GRACE :: Lung Cancer

Stereotactic Body Radiation Therapy (SBRT) for Medically Inoperable Early Stage Lung Cancer

GRACE Cancer Video Library - Lung



Dr. Chris Loiselle, radiation oncologist, describes stereotactic body radiation therapy (SBRT) as a helpful and increasingly favored treatment option for sicker, “medically inoperable” patients with early stage lung cancer.

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For patients with lung cancer who have early stage disease — we regard patients with early stage disease as those with smaller tumors, and tumors typically without lymph node involvement or other metastases — we think about surgery or radiation as, typically, a curative option for treatment. 

There’s interesting history here, and the radiation options for early stage lung cancer have really evolved quite far over the last decade. Historically, radiation therapy for early stage disease was a long course of lower dose radiation therapy, typically a course of 6 to 8 weeks of treatment, and the control rates were somewhat disappointing. The control rates were in the range of 50% over 1 to 2 years and, in those days, a surgical cure for early stage disease was far preferable to radiation treatment.

Over the last decade, we’ve developed a technique referred to as SBRT, stereotactic body radiation therapy; another acronym is SABR. With SBRT or SABR patients, we are looking at a 3 to 5 treatment course where we deliver very high dose radiation to this area of the tumor, and the results are extraordinarily good, and extraordinarily better from that of yesteryear. We see that 90-98% of early stage tumors are controlled with this technique, and patients find the treatment generally quite easy to go through.

We have generally studied this in patients who are not candidates for surgery, but many trials looking at using stereotactic body radiation therapy in patients who are good surgical candidates are ongoing, and some of those results are now forthcoming, and data looks very good for offering stereotactic body radiation therapy to all patients with early stage disease.

Join GRACE at the 2015 ALK, ROS1 & EGFR Lung Cancer Patient Forum

WHAT: Acquired Resistance in Lung Cancer Patient Forum
WHEN: Saturday, Oct. 3, 2015
WHERE: Marriott Waterfront San Francisco, 1800 Old Bayshore Hwy, Burlingame, CA 94010
WHO: ALK, ROS1 & EGFR lung cancer patients and their caregivers


Researchers are making advances in molecularly-driven lung cancer seemingly every day. The need for patient education is on-going and ALK+, ROS1, and EGFR lung cancer patients actively seek it.

ROS1 patients at the 2014 forum

ROS1 patients at the 2014 forum

They will find it at GRACE’s 2015 Acquired Resistance in Lung Cancer Patient Forum. The event will take place Saturday, Oct. 3, 2015, at the Marriott Waterfront San Francisco.

Patients and their caregivers who attend will hear directly from leaders in targeted therapy research. In addition to presentations and question and answer sessions, attendees will have many opportunities to approach the faculty to speak with them directly. An evening reception after the event will enable additional face time and give attendees – many of whom know each other from online support groups – a chance to meet in real life.

Scheduled presentations:

- Acquired Resistance & Why It Occurs
- Brain as a Sanctuary Site
- Repeat Biopsies and Serum-Based Testing
- Selecting Patients for Immunotherapy
- Quality of Life vs Progression Free Survival – What Are the Most Relevant Endpoints?
- Patient Assistance Programs
- Lung Cancer Survivorship

Additionally, breakouts for ALK/ROS1 patients and EGFR patients will cover issues specific to those patients:

- New Ideas and Treatment Options
- Individual Treatments for Individual Mutations
- Combinations to Prevent & Treat Acquired Resistance
- Drug Sequencing

Registration is $25 per person. GRACE has negotiated a group rate for rooms at the Marriott Waterfront San Francisco of $179 per night (request the “GRACE Patient Forum” room rate).

View the agenda for additional details and a list of confirmed faculty.

Register now button





Special Considerations for Lung Cancer Surgery in the Elderly

GRACE Cancer Video Library - Lung



Should older patients with lung cancer undergo surgery? What issues affect the probability of an elderly patients safely undergoing lung cancer surgery. Dr. Eric Vallières, thoracic surgeon, provides an expert perspective.

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The average age, at the time of diagnosis of lung cancer in the United States, is 72 years of age, which means that that’s the average — that means that there is a number of patients who are younger, but there’s also a significant number, the other half, where they are older than 72, and our populations are aging, and we are seeing more and more individuals who are over the age of 80 when they are diagnosed with their lung cancer. Age by itself, chronological age by itself, is not a contraindication to lung cancer surgery; biological or physiological age is more of the issue. There are individuals who are in their mid-80s, very active, and they can handle big surgeries, and there are individuals in their 60s where you look at them very carefully because, physiologically, they are not as healthy.

So, age by itself is not the factor. It’s more — how otherwise healthy the patient is, do they have other comorbidities, or other illnesses that would make their recovery from surgery harder? But that’s something that we’ve explored in our group. We reviewed 45 individuals in the last eight years who had undergone lung cancer surgery, but lobectomy, so, the standard operation for lung cancer, over the age of 80. Obviously, this is patients that we have chosen — these are not all the patients we saw over the age of 80 with lung cancer, but these are the ones that we took a good look at, and we felt we could take them through surgery safely. We had one death out of 45, that’s 2%, and the morbidity, so, the complication rate, was in the 30% range. But 85% of those patients went back home, only 15% were not well enough and had to go to some form of a nursing facility or rehab to recover from surgery. That’s very important — it means that if you choose your patients well, age is not the biggest issue.

