Too high-risk for lung cancer surgery? Maybe not
A recent headline from the Annals of Thoracic Surgery announced that high-risk patients with lung cancer might be candidates for surgery after all. But, to thoracic surgeon Jeffrey Spillane MD, this isn’t groundbreaking news.
“This study is not earth-shaking. It has been known for a while that limited resection has a role in treating lung cancer,” said Dr. Spillane.
Titled “Outcomes After Surgery in High-Risk Patients with Early Stage Lung Cancer,” investigators make the case for surgery, citing the need for alternative approaches to treatment. The study’s authors explained that lung cancer surgery is risky and can have serious complications, but it may offer the best hope for a cure.
Being over 60, with a significant smoking history and other health issues increases surgical risk. Consequently, 20 percent of patients with stage I non-small cell lung cancer are not offered surgery as a treatment option. Non-small lung cancer accounts for 85 to 90 percent of all lung cancer diagnosed.
Researchers at Emory University evaluated the effect of limited surgical resection, where part of the lung is removed, on high-risk patients with early stage non-small cell lung cancer. Their objective was to determine the role and outcome of surgical resection on this challenging population.
Researchers reviewed 490 surgical resection cases performed for stage 1 lung cancer from 2009-2013. Meeting the criteria for high risk as determined by the American College of Surgeons Oncology Group were 180 people. Compared to standard-risk patients, this population was older, had worse lung function, and had a greater number of smoking pack years.
Still The Leading Cause of Death
Lung cancer remains the leading cause of cancer-related death in the United States. Without treatment, survival for patients with non-small cell lung cancer is dismal. Determining operative risk can have a profound effect on the choice of treatments made available to patients. Taking a tailored approach ensures that all patients, regardless of their risk status, are offered the best chance for survival.
The Emory study found that there was essentially no difference in deaths while recovering in the hospital after surgery between the high risk and standard risk groups (2 percent versus 1percent.) The higher risk group did experience more post-surgical illness and on average stayed an additional day in the hospital as compared to the standard risk group. This was not a surprise, as they were sicker to begin with.
Researchers were surprised to discover that 20 percent of the high-risk surgical cases had positive lymph nodes, which were not detected in pre-surgical imaging. As a result of this finding, the affected patients were offered chemotherapy a lot earlier than they would have had they not undergone surgery.
The data also showed acceptable 1-, 2- and 3-year survival rates for the high-risk surgical cases, as compared to historically known rates for non-surgical treatments.
Since determining operative risk is an important part of forming a patient’s treatment plan, this study’s authors acknowledged the arbitrary nature of the process. But, for Dr. Spillane, it’s less about coming up with a rigid classification system and more about taking a tailored approach with each patient.
“We were just discussing this issue in our weekly Thoracic Co ,” said Dr. Spillane. “We ask: ‘What protocol should determine treatment?’ ‘On what factors should we decide?’ We often handle high-risk patients and tailor their treatment to risk.”
Treatment planning goes well beyond the patient’s physical state.
“Everybody is different,” said Dr. Spillane. “Some people live alone, but have a good functional status, and you want to keep them living independently. Some people have a sick spouse to tend to. Others have breathing issues or a cardiac problem. To determine the treatment, we use all of that information as well as look at the tumor characteristics, like the type and location.”
The study may have come about as part of a movement toward smaller resections, to preserve as much lung tissue as possible.
“For a long time there was an “everybody gets a lobectomy” (full removal of the lobe with cancer) philosophy,” said Dr. Spillane. More recently, there has been a shift in thinking that limited resections could be just as effective.
“It’s similar to breast cancer. Everyone used to undergo a radical mastectomy. Now, we do that operation only in certain situations. Still, there is a role for mastectomy. Lung cancer follows other cancers like breast and prostate in that regard,” he said.
Dr. Spillane acknowledges that straightforward cases always go to surgery. In cases where surgery is not an option, stereotactic radiation can offer a similar outcome.
Radiation oncologist Jeffrey Martin MD, who practices at Davenport-Mugar Cancer Center at Cape Cod Hospital, and Clark Cancer Center at Falmouth Hospital, said stereotactic body radiation therapy (SBRT) treats tumors with a high dose in only a few treatments, and is usually well tolerated. It has a clinically comparable outcome to wedge resections (surgical removal of a triangle shaped slice of cancerous lung tissue).
“SBRT is a non-invasive approach demonstrated to provide good control of a tumor, without the perioperative risks that can be associated with surgery,” he said.
Stereotactic radiation can be easier on the patient because it uses highly focused radiation aimed directly at the tumor, he added. Consequently, little of the normal surrounding tissues are affected. Qualified patients get three to five treatments over the course of one to two and a half weeks.
“They tend to tolerate stereotactic radiation treatment quite well,” he said.