Smaller Incisions for Smaller Cancers

Lung cancer is the leading cause of cancer death in both men and women worldwide. The Centers for Medicare & Medicaid Services (CMS) recently approved Medicare coverage for low-dose spiral CT screening in at-risk individuals, leading to more cancers being detected at an earlier stage. As a result, more patients will likely seek out potentially curative surgery. Drs. Cheng and Wood provide a well-written summary of the current state of minimally invasive surgery to resect early-stage lung cancers.[1]

Surgery with complete resection and lymph node removal remains the gold standard for the treatment of early lung cancers. Lobectomy is recommended by the American College of Chest Physicians (ACCP) in patients with stage I or II non–small-cell lung cancer (NSCLC) who will tolerate it (a grade 1B recommendation).[2] For patients who cannot tolerate a lobectomy the ACCP recommends sublobar resection with adequate margins (preferably segmentectomy) over other treatment modalities.[2]

However, the US population is growing older, and the increasing number of elderly patients with early-stage tumors with significant comorbidities will require physicians to consider alternative approaches to these often more frail patients. Stereotactic body radiation therapy (SBRT) is one option that has gained momentum as an alternative to surgical resection in nonoperative patients and those at high risk for postoperative comorbidities. A Surveillance, Epidemiology and End Results (SEER) database analysis of patients 75 years or older with early-stage NSCLC treated between 2003 and 2009 reported a 4.2% rate of SBRT use in the United States.[3] In some parts of Europe, this rate is substantially higher. Palma and colleagues queried the Amsterdam Cancer Registry for patients 75 years or older with early-stage lung cancer treated between 1999 and 2007.[4] They reported a 16% increase in the use of primary radiotherapy during the study period, with 23% of patients being treated with SBRT between 2005 and 2007.[4]

Advantages of SBRT include the ability to achieve negative margins on central lesions, reduced short-term morbidity, the lack of an anesthesia requirement for treatment, and the minimal collateral injury to surrounding tissue. However, patients who undergo SBRT are usually staged radiographically (rather than via systematic sampling of lymph nodes and pathology), introducing the risk of understaging and the potential for denial of adjuvant chemotherapy that might be beneficial. In addition, local recurrence is more difficult to assess following SBRT than it is following surgical resection, on account of the post-surgical inflammation and scar tissue often left after therapy. Thus, for now, surgery remains the preferred treatment modality.

Video-assisted thoracic surgery (VATS) is an approach that may fill the need for a surgical method more likely to be tolerated by frail elderly patients. VATS techniques for lobectomy were introduced more than 20 years ago and have been shown to result in shorter recovery times and equivalent long-term survival compared with open thoracotomy. Despite this evidence, the adoption of VATS for lung cancer surgery has lagged significantly when compared with other minimally invasive procedures, such as laparoscopic cholecystectomy. The reasons for this are many, but are rooted in the fact that less than 50% of lung resections are performed by dedicated general thoracic surgeons. In addition, the complexity of the procedure necessitates a rather long and steep learning curve and requires experience in performing these operations with some regularity.

However, with the approval of lung cancer screening for high-risk individuals by CMS, an increasing number of patients will be diagnosed with early-stage NSCLC. Many of these patients will be frail, and perhaps among those most likely to benefit from a VATS approach. Fortunately, as more patients with lung nodules are identified, the number of surgeons performing VATS pulmonary resections is also expected to rise, for a number of reasons. Residents and fellows graduating from modern training programs have extensive exposure to minimally invasive techniques and are expected to perform VATS lobectomies prior to graduation. In addition, technologic advances in minimally invasive equipment, including robotics, will make it easier for the “open” surgeon to routinely perform VATS surgery. Market pressure, patient demand, and the mounting evidence supporting VATS lobectomy will be catalysts for many surgeons to adopt minimally invasive techniques. Finally, as the Society of Thoracic Surgeons general thoracic database matures and public reporting of outcomes becomes a reality, patients will be able to view ratings and consolidate their care at the highest performing programs. These are likely to be institutions with general thoracic surgeons who are adept at minimally invasive pulmonary surgery.

As we move forward into the promising future of early detection for lung cancer and the prospect of making strides in survival and cure, thoracic surgeons will continue to be called upon to innovate and to determine, for each patient, the surgical approach that will be most effective and have the fewest comorbidities. Smaller early-stage tumors may lend themselves to less radical lung parenchymal sparing resections or no surgery at all. The authors of this review do a fine job of framing the present and future challenges that all of us face when treating lung cancer. I am hopeful we can capitalize on the promise of early detection of this deadly disease.

Financial Disclosure:Dr. Liptay is a consultant and course director for Covidien.

References:

1. Cheng AM, Wood DE. Minimally invasive resection of early lung cancer. Oncology (Williston Park). 2015;29:160-6.

2. Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2013;143(5suppl):e278S-e313S.

3. Shirvani SM, Jiang J, Chang JY, Welsh J, Likhacheva A, Buchholz TA, et al. Lobectomy, sublobar resection, and stereotactic ablative radiotherapy for early-stage non-small cell lung cancers in the elderly. JAMA Surg 2014;149:1244-53.

4. Palma D, Visser O, Lagerwaard FJ, et al. Impact of introducing stereotactic lung radiotherapy for elderly patients with stage I non-small cell lung cancer: a population-based time-trend analysis. J Clin Oncol. 2010;28:5153-9.