 OncLive^® State of the Science Summit on Advanced Non—Small Cell Lung Cancer, Lambright, an associate professor in the Department of Thoracic Surgery, surgical director, Lung Transplant Chief of Thoracic Surgery, Veterans Affairs Medical Center, Vanderbilt University Medical Center, discussed the ongoing role of surgery in the treatment of patients with lung cancer.Lambright: We chatted about the surgeon’s role in the management of lung cancer and how that fits in with all of the other disciplines—medical oncology and radiation oncology—and stressed some of the importance of trying to figure out what people are up against as far as their cancer problem, specifically, defining stages and the tools that we have to do that. Then, it involves trying to help people as best as we can with the tool of surgery. The advances that have come in try to minimize the [invasive impact] that surgery has on people. We talked about how, although no surgery is truly minimally invasive, there are tools, such as thoracoscopic strategy and robotic surgery, that try to remove these problems. Most of the trials are part of the question, “How do we use all of the tools—be it radiation, chemotherapy, and surgery—together to help the patient?” There are not unique trials when it comes to surgery. There are some comparative trials when it comes to the effects and advantages of radiation over surgical treatment and those modalities. Most of it comes to, where does surgery fit in and how can we use all of these tools together to benefit the patient?We all know that the early diagnosis of lung cancer [enhances] our ability to more realistically impact prognosis. If we can move back the time of diagnosis, be it with screening or earlier diagnosis, we can benefit and help more people. We still have a smoking epidemic in the United States and, until those things get better, that is the lower-lying fruit than advancing all of the medical stuff. However, adults can make whatever decisions they like. If I had the crystal ball, I would be getting people smarter about the decisions they make for their own health, specifically cigarette smoking, and trying to improve our ability to diagnosis miserable disease earlier. That is the wish list. That is actually a complex question. Every day in our clinic, we have to answer that question. The fundamentals are to accurately diagnose and stage a patient, determine if the tumors are removable or not, and then try as best as we can to make sure that they can withstand the operation. Do they have enough lung reserve? Is their heart function okay? Do they have any major comorbidities that might preclude surgery? That may become a very challenging decision.

What are the main points for the audience to take away from your presentation?

There are more advanced stages of cancer that are treated with medical therapy and radiation therapy, and localized cancer tends to be more treated with surgery in the right setting. There are some people who are just too sick to have operative care. That is a very good question and it’s a challenging answer from time to time. We have multiple tools to manage this disease called lung cancer. The tools that we have are radiation therapy, chemotherapy, surgery, and biological modifiers. We are all fighting a cancer problem and we all have different tools; we want to try to maximize the advantages of the tools. We also want to minimize the disadvantage. However, part of this is we do know that surgery—still, in this day and age—is one of the means to provide curative-intent treatment for this disease.

The other is we have to, as accurately as we can, determine the stage of a patient’s individual lung cancer before a therapeutic strategy is implemented. This is because surgeons can do a lot of operations that the cancers will “laugh at” and we will not provide an advantage for the patient. Ultimately, it is still a disease that requires multiple team members to work together to optimize the advantage of the tools that we have to treat it.