
Innovations and updates on lung cancer surgery
Transcript
[00:00:00] 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. Dr. Michael Archer spoke recently at an American College of Surgeons meeting about innovations and updates in lung cancer. He's an assistant professor of surgery at Upstate and the medical director of the lung cancer screening program, and he agreed to explain what's new in lung surgery. Welcome back to "The Informed Patient," Dr. Archer
[00:00:33] Michael Archer, DO: Thanks so much, Amber. It's a pleasure to be back with you.
[00:00:36] Host Amber Smith: So what are the innovations and updates that you spoke about at the meeting?
[00:00:40] Michael Archer, DO: The meeting that I went to was out in San Francisco, and it was a bunch of leaders in thoracic surgery talking about what's kind of the latest and greatest going on in the realm of lung cancer.
And two of the main things that we focused on were what we call perioperative chemotherapy or immunotherapy. So treatments that are for what we consider more locally advanced cancers, right? So stage 2, stage 3 cancers, where surgery still has a role but might not be the biggest part of the treatment algorithm. So we talked about that.
And then the other one was really focusing on some of the latest data revolving around surgery for lung cancer.
[00:01:20] Host Amber Smith: Well, I understand the American College of Surgeons Commission on Cancer includes six operative standards for accreditation.
[00:01:27] Michael Archer, DO: Yes.
[00:01:28] Host Amber Smith: Can you explain those?
[00:01:29] Michael Archer, DO: Yeah, it does. And so I've been actually really involved in that component of the Commission on Cancer and the American College of Surgeons. In fact, I'm on the education committee for the operative standards. Now operative standards are a set of standards for surgeons. And what we're supposed to be doing from a surgery standpoint -- for not just lung cancer, but for colorectal cancer, breast cancer, melanoma -- is documenting in the patient chart in such a way that we are setting the standards for what is considered a good cancer operation, right?
So for melanoma and breast surgery, it revolves around margins and certain things you do in the operating room that the Commission on Cancer expects every institution that carries that accreditation to have in the operative note. So it's really telling patients out there that if you go to a COC accredited institution, you're going to get an operation that should be standard across the country and meeting the certain oncologic goals, right? The cancer related goals.
For lung cancer, it's interesting. It's not an operative standard, so it's not in my operative note, but it's what we do in the operating room and what we send to the pathologist. So it's not just important in the eyes of the COC, which is the Commission on Cancer, and nor is it in most surgeons who treat lung cancer. It's not just good enough to take out the lung spot, right? Getting the lung spot out is inherently good. I tell patients this all the time. Taking out the tumor, definitely a goal of the operation. We don't want to leave any residual cancer behind. But what we need to remember, and what the COC standard really is honing in on, is that you have to take out the lung spot, but you have to assess lymph nodes.
And the reason why it's important to assess those lymph nodes is that's where we go from maybe taking a stage 1 lung cancer where all you need is surgery, to maybe having a stage migration to stage 2 or stage 3, which is a huge deal, right? Because if you end up having disease inside a lymph node, which is an area of your body that helps fight off infection in the lung, but if you have cancer, it tends to be one of the first places the cancer spreads to. If you get cancer inside one of those lymph nodes, then we know that surgery, isn't it, right? Surgery is an important part of treatment, but it's not the end all be all, and we need to consider chemotherapy or other sorts of treatments.
So for the COC to set the standard that we need to take out lymph nodes from certain locations is telling us that that is an important part of cancer care because of the implications it could have related to treatment that needs to be given after lung cancer surgery.
[00:04:01] Host Amber Smith: So if lung cancer has spread, it will go to a lymph node first? That's why you're looking at the lymph nodes?
[00:04:08] Michael Archer, DO: That's exactly right. And we want to understand that as early as possible so we can get folks on treatment as early as possible because we know that that impacts survival and our rates of cure, right?
So what we know in this instance where there's cancer that's gone into lymph nodes, if we just stick with surgery and we don't do anything else, our cure rates are lower than when we can include chemotherapy or immunotherapy.
[00:04:29] Host Amber Smith: Now, if I understand correctly, the Commission on Cancer quality metric had been to retrieve 10 lymph nodes from the chest at the time you were removing a lobe, but that changed.
[00:04:40] Michael Archer, DO: It did change. You're right. And it's another one of these hot topics in thoracic surgery revolving around lung cancer care.
What we know is that for other cancer, say colorectal cancer, there's a standard that revolves around getting the number of lymph nodes out. But when we've looked back at using that number metric, looking at less than 10 lymph nodes or more than 10 lymph nodes, it tends not to be as predictive or as important, compared to when you look at where the lymph nodes came from.
So to get a little bit into the weeds, there's different parts of the chest, right? There's the part around the lung itself called the hilum. It's basically where the blood vessels are that are going to that area of the lung, and there's lymph nodes around there. And then there's another part of the chest called the mediastinum. It's a fancy word for the middle part of the chest. And so what we do in a lung cancer operation is we go into those specific areas, and we take out lymph nodes from those specific areas. If they're from what we call the hilum, we designate those as N1 lymph nodes. Or I frequently tell patients level 1 lymph nodes, right? They're the first lymph nodes that the cancer could get into.
