Minimally Invasive Surgery and Multidisciplinary Collaboration Improve Recovery Time in Lung Cancer

Advancements in lung cancer screening, imaging-guided biopsies, and earlier diagnosis have enabled more minimally invasive surgical approaches, making multidisciplinary coordination between medical oncologists and surgeons essential to optimizing recovery for patients with lung cancer, according to Geoffrey B. Pelz, MD.

“A lot of [surgical] decisions are important to know upfront, because that affects what the treatment is going to be as well as [treatment sequencing]. Everybody needs to be intimately involved in that decision-making process,” Pelz explained in an interview with OncLive® for Lung Cancer Awareness Day, observed annually on August 1.

In the interview, Pelz discussed the evolution of thoracic surgical oncology, the current use of video-assisted thoracoscopic surgeries (VATs) and robotic-assisted surgeries, unmet needs in the surgical space, and surgical developments coming down the pike in lung cancer.

Pelz is a thoracic surgeon at the Hackensack University Medical Group at Hackensack University Medical Center in New Jersey.

OncLive: How has the role of thoracic surgical oncology evolved in the multidisciplinary management of lung cancer within the past decade?

Pelz: [We are] no longer in the days where it is either the medical oncologist or the surgeon treating a patient, where [patients] had either surgery and/or chemotherapy and radiation as their only 3 treatment options. Perhaps we combine them in different ways; [however,] there's so much more information that's out there with mutational testing, targeted treatments, etc. There are all sorts of different and newer medications, and things that can be done to treat lung cancer. It's not just [identifying whether a patient is] a surgical candidate or not, and then whether they need adjuvant treatment.

Multidisciplinary tumor boards, where there is the medical oncologist, radiation oncologist, surgeons, pulmonologists, pathologists, radiologists, and others there to [offer] their best opinion, are very important. [They are vital for determining] an individualized patient treatment plan and being able to come up with what's the best course of treatment for that individual patient.

With minimally invasive approaches on the rise, how are modalities such as VATs or robotic-assisted surgeries being utilized in clinical practice?

Minimally invasive surgery has revolutionized the surgical care of patients with lung cancer. [Historically,] everybody got a huge thoracotomy, stayed in the hospital for a week and a half, and took a couple of months to recover. Part of the challenge is to make sure patients are aware [of this]. A lot of patients may have a family member who had undergone surgery in the past, and they think that everybody comes out with a very morbid operation and a very long recovery with complications. [This could be] a barrier to patients even getting screened for lung cancer, because they don't want to know if they have it and don't want to undergo surgery. It's about being able to get patients in and out of the hospital within the same day or a day or two. Sometimes [they recover] within 2 weeks after surgery and go back to their normal lives. This makes a tremendous difference, and it's all due to minimally invasive surgery. [However,] we need to be able to make sure patients are aware that those are options and lower the barrier for them to seek treatment.

What are some ongoing challenges or unmet needs in the lung cancer space from a surgical standpoint?

The biggest [challenge] is lung cancer screening and getting patients their low-dose CT scans, where you can detect something early, because most patients will not have symptoms until they're at an advanced stage, and you lose the chance of potentially curing that patient. Over the years, the adoption of lung cancer screening scans has gone up. Last I read, it was [approximately] 20% overall, whereas it had been 5% or 6% for many years. Still, this is nowhere near the 80% [seen in] breast cancer with mammograms, in terms of [adherence]. Pulmonologists and primary care physicians are doing a better job of getting those scans ordered and caring for patients, but that's still something that needs to continue to be focused on.

From a surgical perspective, most advanced thoracic surgery for lung cancer needs to be done in tertiary care settings where there is equipment with the latest [robotic] models. We have options for navigational bronchoscopy platforms in a bronchial ultrasound, where, in a patient [who undergoes a] CT scan, we can biopsy the lung, do staging with lymph nodes, and then get that patient to minimally invasive robotic surgery, potentially. There's still a barrier for getting patients to those centers that have all that equipment and technology. Not every local hospital will have both the surgical expertise as well as the technology.

Looking ahead, endobronchial treatment is in its infancy, but that's something that may be part of this multidisciplinary approach as well. [For a patient] with multiple lesions, we may treat certain ones with surgery, some with radiation, and then maybe [employ an approach] where we ablate the tumor from the inside of the airway with a navigational bronchoscopy platform. That's on the horizon as well.

What advice would you offer regarding follow-up care after surgery, and how can other disciplines become involved to achieve optimal care for patients?

With minimally invasive surgery, most patients should be going home fairly quickly and recovering fairly soon after their surgery. [Nevertheless,] there are some patients who either could have marginal lung function ahead of time and may need a little more assistance from either their primary care physician or pulmonologist. Patients may benefit from pulmonary rehab after surgery or something [similar], to [help them] fully recover and get back to their normal lives.

Taking care of patients is certainly a team approach, and we want to send the patients back to their primary doctors to help take care of some of the other medical issues. Going forward, for anybody who has undergone a resection with lung cancer, depending on the pathology and the stage, they may need additional treatment afterward from the medical oncologist or radiation oncologist. [Maintaining] a multidisciplinary team approach is important.

What ongoing lung cancer research in the surgical sphere are you most interested to see read out?

There are many ongoing trials and [therapeutic approaches] coming down the pike. Trying to diagnose somebody with lung cancer, short of doing a CT scan, is going to be something that hopefully can come to fruition here. Circulating tumor DNA markers are one thing [being evaluated]. [Some colleagues and I are] involved in a study with exhaled breath analysis, where we’re trying to diagnose those tumor cells in patients just from exhaled breath, things like that, where we have limited resources with having to do a CT scan on everybody. At some point, as more screening scans are done, imaging centers start to back up on those numbers, and we may reach a point where not everybody can get their scans in a timely fashion. From a patient's perspective, if they can just get a blood test, it's the initial screening. If something's concerning on that, they should get a CT scan afterward to confirm things.

[Data from] a [phase 3] trial [(NCT00499330) published in the New England Journal of Medicine] in 2023 finally confirmed our suspicions that sublobar resection, whether that's wedge resection or segmentectomy, is equivalent to lobectomy in many instances for certain types of tumors. [We are] moving away from a more advanced [approach by] taking more lung tissue out and going more with lung-sparing operations. All of that [is made possible through] lung cancer screening scans, [early diagnosis], and being able to intervene and do biopsies, whether they are guided by CT scan or endobronchial navigational bronchoscopy. [This allows us to perform] minimally invasive surgery to treat those and spare lung tissues. As we're diagnosing things earlier, patients will be at a higher risk of developing a second or even a third lung cancer. We want to be able to have all treatment options available to them.