Minimally invasive surgery can cure early lung cancers

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Cancer centers across the country do minimally invasive surgical procedures for people with early-stage lung cancers almost 89% of the time.

But in Syracuse, at the Upstate Cancer Center, it's 100% of the time. Today I'll talk with Dr. Jason Wallen about why this is good news for patients. He's the medical director of the Lung Cancer and Thoracic Oncology Program at Upstate.

Welcome back to "The Informed Patient," Dr. Wallen.

Jason Wallen, MD: Thanks, Amber.

Host Amber Smith: Lung cancer accounts for about one in five cancer deaths, making it the deadliest cancer.

Is it true that if it's caught early, it can be cured?

Jason Wallen, MD: It's absolutely true. In fact, we utilize our lung cancer screening program, so we can catch more of these cancers earlier, so we can cure more people.

Host Amber Smith: Can you tell us about the various stages and what they mean?

Jason Wallen, MD: All cancers are staged with similar characteristics. Usually, a Stage 1 cancer is a small tumor, and it's only where it began. A Stage 4 cancer tends to have spread to other parts of the body. Stage 2 and 3 cancers usually are bigger tumors, or maybe lymph nodes are involved, or, maybe even both of those things.

And we use those stages to determine what are the appropriate treatments for any given patient.

Host Amber Smith: Now, there's different types of lung cancers, but the majority are the non-small cell. Is that right?

Jason Wallen, MD: That's right. About 70% of lung cancers are qualified as a non-small cell lung carcinoma. And those are the ones that usually people are talking about when they say, "I have lung cancer," or "I know somebody who has lung cancer."

Host Amber Smith: And what percent of those are smokers or former smokers?

Jason Wallen, MD: The vast majority are patients who have smoked at least some point in their life.

Host Amber Smith: So can you explain what happens when someone is first diagnosed with non-small cell lung cancer?

Jason Wallen, MD: The most important thing to figure out after somebody is diagnosed with any kind of a cancer is to figure out the stage number, because, like I said, it's very important to understand what the stage is so that we can figure out what are the reasonable treatment options for somebody.

And so that can mean additional X-rays, sometimes it might mean additional biopsies or procedures to firm up, as much as possible, what that stage number is.

Host Amber Smith: So is this a fast-moving cancer, where things are going to happen very quickly, the treatment ideas, and making a decision on what to do? Or do you have some time to kind of plan things out more?

Jason Wallen, MD: It's an interesting question. I always tell patients that if you had to pick a cancer to get, this is probably not one of the ones that you would choose. But that being said, there are varieties that can be quite aggressive, and there are other varieties that are much less aggressive and can take very long periods of time to progress.

But the most important thing to remember is cancer is never an emergency. Whenever we diagnose cancer, even the aggressive ones take several months to get to the point where we can even see them, and maybe even years. And so, what generally happens over the next few weeks is we're trying to understand somebody's diagnosis and stage is probably not what's having the most impact on how they're eventually going to do.

Host Amber Smith: So if someone is recommended for surgery, and that's usually what's recommended, right?

Jason Wallen, MD: For an early-stage lung cancer, you definitely want to be in the group of folks who's going to be offered an operation. That doesn't mean it's the only way to cure somebody, and it's not necessarily the best treatment for everybody, but if there are multiple options for a given patient, and surgery is included in one of those options, you probably want to be in the group that gets the surgery.

Host Amber Smith: So why is minimally invasive surgery preferred for someone with Stage 1 lung cancer over ... did it used to be an open surgery?

Jason Wallen, MD: Yeah, over the last 20 years or so, there's been a transition from patients getting, as you mentioned, quote-unquote open surgery.

People have lots of words for this. I hear people talking about cracking the chest or cracking the ribs or other, sort of brutal, terms, which we certainly try to avoid. And, happily, over these last 20 years, the number of surgeries that are done in that way have decreased dramatically. And that's come through the advancement in minimally invasive techniques, and, more recently, robotic surgery, which is a form of minimally invasive surgery.

And it's better for patients because the incisions are smaller, which generally means that they hurt less. There's less damage to bones, so less cracking or cutting of bone involved. In fact, in most minimally invasive surgeries, there's none of that.

And so you see faster recoveries, less use of narcotics, which many people are concerned about these days. You see shorter hospital stays and, even more importantly, fewer complications. So we definitely want to be doing as much minimally invasive surgery as possible.