The other thing that kicks in some is the fact that we are now being able to do minimally invasive surgery, which is beneficial particularly in that population group, in that the recovery from a minimally invasive surgery, whether it’s video surgery (or VATS), or robotic surgery, the advantages of that are dominant in the older patients. The main reason is they don’t hurt as much, and because they don’t hurt as much, they don’t need as much pain medication, and as a result, they don’t run into the complications that some older folks will run into when they take narcotics — confusion, and everything else that comes in. So, minimally invasive surgery — big asset for the older crowd, no doubt in my mind about that.

The fact is that, if you estimate and judge someone to be a good candidate for surgery, stage for stage, their survival after surgery is very close to, if not equivalent, to the younger population. So if they are judged to be good candidates for surgery, they do well after surgery, and their cancer survival is equivalent as well — stage for stage.

Challenges of Pneumonectomy Surgery

GRACE Cancer Video Library - Lung



Dr. Eric Vallières, thoracic surgeon, describes the phsycial challenges and risks for patients who undergo a pneumonectomy for lung cancer.

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The pneumonectomy, which I’ve described as when you remove the entire lung, for most patients is, physiologically, a bigger challenge. It is also a more risky operation; in general, patients who undergo a pneumonectomy — their risk of operative death, meaning dying as a result of surgery in the next 30 to 90 days, is three to four times higher than if they had only required a lobectomy. So the more lung you remove, the higher the risk.

GCVL_LU-D05_Pneumonectomy_Surgery_Challenges ML.001

Now, that’s not true for everyone. If someone comes to us and they already have a tumor that is completely occluding their lung, and they’ve been living like this for months, for us to go in and remove that lung — they’ve already shown everyone, including themselves, that they don’t need that lung, they’re living fine. But for someone who is utilizing that lung, for a significant portion, and when in the operating room you just take it out in one swoop, that is a physiological challenge, and that’s something that we have to evaluate seriously.

So the mortality is higher, and the complication rates of a pneumonectomy are also higher — two to three times higher, so it is a bigger challenge to take someone through a pneumonectomy short-term, and long-term. There is evidence now that there are a significant number of patients where they may survive the operation, but two years, three years, five years down the line, the fact that they only have one lung takes a toll on them, and there are some long-term issues for some patients — not all, but for some patients, in having undergone what’s called a pneumonectomy.

Interestingly enough, a left pneumonectomy is not as challenging to the patient, nor to the surgeon, as a right pneumonectomy. Our right lung is a bigger lung, and losing your right lung, in general, it’s not universal, is more of a challenge that losing the left lung.

GCVL_LU-D05_Pneumonectomy_Surgery_Challenges ML.002b

There is an alternative for some patients to pneumonectomy, and that’s called a sleeve resection. Now, a sleeve resection is an operation where the tumor that you’re removing is fairly central, and what you do is you cut the airway above the tumor, cut the airway below the tumor, take out the tumor and the lobe — usually the upper lobe on either side, and then you reimplant the bottom part of the lung to where you cut things up. That’s a good alternative, oncologically — so as far as cancer results, it’s as good as a pneumonectomy. But it is physiologically, in the long run, a much better operation for the patients. Some patients who are considered for a pneumonectomy are candidates for these sleeve type of resections, which are done in centers of excellence, but that’s something to be aware of.

Types of Lung Surgery: From Wedge Resection to Pneumonectomy

GRACE Cancer Video Library - Lung



There are multiple different types of lung cancer surgery. Dr. Eric Vallières, thoracic surgeon, reviews the different forms of lung surgery, include wedge resection, segmentectomy, lobectomy, and pneumonectomy.

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So, in lung cancer surgery, there are different types of operations that one can perform. The smallest amount of lung that one would consider removing is called a wedge resection, which is the equivalent of taking a bite into the lung without looking at boundaries and anatomy.

GCVL_LU-D02_Figs for Lung_Cancer_Surgery_Types ML.001

As you move up into the magnitude of the surgery, the next operation in line would be called a segmentectomy, which relates to the smallest anatomical division that the pulmonary lobes have. Those who have not had surgery — we all have five lobes in our two lungs, so three on the right, two on the left, and each lobe is divided into a number of segments. So, if you will remove only a segment, it’s called a segmentectomy, two segments would be a bisegmentectomy, and so on.

GCVL_LU-D02_Figs for Lung_Cancer_Surgery_Types ML.002

Beyond the segmentectomy, is the next amount of lung we would remove, consider removing — is a lobectomy, meaning one lobe, and as I’ve said just a few minutes ago, there are five of those: three on the right, two on the left. On the right side, sometimes, we will remove two lobes — the middle lobe, and either the upper lobe, or the lower lobe, and that is called a bilobectomy.

GCVL_LU-D02_Figs for Lung_Cancer_Surgery_Types ML.003

If we remove the entire lung, that is called a pneumonectomy, and that’s the magnitude — that’s the highest amount of lung that you can remove from one side, for obvious reasons.

GCVL_LU-D02_Figs for Lung_Cancer_Surgery_Types ML.004

In 2015, for a tumor that has still localized to the lung itself, for a tumor that has not spread anywhere, and in a patient who has the adequate cardiac and pulmonary reserves to tolerate the operation that is required, surgery is considered the standard of care — that’s the main option. There are other options, but at this stage in the game, they’re considered secondary, or less than standard of care options.

Now, when someone is evaluated for lung cancer surgery, not only do we evaluate whether the tumor is still localized, meaning it hasn’t spread anywhere, meaning that it’s a tumor that should be considered for surgery — that’s called resectability, but we also have to evaluate whether someone can handle that operation — that’s called operability, and that usually means, mainly, that we evaluate whether they have enough lung reserves to lose part of their lung, and that’s how we decide whether or not someone can handle, for example, a lobectomy.

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