I’m heading off today to Hawaii (Maui), which I must hasten to add is for a conference, the Eighth International Lung Cancer Congress, not just a vacation, although working in Hawaii often seems better than time off at home. The meeting not only includes a lot of good lectures and debates, but it gives us the opportunity to actually discuss the importance and implications of the trials that were just presented a few weeks before at ASCO. Some of the important clinical trials and collaborations are developed during free hours at this meeting.
In addition to participating in a panel discussion on optimal management of never-smokers with lung cancer, I’ll be arguing in a debate on how to manage stage IIIA NSCLC. The specific topic is whether this stage of cancer should be treated with surgery (generally combined with chemo and sometimes also radiation) or whether chemo and radiation together without surgery should be more commonly recommended. Some of my posts that discuss the controversy about this issue are here and here. My debate will be with a surgeon from the MD Anderson Cancer Center, so it should be a challenge, but it’s all pretty light-hearted. We couldn’t have a debate if there was a clear right answer.
In lung cancer, as in many other types of cancer, people generally receive surgery if it’s possible to resect the tumor, and other treatments are considered alternatives. Part of this is historical: before there was chemotherapy or radiation, surgery was the only way to manage cancer. In addition, surgeons are often the first specialists to meet a cancer patient, since they often perform the biopsies that establish a tissue diagnosis. And, in truth, surgery often is a very effective treatment, particularly for earlier stage cancers.
So I have a question for members here: would most people definitely prefer surgery if it’s possible (”get it out!”), and consider non-surgical treatments to be a less desirable alternative, or would people be very happy to pursue a non-invasive approach if it produces comparable results? I’m making this the new polling topic for the next several days. When options produce similar outcomes, patient preferences should be a key component of what strategy to follow. So offer your comments here, and I hope you’ll vote in the poll on the right column.
posted by Dr. West @ 7:38 am link to this post
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June 24th, 2007 at 4:10 pm
Hi Dr. West. Wow, what a question and I just want to give an explanation for my vote. From the moment I found out I had lung cancer I literally wanted to go in there myself and “get it out!” Luckily I was offered VATS due to location and size, but truthfully I don’t think the thought ever crossed my mind to say no to surgery no matter what it involved. My surgeon said many times that I was “lucky” to be able to have surgery and I suppose that is still my mindset. However, if there was absolute proof that something other than surgery worked toward curing cancer then I would definitely be willing to do that. I would not want to be the guinea pig though to find out if the results were comparable. For example in Japan they are only doing wedge resections on BAC’s and my surgeon actually discussed what to do with me during surgery with his colleague - wedge or lobectomy. His partner recommended the lobectomy as I was young and he should be as aggressive as possible. I am not at all sorry he did that as to date it has not been proven that wedge is as good as lobectomy in this situation. Twenty years down the road they will have more significant statistics, but they don’t have the numbers to support it right now. I am hopeful that this DCA trial in Edmonton AB at the U of A will some years down the road provide this very thing or some other miracle will arrive(never hurts to wish does it). Good luck on your debate!
June 24th, 2007 at 11:22 pm
In truth, I think the surgeon I’ll be debating also shares my opinion that this issue isn’t an all or nothing discussion. I believe he’ll note that many patients with stage IIIA NSCLC would not be well served by surgery, as I would concede that there are some patients with this stage for whom surgery is a very appropriate and maybe optimal choice. I just think it’s interesting that we sometimes act as if surgery is the endpoint, and many of my stage IV patients ask why they can’t have surgery as well. But one of the key issues is that surgery is the preferred treatment for the lowest stage, best prognosis patients, so the reason to celebrate being a surgical candidate is because of the stage it means that someone is. Someone is almost always willing to do surgery, whether it’s a good idea or not, but that isn’t something to celebrate if it won’t do anything more than leave surgical scars and a healing process.
-Dr. West
June 25th, 2007 at 6:10 am
Oops … sorry Dr. West I guess I missed the most important information in your post - it was on debating Stage IIIA so I really shouldn’t have chimed in at all on this one. My speed reading gets me into trouble sometimes (and this is one of them). My apologies. Linda
June 25th, 2007 at 12:06 pm
Not a problem. The question of whether people would prefer surgery or not if you could reach more or less equivalent results could apply to earlier stage disease as well. There is increasing interest in using new radiation techniques as an alternative to surgery for stage I disease, for instance. So my question is really whether people want surgery if they can get it, or only if it provides some added benefit above a non-surgical approach.
-Dr. West
June 25th, 2007 at 1:00 pm
Having had surgery, radiation and chemo, I would say that if there were an alternative that would accomplish a cure I would definitely take it.
My surgery was hopeful at the start, once in he found possible vena cava involvement, closed me up and sent me home. 6 months later I am still trying to recover from that. After surgery I had chemo concurrent with radiation and that was no picnic either and I am sure delayed my ability to bounce back from the surgery. Now I am hopefully, dealing with the side effects of all that and no recurrence, have either inflammation or atelectesis.
June 25th, 2007 at 9:36 pm
Dr West,
It should be an good debate.
I had received two conflicting opinions during my diagnosis. Two surgeons recommended surgery. The third surgeon leaned towards radiation and chemo followed by surgery. I elected to get the lobectomy done on the basis of majority opinion. I was staged 1A before the surgery, upstaged to 3A immediately after the surgery (lymph nodes involvement was found during the surgery, but suspected by the third surgeon on the basis of PET scan). As I began the chemo after six weeks, spots were noticed on the bones upgrading the disease to stage 4. I have wondered if surgery resulted in the spread of cancer to the bones and could have been averted if chemo/radiation had been attempted before surgery.
Prem
June 26th, 2007 at 12:39 am
I don’t know of any reason to believe that surgery would facilitate metastatic spread, which is a very common myth, but I do think that it is a lot to go through if someone is at significant risk of having distant spread (which stage IIIA involvement of the mediastinal nodes really represent). While I don’t think chemo/radiation short-changes patients with stage III disease, I wouldn’t suspect that the outcomes would likely be better, more likely pretty comparable in efficacy and maybe better overall to tolerate.
-Dr. West
June 26th, 2007 at 9:03 am
I was staged 3B (adeno w/squamous features) in August ‘05 and it was hoped that after chemo, followed by chemo/radiation, I would be a candidate for a pneumonectomy. That didn’t happen as a mediastinoscopy revealed that there was still lymph node involvement opposite the tumor. So it was back to chemo/radiation, followed by chemo, now Tarceva (started Tarceva April ‘06). Currently, no evidence of active disease.
I was devastated when I learned I couldn’t have surgery — I wanted the cancer OUT! Now, however, I’m not so sorry that I didn’t have surgery. My lung capacity is great — I walk 3 miles a day, (6 miles on Sat. and Sun.) and have no SOB issues, have never had bronchitis or pneumonia, and haven’t needed to take a sick day for the last year. I feel GREAT and I don’t know that that would be true had I had the surgery.
In summary, wanted it, couldn’t have it, glad I didn’t have it.
Thanks for this site. You’re a godsend.
Trish
June 26th, 2007 at 9:28 am
Trish,
I hope and expect that your comment will provide comfort to other people in this situation, which is not uncommon. A doc’s perspective can only do so much; it really helps to learn how people feel who have actuall been through it. Thanks for writing.
-Dr. West