Host Amber Smith: Does surgery sometimes replace chemotherapy or radiation?

Can lung cancer be treated with just surgery sometimes?

Jason Wallen, MD: Absolutely. In fact, in Stage 1 lung cancer, generally speaking, surgery is the mainstay of treatment. There are different types of treatments, as you mentioned, and oftentimes we use surgery and radiation somewhat interchangeably. Those are both what we call local therapies, and what I mean by that is those are treatments that only work at what you point them at. Radiation is somewhat like a ray gun. If you point the radiation at a target, then it hits the target.

Surgery doesn't have a ray gun, but it does have a scalpel, and so surgery only works at where you cut. Other treatments, like chemotherapy, are what we call systemic. They go everywhere. And so you don't point them at anything. You hope they find the cancer, wherever it's hiding. And so those are better when you might not know where the cancer is.

And so sometimes radiation can be exchanged for surgery, and there can be various reasons to do that.

Host Amber Smith: When you're doing a minimally invasive surgery, are those done with robotic assistance?

Jason Wallen, MD: At Upstate, all of the lung cancer surgeries are done minimally invasively, with robotic assistance.

Certainly you can do them without that, and years ago, we did many surgeries in that way, but the current standard at University Hospital is 100% robotics.

Host Amber Smith: Do you know if cancer centers across the country, are they all moving toward this? Is this a goal?

Jason Wallen, MD: Definitely minimally invasive surgery is the goal.

And I think most cancer centers across the country are adopting minimally invasive surgery. There certainly are places where open surgery is still done. And there are certain places where open surgery sometimes is the preferred option if people have particularly advanced cancers or cancers in difficult locations.

But as we get better at robotic surgery and minimally invasive surgery, some of those complex surgeries, fewer and fewer of them are done open. But there still are certain things that have to be done that way. But every day, there seems to be fewer and fewer of those as the technology improves.

Host Amber Smith: So for the more advanced cancer, say Stage 2 or 3, if surgery's offered, it might not be minimally invasive. Is that right?

Jason Wallen, MD: That is more possible. At Upstate, the vast majority of lung lobectomies that are done for lung cancers in Stage 2 and Stage 3 are also done minimally invasively.

Host Amber Smith: You used the term "lobectomy." Can you define that?

Jason Wallen, MD: Most people know that we have two lungs. You have a right and the left.

Less people know that the lungs are divided into lobes. And we have five of those. You've got three on the right and two on the left. And they're all different sizes, and lung cancers can end up in any of the five lobes. And so sometimes we remove an entire lobe, and sometimes we do other operations to remove the lung cancers.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking about minimally invasive surgery for lung cancer with Dr. Jason Wallen from the Upstate Cancer Center.

As the surgeon, is your goal to remove just the tumor or an entire lobe of the lung?

Jason Wallen, MD: So that depends on the situation. We generally don't remove only the tumor, and up until recently, the standard was to always remove the entire lobe of the lung where the cancer was.

Now we're doing increasing amounts of what we call sublobar resections, or less than a lobe. And so there are multiple other operations where we can do that and take out a little bit less lung and try to save some breathing capacity, and whether or not we can do that depends on the size and location of the tumor.

And sometimes it also depends on how much breathing capacity a patient has. For example, some patients have limited breathing capacity, and even though they might have a bigger tumor, we might still take out less than the lobe to try to save them that lung capacity.

Host Amber Smith: So if you're going to take out the entire lobe, how big is a lobe?

Jason Wallen, MD: They're all different.

Host Amber Smith: But they're not small. I mean, I'm just wondering, how do they fit through? If it's minimally invasive, how does a lobe fit through that little hole?

Jason Wallen, MD: It's a great question. We almost always have to make one of the incisions a little bit bigger to pull out the piece of lung with the tumor that we are removing. And the nice thing about lungs, though, is they're mostly filled with air, and so you can squeeze them down quite a bit to get them through a smaller incision.

Host Amber Smith: So what is the recovery like for the patient? Are they hospitalized afterward?

Jason Wallen, MD: Yeah, these are still inpatient surgeries, and so, in most cases, patients spend at least two or three days in hospital after a surgery like this. They can spend up to four or five days in hospital, in certain situations, and every once in a while people go home the next day, but there's no outpatient lung cancer surgery at Upstate right now.

Host Amber Smith: Is the patient's breathing noticeably different? Do they have trouble taking a deep breath after they've had a lobe of their lung removed?