Then if they get into the lymph nodes in the middle part of the chest, the mediastinum, we call those N2 lymph nodes or level 2 lymph nodes. And when those are involved, that takes us from stage 2 lung cancer, which is when they're around the lymph nodes in the hilum, and it takes us into stage 3. And so what we know is it's not whether or not we get 10 lymph nodes out, but it's that we physically went into those specific locations and took out those lymph nodes.
That's the really important part of this. If you only took out 10 lymph nodes and they were all just in the N1 station or in the hilum, it's not as good. You need to go into the mediastinum and get those lymph nodes out to make sure you have the complete picture.
[00:06:21] Host Amber Smith: Now, can you remove lymph nodes if the surgery is a robotic or a minimally invasive surgery? Or do you have to do open surgery in order to get lymph nodes?
[00:06:30] Michael Archer, DO: No, we do all -- well, knock on wood, the last four years we've done all of our early stage lung cancers, 100 percent of them have been robotic, and upwards of 90% of the time we are able to get lymph nodes out from all of those locations robotically. In fact, I would say as a robotic surgeon, doing minimally invasive surgery, it is safer, and I can get a more thorough assessment of all of those areas using the robotics platform compared to when we used to do open surgery, and it's just not as precise as it is when we use the robot.
[00:07:00] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host Amber Smith. I'm talking with Dr. Michael Archer about what's new in lung cancer surgery.
So let me ask you about early stage non-small cell lung cancers. How do you determine if a lobectomy where the entire lobe is removed is the best course of action, versus removing only a small portion of the lobe?
[00:07:26] Michael Archer, DO: I love this question, because this is really where, in the last two years, we've had a seismic shift in lung cancer surgery. Just to give you some background, in 1995, a paper came out of Memorial Sloan Kettering (Cancer Center New York) and it was the end all be all for what we should do for lung cancer. So any lung cancer, early stage, less than 3 centimeters, they looked at whether or not you should do a lobectomy or what we call a sub lobar resection. So a wedge resection, which is like taking a very small pizza pie type size bite out of the lung with the nodule itself, or doing something called a segmentectomy where you take out a little bit less lung.
And they looked at that, and the recurrence rate was higher in those instances where you didn't do a lobectomy. So at 1995, they said everybody should have a lobectomy. And what we know is that for years people were saying that can't be true. That can't be true, that we should just be doing lobectomies for these things that are just a centimeter or 2 centimeters. That just doesn't make sense that we have to take out the entire lobe.
And so in Japan and then here in the United States -- in fact, Upstate was a part of the clinical trial that that was performed in the United States -- we asked the questions, as lung surgeons, can we do sub lobar resections and get the same outcomes as we did when we did lobectomy, for early stage lung cancer?
So in order to consider being a part of that trial and answering that questions, we looked at only patients with early stage cancer, so it had to be less than 2 centimeters for both trials. And we had to have a PET scan, which is a special scan we do beforehand that showed that there was no evidence of any lymph node involvement.
So preoperatively, we said we're gonna take all the patients with small tumors, early stage cancer, stage 1 cancers, and we're going to randomize. We're going to say either you're getting a lobectomy or you're going to get one of these sublobar sections. And what we found in both of those trials, not only in Japan, but here in the United States, was that there was no difference whether you did a lobectomy or a segmentectomy or a wedge resection.
So what this now tells us is that we can take out less lung and still give patients the same oncologic outcome or the same cure rate, which is phenomenal. So in my practice, there are certain things that I look at to determine whether or not we should do a sublobar resection or a lobectomy, right? The classic way to determine who should get less lung taken out was breathing tests, right? Some people -- we know that smokers are very likely to develop lung cancer, or they're more likely than the rest of the population to develop lung cancer; that's why we have screening and all those things -- and so sometimes breathing tests or pulmonary function tests, the special tests we do to assess breathing, are poor in patients. And if we do an operation, we might make them worse off if we take out an entire lobe.
So that's kind of the first litmus test is do they have enough pulmonary function to tolerate a lobectomy? If they do, then I ask the question, well, where is the tumor located? Is it in an area where it would be easy for me to do a wedge resection or a segmentectomy, and do I think I can actually get the tumor out without compromising the margin? Now margin is just the idea that we need to have some normal lung between the tumor and where we cut through it. Otherwise, you might be leaving cancer cells behind.
So some of that comes down to judgment. I look at a CT scan and if something's way out in the very edge of the lung, and it's something where I can easily pick it up, and I can get far beyond that and deep into the lung, then I'll consider doing a wedge resection or a segmentectomy. But if I think that I'm going to compromise my ability to actually get the entire thing out, as long as the patient has good pulmonary function, I still tend to use lobectomy in that scenario.
The other instances are if the tumor's bigger than 2 centimeters, we don't know whether or not you should be doing wedge resections or segmentectomy. So if the tumor's greater than 2 centimeters, we're doing a lobectomy.
