Dr Vallieres on the Role of Induction Therapy on Surgical Candidacy in Lung Cancer

Eric Vallieres, MD, FRCSC, medical director, Division of Thoracic Surgery, Swedish Medical Center, discusses key considerations for determining candidacy for surgery in patients with lung cancer undergoing induction therapy.

Vallieres notes that the primary consideration revolves around a patient's continued suitability for surgical intervention following induction therapy. A critical aspect is assessing whether the extent of the disease remains amenable to surgical resection, he continues.

In general, surgical decisions should be made prior to the start of induction therapy, Vallieres explains; however, factors can change for some patients during the course of induction therapy. Vallieres notes that a subset of patients undergoing induction therapy may experience disease progression, rendering them unsuitable for surgery. However, with the available data from neoadjuvant chemoimmunotherapy, the proportion of patients who progress during induction therapy is small, Vallieres emphasizes.

Additionally, adverse effects arising from induction therapy, although infrequent, can potentially contraindicate surgical intervention due to compromised medical fitness, he continues. These factors underscore the necessity for thorough pre-treatment assessments to ascertain surgical candidacy and anticipate potential impediments to surgery, Vallieres explained.

Vallieres also addresses the variability in surgical complexity following induction therapy. Contrary to conventional assumptions, the notion that surgery may be more challenging post–induction therapy is not universally applicable, he explains. Induction therapy—with chemotherapy alone, chemoimmunotherapy, or chemoradiation—will not necessarily complicate the surgical procedure, he notes, adding that current imaging cannot fully assess the potential difficulty of surgery.

Conversely, Vallieres acknowledges that patients who present with bulky nodal disease up-front could require a more difficult surgery. However, this will not always be the case, he concludes.

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Eric Vallieres, MD, medical director, Division of Thoracic Surgery, Swedish Medical Center, discusses comparisons between video-assisted thoracic surgery (VATS) and robotic surgery in the treatment of patients with lung cancer.

For straightforward lung resections, there are no obvious benefits for robotic thoracic surgery over VATS, Vallieres says. For the surgeons who are still comfortable performing VATS, they are not doing a disservice to patients. Robotic surgery is still video-based, but the surgeon is using a different field of view that offers a more precise way of controlling the instruments inside the chest. Vallieres says the noticeable differences between these modalities might be more apparent with more complex procedures, but this remains to be seen. There have not been randomized studies comparing 1 surgical approach with the other.

In terms of postoperative quality of life, Vallieres notes that what keeps patients in the hospital is not incision size but air leaks and other complications. If a surgeon does an open surgery, VATS, or robotic surgery, the patient’s hospital stay remains the same if they have no air leaks.

There is also the issue of cost. Robotic surgeries are more expensive, but Vallieres suggests that as this approach becomes more universal, the cost will go down. Currently, for a robotic procedure to make sense, it would have to result in 1 less day of hospital stay or less staples being used.

Eric Vallieres, MD, medical director, Division of Thoracic Surgery, Swedish Medical Center, discusses comparisons between video-assisted surgery and robotic surgery in the treatment of patients with lung cancer.

Dr. Vallieres on Comparing VATS to Robotic Surgery in Lung Cancer

Eric Vallieres, MD, medical director, Division of Thoracic Oncology, Swedish Cancer Institute, discusses postoperative quality of life (QoL) in patients with lung cancer.

Recent advances made in thoracic surgery have moved the needle forward in a favorable way, Vallieres says. Not only has length of stay after these procedures been reduced, but surgeons are also able to manage patients’ pain perioperatively. Further, the use of a minimally invasive approach causes less surgical trauma in the chest wall, which ultimately translates to early recovery.

Vallieres adds that the approach used for open surgery has also undergone several changes in the past 2 decades. Even patients who are undergoing major procedures are recovering much faster. As a result of the progress that has been made in the space, patients with lung cancer are able to return to a fairly decent QoL much earlier following surgery; they are able to be active in their postoperative care with early ambulation. On average, patients are off all pain medication and back to baseline just 2 to 4 weeks after surgery.

Eric Vallieres, MD, medical director, Division of Thoracic Oncology, Swedish Cancer Institute, discusses postoperative quality of life in patients with lung cancer.

Dr. Vallieres on Postoperative QoL in Patients With Lung Cancer

Eric Vallieres, MD, medical director, Division of Thoracic Surgery, Swedish Cancer Institute, discusses the potential for incorporating immunotherapy into surgical treatment for patients with lung cancer.

For patients with oncogene-driven non—small cell lung cancer (NSCLC), the advent of targeted therapies before and after surgery has not had much of an impact on the role of early-stage surgery, Vallieres says. There’s a lot of excitement about factoring immunotherapy into surgical therapy, but in what setting and for which patient population remains unclear. Another big unanswered question is whether immunotherapy will provide the same benefit in the neoadjuvant setting, when patients still have their lymph nodes and lymphatics in place.

Vallieres also notes how the PACIFIC trial has transformed the way researchers view lung cancer. In that study, the checkpoint inhibitor durvalumab (Imfinzi) demonstrated survival benefit in patients with locally advanced, unresectable stage III NSCLC who had not progressed following chemoradiotherapy. He says that researchers are wondering if a similar approach can be beneficial for patients with resectable disease, and if immunotherapy can be added to the backend of surgery to prolong survival.

This research is ongoing, but Vallieries says the preliminary data have been encouraging.

Eric Vallieres, MD, medical director, Division of Thoracic Surgery, Swedish Cancer Institute, discusses future applications for surgery in the treatment of patients with lung cancer.

Eric Vallieres, MD

Articles

Dr Vallieres on the Role of Induction Therapy on Surgical Candidacy in Lung Cancer

Dr. Vallieres on Comparing VATS to Robotic Surgery in Lung Cancer

Dr. Vallieres on Postoperative QoL in Patients With Lung Cancer

Dr. Vallieres Discusses Future Applications for Surgery in Lung Cancer