Jason Wallen, MD: How much you notice what we remove really depends on how much you use what you've got. And that's something that's difficult to measure. So, it's a factor of how much lung capacity somebody has. But, if patients are very active, for example, if they're CrossFit instructors, then they're most likely to recognize that we removed something.

If they have more of a sedate lifestyle, like me, then they're less likely to notice the lung that we removed.

Host Amber Smith: How soon do they get back to that CrossFit training and the regular activity?

Jason Wallen, MD: People are up and around right away after surgery, but they're definitely not up for CrossFit for the first few weeks.

I would say for really vigorous physical activity, you're looking at least a month. We usually ask people not to drive for about two weeks. It's not because you can't get a car around the block, but because you might react a little differently if somebody pulled out suddenly in front of you.

Most people, it's better to avoid heavy lifting right away, because we've punched some holes through some important muscles that are used in lifting. You're not going to do any damage, but you'll probably regret it, so it's better to take it easy for about a month.

Host Amber Smith: Can you tell us about the most common complications and the rate of complications at Upstate?

Jason Wallen, MD: So the most common complications are pneumonia and air leaks, and every once in a while, people get irregular heartbeats after surgery. Those are all relatively easy to take care of, and Upstate has one of the lower complication rates in the country for all of these complications.

Host Amber Smith: How is overall quality measured for lung cancer treatment at a cancer center? And how does Upstate fare?

Jason Wallen, MD: We submit data to the Society of Thoracic Surgeons' national database, which is a database that collects data across all the major thoracic surgical centers in the United States.

And, we are above average for our complication rates. We are amongst the top for our rates of minimally invasive surgery, and we have one of the lowest mortality rates in the country.

Host Amber Smith: So if someone had an early-stage lung cancer that was successfully treated, are they at risk for additional cancers?

Jason Wallen, MD: We really worry about subsequent lung cancers. Sometimes I think we worry more about subsequent lung cancers than we do about the original one coming back. And so it's very important to keep track of folks after they undergo surgery for lung cancer, with regular doctor's visits and often additional CT scans.

Host Amber Smith: So you're more concerned about another lung cancer, or you're also concerned about skin cancers and breast cancers and colon cancers? Is it both?

Jason Wallen, MD: It's very important for patients to do all of their recommended cancer screenings. For women, obviously, continuing to get their mammograms for breast cancer; for everybody, continuing to get their colonoscopies and evaluations for colon cancers and whatever other screenings are recommended by their doctors, based on their age and risk factors.

Lung cancer doesn't necessarily predispose people to that, but it's also very important not to lose sight of your other health maintenance just because you were treated for lung cancer and are going through that evaluation.

The surveillance for recurrent lung cancers is not good enough to pick up any of these other cancers. For example, just because you got a CT scan for your lung cancer doesn't mean you can skip your mammogram, even though they were in the same area of the body.

Host Amber Smith: So you have to be vigilant. So when you have a new patient with early-stage lung cancer, do they see an oncologist as well as a surgeon?

Jason Wallen, MD: Not typically. The oncologist is the doctor, most practically, who would administer things like chemotherapy or immunotherapy if that was indicated. But like we said, for a Stage 1 lung cancer, that usually is not indicated, and so you might end up only seeing your surgeon or radiation oncologist or whoever ends up being your treating doctor.

Host Amber Smith: So if you had the lung cancer treated surgically and then years later or months later, if it came back, if another lung cancer appeared, would surgery still be an option for that person a second time?

Jason Wallen, MD: It certainly can be. We have many patients who we've removed multiple lung cancers on. We've even had patients where we've diagnosed two simultaneous lung cancers and had to make complicated plans based on that.

But again, it really depends on how much lung you have to spare, because every time we remove a lung cancer, we have to remove some lung. And your breathing capacity is important enough that sometimes we will decide not to do surgery, because we can't spare the breathing.

Host Amber Smith: Well, I appreciate you making time for this interview, Dr. Wallen.

Jason Wallen, MD: Thanks for having me, Amber. It's been wonderful.

Host Amber Smith: My guest has been Dr. Jason Wallen. He's the medical director of the Lung Cancer and Thoracic oncology program at the Upstate Cancer Center.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

If you enjoyed this episode, please tell a friend to listen, too, and you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube or wherever you tune in.

This is your host, Amber Smith, thanking you for listening.