Mason Spotlights on Surgical Implications of New Lung Cancer Developments

David P. Mason, MD

Ongoing education is imperative for lung cancer surgeons, according to David P. Mason, MD, so that they are continuously providing additional resources and insights on next steps in care, especially following intriguing data with drugs in the localized setting from the 2021 ASCO Annual Meeting.

“Certainly, as surgeons, we need to be educated in terms of what is going to happen [to our patients] after surgery,” Mason said. “Patients frequently want us to talk to them about their diagnosis and their pathology.”

The Institutional Perspectives in Cancer webinar on lung cancer covered advances in the frontline treatment of patients with NSCLC, as well as targeted therapies, updates with extensive-stage small cell lung cancer, and the role of nurse practitioners in the surgical management of patients with lung cancer.

In an interview with OncLive during a 2021 Institutional Perspectives in Cancer webinar on lung cancer, Mason, chief of Thoracic Surgery and Lung Transplantation at Baylor Scott & White Health, discussed new neoadjuvant and adjuvant developments in the treatment of patients with NSCLC, as well as what those data mean from a surgical perspective.

OncLive: From a surgical perspective, how have recent therapeutic developments impacted the lung cancer treatment paradigm?

Mason: We need to understand what is going on just from an educational standpoint, [so we can] answer questions for patients, tell them that there are promising new areas, and that they should have hope. [Patients will often ask], “How am I going to do?” Or, “What is my prognosis going to be?” I [sometimes] see patients where I am the first one to give them the diagnosis of metastatic disease, and they want to know what is going to happen. [As such], I feel fortunate to be practicing in an era where we have more than just palliative care. Generally, with short-term palliative care, patients with advanced cancers would die quickly. [Now] there is there is more out there for them.

How do the 5-year follow-up findings from the phase 3 PACIFIC trial (NCT02125461) supplement the clinical utility of durvalumab (Imfinzi) as a therapy for patients with stage III non–small cell lung cancer (NSCLC)?

The data are really promising. While there are survivors of stage III lung cancer, the prognosis is less than optimal. Certainly, these data give a lot of optimism in terms of treatment, and it makes us more reluctant to operate on patients if we are looking at it from the surgical side of things, because they seem to be getting good results with nonsurgical management.

[However,] thinking ahead, why can’t some of this knowledge that we are gaining [with systemic] therapy also pertain to surgical patients, and how might we be able to apply the positive PACIFIC findings to surgery?

[In terms of] how exactly to do that, clinical trials are underway looking into this, but it is very promising. We are all happy about it. I see patients in the office and make the diagnosis for stage III lung cancer frequently through mediastinoscopy or endobronchial ultrasound [EBUS].

Adjuvant immunotherapy also has gained a significant role with the addition of adjuvant osimertinib (Tagrisso) in select patients with EGFR-positive disease. What are your thoughts on the activity with this agent in the early-stage population?

I feel very positively about [this trial]. It seems like [some are] talking about it like it is a miracle, and we need to be a little bit more circumspect on the data. Long term, the disease-free survival and overall survival data will likely correlate; however, at the same time, that remains to be seen.

There [is also] a lot of long-term treatment that [patients] need to be aware of. [We need to think about] how patients can continue to take these medications for long periods of time. To me, I find it hard to take any medication for a prolonged period. Taking medicines for years on end, with side effects, [can be] challenging.

[However], [this trial is] promising. I am not ready to say this is the “holy grail,” but certainly, it is something that everyone feels positively about. We have been seeing a lot of it and hearing a lot about it on the surgical side because. It still is a relatively small percentage of the overall patients who get lung cancer who are even going to be candidates [for this treatment], which needs to be realized.

Have you changed your criteria for eligibility for lung cancer resection?

We need to be a little bit more open minded as surgeons, in terms of who we think are candidates for surgery. This is going to happen more and more—not just in targeted therapy—but in other arenas, where patients appear to have advanced disease but have lived long periods of time. Is there something that we should do locally, whether it be surgery or radiation, to try to improve a patient's long-term survival? The answer will be “Yes.” There are circumstances and we need to be open minded to those, but we also need to balance the morbidity of surgery vs the potential likelihood of cure.

How do you generally utilize a multidisciplinary approach in clinical practice to treat patients with lung cancer?

There are a lot of needs that a patient with lung cancer has. There is the issue of the initial diagnosis, and the treatment frequently will involve more than just a surgeon. Then, there are the expectations and understanding of the disease that they have, and the long term follow-up, specifically with lung cancer where recurrences are common. All those things need to be attended to. As to whether they need to have the [type of] multidisciplinary approach where everyone sits in one room with one patient at the same time, I do not believe that is the case. That can happen in a stepwise fashion. [However], the more communication that there is, the more comfortable the patient feels that their care is being appropriately coordinated.

I always make a point after I see a patient to tell them [that I spoke with their cancer care provider, or their] pulmonologist, so they feel [that we] are all on the same page. It cannot be overstated—in terms of the patient's comfort, or if they are not a surgical candidate—that we all spoke and agreed that that is the best course of action.

[Additionally], nurse practitioners are very important in providing continuity of care, because the care that we provide goes on for years. We keep track of patients for many different reasons. [Firstly], I enjoy it, and [also] I think the patients feel comfortable knowing that someone else is following them along who has known them through the whole journey. We pick things up and can keep things in context more, as well.

Because my schedule is busy, and other surgeons’ schedules are busy, occasionally I will not be there for that visit. [However], there is still that point person, and through the nurse practitioner, [the patient can feel] that connection to the surgeon there. [Nurse practitioners also] spend a little bit more time [with patients] and explain things a little better, and they are better at providing education, as well as that special personal touch, which is very important. Someone needs to follow these patients in continuity. It is very important. For example, we follow many [patients with stage I disease], but that does not necessarily have to be a medical oncologist. It needs to be somebody who is paying attention to their CT scans and [asking] how they are doing.

What else would you like to highlight from the lung cancer arena as it relates to surgery?

Minimally invasive surgery is something that has really changed how patients view and recover from surgery. The technology related to the actual carrying out of surgery has not changed much within the last decade. Postoperative pathways, or recovery, have become streamlined and optimized. There is [also] some new technology out there from the surgical side of things, in terms of tissue diagnosis. There is a role for everything.

One thing that is for certain is that those who operate on [patients with] lung cancer should be the people who do that on a day-to-day basis—not part-time lung cancer surgeons, but full-time lung cancer surgeons. There are a lot of nuances, not only in the technical aspects of the operation, but even in choosing the operation, and the conduct of that a particular operation as well. That is very important; experience is important.