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The Surgical Decision: Assessing and Discussing the Patient’s Options

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Dr. David Harpole, Duke University Medical Center, describes how he assists patients with the surgical decision-making process.

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As a thoracic surgeon, we are the physicians that a lot of patients come to with lung cancer. Unfortunately, the outcomes for lung cancer have not been great, and I would say that there are some physicians that are surgeons where the patients come to them and are wary and don’t want surgery. It’s pretty much the opposite in lung cancer, most patients know that if we’re able to take the tumor out, that’s their best chance for survival.

So the first thing I do when patients come to us is reassure them that we need to adequately assess their strength and so forth for surgery, detail the extent of their disease which often involves not just surgeons but a medical oncologist, a radiation oncologist and an interventional pulmonologist in our practice. We discuss the fact that lung cancer is not treated with any one hammer — I usually say I use two or three different hammers depending on which modality we’re going to take on. Then at the location of their mass, we’ll take pictures from their CT scan and show it to them and discuss what are the surgical options, whether it’s something small that we can do with video-assisted techniques, or is it something that’s going to require quite a bit larger operation, then we discuss those with them.

I have a rule in my practice that I never let a patient decide on their care the very first visit that we have. We always want them and their family to spend time thinking about it, read the materials, then they come back and we decide on the best course of treatment. It’s an awful lot that comes at you when you’ve had the diagnosis of lung cancer and I feel like a judicious, slow approach is the thing that most patients appreciate from their physicians.


GRACE Video

The Basics of a Lung Cancer Workup

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Dr. Gerard Silvestri, Medical University of South Carolina, describes the steps necessary to work up a lung cancer diagnosis, from initial scan to choice of treatment.

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What are the basics of working up a lung cancer? When I see a patient in my clinic, usually they haven’t had anything done yet. They’ve been referred to me with a “spot” or lesion, or a mass on their lungs, and again, the first thing I need to do is take a good history and physical. How long have you had your symptoms, have you had weight loss, do you have bone pain, have you had headaches, what are some of the things going on — what diagnostic workup have you had? Sometimes they’ll already have had a biopsy. My job though is to do these three steps, absolutely simultaneously and sometimes in order — what is it, where is it, what I can do about it — diagnosis, stage and treatment.

The first visit is almost always trying to review the imaging and decide whether you need more imaging, do a good physical exam, do a good smoking history, find out what other health issues the person may have like heart disease, that can give us a challenge in terms of how we’re going to treat the cancer. So that’s the first part.

Sometimes I have to say that some patients are — it’s thought they may have a lung cancer, and in fact it’s something else. It could be a fungal infection or something else going on in the lungs. So usually what happens over sort of the course of the next ten working days is, either some more imaging, or a biopsy, and then perhaps a PET scan to help us with the staging portion of this. So sometimes we get a PET scan that will help us both direct the biopsy, but also help us with the stage. Over the next ten days or so we’ll try to get those tests done.

In addition, we always present our new cases at a multidisciplinary tumor board. What’s that? A multidisciplinary tumor board is where all the different specialties get together to look over the imaging, the biopsy results, the pathologic results, and come up with a better treatment plan. So who’s in the room during the tumor board? A pulmonologist usually, a chest surgeon or a thoracic surgeon, a medical oncologist, a radiation therapist, a pathologist, sometimes you’ll have a dedicated chest radiologist who will help review the films, and then also people from other ancillary services that are extremely helpful like clinical trials staff, like palliative care nursing. So we have all those people in the room at the same time, and they’re either reviewing brand new cases, or difficult and challenging cases that are coming back to the tumor board for consideration.

So that kind of happens in that first ten days and for us, we know how anxious patients can get during that time period that they just want to get something started, but I would urge anyone listening to this to consider is, if you don’t get it right, if you don’t give the person the correct stage and the correct treatment options, you won’t get the best care. Yes, speed is important, but you’ve got to get it right — what is it, the diagnosis, where is it, the appropriate stage, and then what are your treatment options, which really differ depending on stage. For stage I it’s usually surgery, for stage II, surgery followed by chemotherapy, for stage III, chemotherapy and radiation, and for stage IV, chemotherapy alone or some of the targeted agents. So if you don’t get that right, you’re going to get the wrong treatment, so be patient with that and if your doctors need to biopsy in a different area, as long as they’re explaining it appropriately to you, you should try to stay with that program.

