Lung Cancer
with Neri Cohen, MD, PhD
What is a “thoracic” procedure?
Lung cancer is the most deadly form of cancer. Each year, it claims the lives of nearly 165,000 Americans, which accounts for more annual deaths than colon, breast and prostate cancer combined. One reason lung cancer is so serious is because it often has no symptoms until its later, less curable stages.
Persistent cough, shortness of breath, ongoing chest pain, wheezing, coughing up blood, hoarseness and swelling of the face and neck are possible signs of lung cancer and should be evaluated by a physician. Although cigarette smoking is the most common risk factor for lung cancer, exposure to secondhand smoke, asbestos or radon also presents risks.
Lung cancer treatment, like all cancer treatment, depends on the stage of the disease. Neri Cohen, MD, PhD, Thoracic Surgeon and Chief of the Division of Thoracic Surgery at GBMC says the letters T,N and M help determine the stages. “Three primary factors define the stage of lung cancer: the size and location of the tumor (T), the extent of lymph node (N) involvement and whether the disease has metastasized (M), or spread,” he says. Through a number of diagnostic measures including history, physical exam, computer imaging, lab tests and biopsy, physicians are able to diagnose lung cancer and assign a stage between I and IV, with IV being the most serious.
Each week at GBMC, a multidisciplinary team of medical oncologists, surgical oncologists, radiation oncologists, radiologists, genetic counselors and other experts discuss difficult cancer cases and design customized treatment plans. “Typically, stage I and stage II lung cancers are best treated by surgery,” says Dr. Cohen. “Although it’s much less common, some stage III lung cancers are also treated surgically.”
Most stage III and IV lung cancers are treated with chemotherapy, radiation or a combination of the two. “Usually, combination therapy uses radiosensitizing chemotherapy agents. Once the radiation is administered, it is more likely to kill the cancer cells because it is working synergistically with the chemotherapy,” says Dr. Cohen. This combined approach allows lower doses of chemotherapy and radiation than when the therapies are given individually.
At GBMC, biologic therapy may also be used to treat lung cancer. Also known as targeted therapy, these treatments use the patient’s own systems to fight cancer. Natural substances, or those made in a lab, are used to boost, direct or restore the body’s defense mechanisms. In addition, clinical trials are underway at GBMC to help improve outcomes by combining lung cancer treatments.
Lung cancer surgery is a “thoracic” procedure, which is a term to describe lung, esophageal and other chest diseases. Modern thoracic surgery requires a significantly smaller incision than traditional open surgery. Today, surgeons use muscle-sparing minimally invasive approaches, which result in smaller scars and shorter recovery times. “We can remove the affected part of the lung and lymph nodes through a four-inch incision or several one-inch incisions. We do the same operation that used to require a large incision cutting through muscle tissue, except now we focus on reducing the trauma from the operation and preserving function as much as possible,” says Dr. Cohen.
After lung cancer surgery at GBMC, a patient can expect to spend one night in the intensive care unit and a total of about three days in the hospital before returning home. Most patients return to work two weeks after surgery, which is a substantial improvement over the three-month recovery period for open surgery.
In addition to the stage of cancer, there are other factors to consider before going ahead with surgery. “When deciding to include surgery in the treatment plan, we ask ourselves two questions: ‘Is the tumor resectable?’, meaning can it be cut out and ‘Is the patient operable?’” says Dr. Cohen.
Imaging techniques such as computed tomography (CT) and positron emission tomography (PET) scans allow physicians to determine how successfully the tumor can be removed. CT scans are used to examine the size and location of the tumor. “We want to know if the tumor is completely embedded in the lung or if it has invaded vital structures such as the heart and vertebrae,” says Dr. Cohen.
A PET scan looks at the biological behavior of the tumor. “We look for disease elsewhere in the body, for instance whether it has metastasized to other organs such as the liver, adrenal gland or brain,” says Dr. Cohen. If cancer has spread to other organs, surgery may not be an option.
Patients who are elderly or suffering from other health conditions may not be good candidates for lung cancer surgery. During treatment planning, patients undergo two tests to evaluate the preparedness of their heart and lungs. “Pulmonary functioning testing is done to determine how much breathing capacity patients have in their lungs. And, a cardiac stress test is done to make sure they do not have coronary heart disease or other heart problems,” says Dr. Cohen.
Although the overall five-year survival rate for lung cancer has doubled in the past 30 years, it has only improved from seven to 15 percent. Dr. Cohen says there is still a lot of work to be done – especially in the area of prevention. “It’s really only been since the mid 1980s that people have started to understand cigarette smoking is an addiction,” he says. Smoking cessation plans and behavioral therapy may help prevent the development of lung cancer altogether.