The other thing is lymph nodes. So we talked about the importance of assessing lymph nodes. I said that you couldn't get into these clinical trials that showed that there was equivalence between the two, right? Segmentectomy and wedge resection and lobectomy, they were the same as long as the lymph nodes looked okay on the PET scan. What we ended up finding in the operating room, and in order to be included in the trial, you needed to take out lymph nodes from all these places we talked about before, in the operating room and in real time have them assessed. So if the lymph nodes were positive for cancer, all of those patients then fell out of the trial and they just had a lobectomy.
So what we do in the operating room is during the patient's operation for lung cancer, if we're deciding we're going to not do a lobectomy, we're going to take out less lung, we look in all of those locations for the lymph nodes, and we send them to the pathologist, or the special doctor that looks at the lymph nodes underneath the microscope, and if they call me back and they say, "Dr. Archer, all of the lymph nodes look good," then I say, OK, we're going to do the wedge resection, or we're going to take less lung out. If they call back and say, "there's cancer in those lymph nodes," then I do a lobectomy in that scenario, as long as the patient can tolerate it, understanding that when lymph nodes are involved, again, it means we've had a stage migration, and we're going to need to consider doing chemotherapy afterwards, or immunotherapy.
[00:12:23] Host Amber Smith: Wow. Well, I've heard that you should seek a high volume center for lung cancer surgery. What counts as high volume?
[00:12:31] Michael Archer, DO: Twenty-five cases. There was an article published in 2023 that looked at volume related outcomes, and they used 25 lung cancer cases as the threshold for what is considered a high volume lung center.
So at Upstate, it's myself and I have two partners, and we do many, many more than 25 per year. And so, the upside of that is that this is what we do day in and day out.
The surprising thing is that if you look at across the country -- we're fortunate at Upstate that there's three of us here that do lung cancer surgery -- but if you look across the country and you especially get into maybe some flyover type states, a lot of the operations that are being done for lung cancer are still being done by general surgeons. When I was a part of this education committee for the American College of Surgeons to get the word out about this standard, what we realized is that we need to be educating...
You know, myself and my partners, we do lung cancer every day. So we kind of knew what the standard was, and we were doing it already before the college said, you need to be doing this. But more importantly is if you're out in a rural community in Kansas and you have a lung cancer, it might be a general surgeon that maybe does five of these a year. And you got to make sure that those doctors are the ones being educated so they know to get the lymph nodes out and give each patient a good cancer operation.
[00:13:47] Host Amber Smith: Well, let me ask you about some more advice for patients once they're diagnosed with lung cancer. Obviously if they can come to a high volume center, how do they go about picking a surgeon, and what should they be asking?
[00:14:00] Michael Archer, DO: The first question that needs to be asked is, are we operable? Right? And that really can only be answered by a surgeon. So finding a surgeon that does volume, but that is also associated with a multidisciplinary team. I can't stress how important that is.
And, that meeting that I was a part of out in San Francisco for the American College of Surgeons the innovation comes from working with the medical oncologist and the radiation oncologist and the pulmonologist and all working together to figure out what's right for individual patients. But then asking the bigger questions about, well, what is the real best way that we should be treating lung cancer? And that's how we get all these great papers that tell us all these important things.
But I think when patients are trying to figure out where they should go, and where they should get treated, and who should be their doctors for these things, I think being surrounded by a great group of people and a multidisciplinary team is important because there are times where patients will come to me. At the outset, they'll have a tumor, and I'll say, OK, well this is what we need to do. We need to get your breathing test. We need to get your PET scan. We need to do the staging studies to determine whether or not you're operable and what stage we think we're at beforehand.
It is a lot easier for me to turn to a colleague in a meeting who is a radiation doctor or medical oncologist and say, "OK I saw Mrs. Jones a week ago, and this is what her PET scan looks like. I think we need to do maybe chemotherapy or immune therapy before we do an operation. What do you think about that?" And having that teamwork and that connectedness really is just, honestly, the best thing for the patient. Finding a surgeon who does minimally invasive surgery is important I think just because we want patients to bounce back and get back to their normal life, right?
This getting diagnosed with cancer is a lot emotionally to go through. If we can get people in and out of the hospital quick -- you know, on average we keep people in the hospital about two days after these operations -- and then within a couple of weeks people are back doing what they love to do. So when you use minimally invasive techniques, you're more likely to have that course.
If you have the old school surgery with a big operation and spreading the ribs in the old school way, that can be a little bit more to overcome.
Board certification is always an important thing. When my parents are asking who they should see, figuring out whether or not somebody cuts the mustard from a board standpoint is always important as well. So I think, finding the right team is, at the end of the day, I think the most important thing though.
[00:16:19] Host Amber Smith: Well, that's very helpful information. Thank you. And I appreciate you making time for this interview, Dr. Archer.
[00:16:24] Michael Archer, DO: Yeah. Well, you're very welcome, Amber, and I always love chatting with you, and I hope this helps folks out there that are thinking about what needs to be done for lung cancer. And, we're always here to help, and happy to chat with you in the future about anything related to lung cancer.
[00:16:37] Host Amber Smith: My guest has been Dr. Michael Archer, an assistant professor of surgery at Upstate and medical director of the lung cancer screening program. "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 with sound engineering by Bill Broeckel and graphic design by Dan Cameron. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please invite a friend to listen. You can also 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.