Changing prognosis for inoperable lung cancer

By David Tom Cooke, MD, as told to Susan Bernstein

The term is “inoperable lung cancer”. That means the risk of surgery to remove lung cancer is greater than the benefit of surgery to the patient. However, it is difficult to tell if someone is “disabled”.

Age is one factor that can slightly increase your risk, but it’s not necessarily fatal. I have operated on 90 year olds. Other health problems you have may be a factor, such as reduced lung function. If we remove a lung tumor in a person who already has minimal lung function due to severe COPD or emphysema, this can make surgery risky, for example. The number of people who fit that description is increasing. To find out that your lung cancer is “inoperable” you really need to see a thoracic surgeon.

The gold standard for treating early stage inoperable lung cancer is something we call SBRT, or stereotactic body radiation therapy. This is high-dose, targeted radiation. SBRT is used to try to destroy the tumor. It is very targeted and we use special imaging to be very precise with this treatment, usually CT scans. Shrinking or killing tumors is different from conventional high-dose radiation therapy. SBRT has the potential to cure lung cancer, but it is not known whether it has the same cure rate for patients as surgery. We usually do one or two SBRT treatments and then you have routine follow-up for 5 years.

There are some newer experiments going on in this area. It is believed that radiation can cause the release of antigens, small proteins that activate the immune system. There are studies to see if the combination of SBRT and immunotherapy drugs called checkpoint inhibitors can increase the chances of killing and eliminating lung tumors. Checkpoint inhibitors activate a person’s own immune system — to remove “checkpoints” that slow down the immune system — to fight cancer.

Researchers are studying not only the effects of this combination therapy, but also how long patients need to take these drugs. There have now been phase I trials to examine the safety of this SBRT/checkpoint inhibitor combination, as well as clinical trials underway to examine the outcomes of the combination therapy.

Another treatment used in the early stages is use [local scopes to treat the tumor], such as navigational bronchoscopy. For this treatment, we take a camera attached to the end of the catheter and insert it into the patient’s trachea, or windpipe. Then, either using a high-tech guidance device or in combination with a CT scan, we direct the catheter to the tumor. This is also done using robotic technology along with a CT scan to guide the catheter to the tumor, followed by microwaves to kill the tumor or to inject chemotherapy directly into the tumor. Animal studies are currently being conducted to test this type of technology.

Recent advances have been made in surgery, so people who were once considered inoperable with lung cancer may become operable. One key element here is robotic surgery. We can make smaller incisions for less stress on the body. Robotic surgery also allows us to take out less lung tissue to remove your tumor.

There is another new technology on the horizon for lung cancer treatment. One could be a combination of robotic surgery technology with 3D imaging and heads-up monitors in the operating room to guide the operation carefully. I always use this comparison: If your child is going to prom, do you want them to ride in a 1992 Ford Taurus or a 2022 Toyota Camry with all the latest safety innovations, such as blind spot assist, side airbags, and a backup camera? We can use this technology to greatly increase safety during surgery.

There is another point that is important to the overall picture of lung cancer treatment. According to the American Lung Association’s 2021 “State of Lung Cancer” report, over 20% of patients diagnosed with lung cancer received no treatment. In addition, black patients with lung cancer are 23% less likely to receive surgery and 9% less likely to receive any treatment compared to white patients.

Before undergoing any treatment for lung cancer, it is best to discuss it with a team of doctors, including a thoracic surgeon, because we have so many different options to fight your disease.

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