So that’s the general workup of a patient. I will say, every patient gives a little bit of a nuance and so sometimes a patient seemingly needs something that’s a bit unusual in terms of a biopsy or the location of a biopsy or how to best go about getting that biopsy, and I can also say that sometimes the tumor board is split. Sometimes there’s no right answer about whether we should do it via a needle biopsy through the chest wall, or a bronchoscopy, and sometimes talking that through with a patient, they can help us – you can help us as patients make a decision about which way we would go next. That’s the general workup of a lung cancer.


GRACE Video

PET Scan Imaging: What Does It Tell Us?

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Dr. Gerard Silvestri, Medical University of South Carolina, discusses the use of PET scans in lung cancer workup.

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You may be asked when you’re diagnosed with lung cancer to have something called a PET scan. Unlike a CT scan, a PET scan tells us not where it is, but is it active — so a PET scan works on this idea that if it “lights up,” it’s an active lesion. Now things that are active tend to be rapidly dividing cells, and so PET is actually not useful in the brain where we are thinking all the time, we have very rapid metabolism. If a lesion lights up in the lung it’s rapidly dividing cells and it may be cancer, although sometimes infections in the lung can cause the PET scan to light up and even changes after radiation treatments can cause a PET scan to “light up.”

The PET scan can tell us if and where lesions are active, and they sometimes pick up disease we didn’t suspect outside the chest, for example in the bone, or the adrenal gland, or the liver, so the PET scan is useful if it’s positive and it tells us that a lesion is active. It’s also incredibly useful if it’s negative — so sometimes we have benign spots in our lung and if the PET scan is negative in that area it means, by and large, it’s not cancer.

One strong recommendation in this area though is if you have a positive PET scan it doesn’t always mean cancer; 20% of the time it’s falsely positive, especially in patients that have infections around a certain area. We often recommend doing a biopsy to confirm that the PET scan is in fact really cancer, or could it be something else. Sometimes we’re really surprised at the results of the biopsy in patients who have a positive PET scan and it turned out not to be cancer, which is good news for our patients.


GRACE Video

Potential Advantages, Disadvantages and Limitations of Lung Cancer Screening

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Dr. Gerard Silvestri, Medical University of South Carolina, discusses the benefits and drawbacks of lung cancer screenings.

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Lung cancer screening is something that’s quite new in the United States. In 2010, the data was published on a 50,000 person trial where patients were either randomly allocated to get a CT (CAT) scan of their chest, a low dose radiation CT scan, or a chest x-ray, and the study showed a 20% reduction in lung cancer mortality in the patients who got screened for lung cancer with a CT.

There are a few things that you need to understand about that trial. One, it only included patients between the ages of 55 and 74; two, you had to have smoked at least 30 pack-years — that’s 30 years at a pack a day, or for example, 15 years at two packs a day. So you need to have a certain smoking history and be of a certain age to enter into that trial, and now patients in that age range with that smoking history are eligible to be screened for lung cancer with a yearly CT.

The advantage is that you hope to get the cancer when it’s quite small, and so it can be resected with a surgery, taken out, and that patient will have a better chance of being cured of their cancer because as we get to more advanced stages like when the cancer has spread outside of the chest, the hope for a complete cure is lessened. Early stage cancer, screen-detected cancer, has a better chance for cure.

There are some disadvantages to screening though that people need to be aware of. About one quarter of the time, patients who have a scan will have a spot on their lung, or a nodule, or a lesion it’s sometimes called — a quarter of the time those spots are there, and 96% of the time they’re benign spots, but they still need to be evaluated. Sometimes they’re evaluated just with following up with a CT scan, sometimes they’re evaluated with a biopsy, and even sometimes it requires surgery to get those out. That can cause a lot of anxiety in patients and certainly put them at risk for unnecessary procedures, particularly if you’re taking out something that was going to be benign all along. So that’s some of the disadvantage of being screened for lung cancer.

Also, as folks get older, so when you get up into that 75-77 age range, you also have other comorbidities, other things, other health issues that make it difficult for you to undergo surgery, and so some patients may not want to be screened if they have other health problems that may preclude a long life expectancy.

Overall, screening is being implemented in the United States the same way breast cancer screening was implemented years ago in the United States, and we’re doing it very carefully to make sure the patients are of the appropriate setting. The other thing we’re doing is making sure that if patients are smoking, that they get some smoking cessation as part of their screening endeavor.


Dr West

How do we manage a “mixed response” to lung cancer treatment?

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Here’s a brief video that explains my approach to a so-called “mixed response” to treatment for a lung cancer.  

There isn’t a formal teaching or “best answer” about how to approach this issue, but what I explain here is a common and I think very sensible strategy for a still controversial clinical setting (if I do say so myself).  I’d welcome your comments.

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