Role of Surgery in Early Lung Cancer Remains Invaluable

Mark Widmann, MD, associate professor of oncology and urology at Johns Hopkins Medicine

Mark Widmann, MD

Refinements in surgical techniques have propelled the evolution of the management of patients with early-stage lung cancer, said Mark Widmann, MD.

The majority of patients diagnosed with early lung cancer are eligible to undergo a lobectomy. Moreover, for those who are unfit for surgery or have concerning comorbidities, some ablative options exist.

"The advancements in thoracoscopy and video-assisted thoracic surgery clearly have revolutionized lung surgery," said Widmann, chief of thoracic surgery at Morristown Medical Center. "The other side of it is CT screening. Hopefully, there will be a day when 75% of patients are diagnosed with early-stage disease so we can start off a little ahead of the game."

OncLive: What is the history of lobectomy in early-stage lung cancer?

In an interview during the 2018 OncLive^® State of the Science Summit™ on Lung Cancer, Widmann discussed the role of surgery in the treatment of patients with early-stage lung cancer.Widmann: There has been an evolution in the management of lung cancer. Eighty years or so ago, pneumonectomy was the only option. As there have been both refinements in surgical technique and a better understanding of early diagnosis of the disease, people have recognized that lesser resections or other therapies are potentially as effective, or are better alternatives, for patients who do not have good surgical risk. We have expanded our armamentarium of ablative therapy. That includes things such as radiation therapy, radiofrequency ablation, and cryotherapy.

For early-stage lung cancer, certainly for tumors over 1 cm to 1.5 cm [a lobectomy is appropriate]. For patients who are either frail, have multiple medical comorbidities, or have advanced emphysema who aren't candidates for lobectomy, there needs to be alternatives. The data are clear that [having] no treatment is not satisfactory. Someone who has a good expected lifespan other than their comorbidities is a candidate for ablative therapy. Those are the patients we look at for these other techniques.

As a technique, where does lobectomy stand now?

With recent advancements in targeted therapy, how will the role of surgery evolve in the coming years?

Could you speak to the importance of screening?

Three-fourths of patients with early-stage lung cancer are still candidates for lobectomy. We have had advances in video-assisted thoracic surgery, and we have been able to expand our surgical patient population, but there are still patients who are not candidates for surgery.We pushed the envelope pretty well with our minimally invasive surgical techniques. Patients are often back to full activity within 2 or 3 weeks. For patients who are good surgical candidates, it is an excellent option. The robotic revolution has paralleled the experience with thoracoscopy and video-assisted thoracic surgery. A good minimally invasive operation is still the standard of care for early-stage lung cancer if the patient has adequate medical reserves.We have a revolution in early diagnosis with CT scans and screenings, where we find nodules that are much smaller than what we would have found 20 years ago. You still need to be able to biopsy these small lesions, so surgery is still a major component. If one is going to surgically remove it, you have to have a plan for control of the primary site. Surgical incision is probably the most complete ablative therapy that we can offer. That will be a mainstay in the near future.The guidelines that are established by the major societies are pretty clear that, first and foremost, you have to screen patients who are at risk. Secondly, these need to be patients who are eligible for treatment. That balance is sometimes not met, and it is essential that both of those criteria are met when one applies a screening program.

In the right setting, it is going to make a major impact and hopefully shift the balance, as we are only finding 25% of patients with early-stage lung cancer—while 75% are advanced. If we screen patients in an appropriate and timely manner, hopefully those numbers will flip.

What are your thoughts on the current neoadjuvant options in this space?

There is a third component to screening for early-stage lung cancer. The whole point of that is finding early-stage disease. What we want to do is identify patients at risk, patients who are candidates for treatment, and then the patients have to go to a center that can offer excellent minimally invasive surgery or an ablative option. Both patient selection and center selection are essential.The neoadjuvant approach applies to patients with nodal metastases who will need systemic therapy. In the past, data have been pretty clear that patients who get a combination of therapies with neoadjuvant chemotherapy followed by surgery generally do better than those who enter that protocol on the reverse side.

That being said, there is another population of patients with early-stage solitary masses who can be downstaged with chemotherapy first, or at least their tumor size can be reduced so that they can have a lesser resection, and we can convert them from needing a pneumonectomy to a lobectomy. That can make a significant impact on their quality of life and overall survival.