chemo before surgery - 1259760

Hi Rita,

Surgery near major vessels is certainly risky, and many surgeons simply do not have the experience to attempt it. Your dad's situation is one which calls for an opinion from an experienced thoracic surgeon, rather than a surgeon who performs many types of surgery, with only occasional resections of this sort. It may be helpful if you can find a nearby academic center at which you can obtain a second opinion from a thoracic surgeon. You may be told that the surgery is too risky, but then you will be more comfortable that chemo is the proper course.

JimC
Forum moderator

So very sorry Rita about your dad.

In a case study Dr. West asks several onc to comment. While this case involves malignant nodes as the reason for locally advanced it can apply in many ways to your dad's case, "Here’s another case in the recording I did with Drs. Jyoti Patel from Northwestern and Bob Doebele from University of Colorado, discussing a series of perplexing cases in lung cancer management, then combining their comments with the responses from several other terrific experts (Drs. Suresh Ramalingam, Jonathan Goldman, Julie Brahmer, Heather Wakelee, and Karen Reckamp) about the same case. From each one, you can get a sense of the variability in how different lung cancer experts share the same set of data but have their own interpretation and style for cases where there are significant gaps in what the data tell us.", http://cancergrace.org/lung/2011/08/30/unresectable-stage-iiib-nsclc-ca… this too, http://cancergrace.org/lung/2011/07/10/challenging-cases-in-lung-cancer…

http://cancergrace.org/lung/2011/05/14/balancing-risks-of-undertreatmen…

Suffice it to say there is no good answer and excellent doctors have a wide range of perspectives. As Jim suggested, a second opinion in a situation like this is so very reasonable. http://cancergrace.org/cancer-101/2011/11/13/an-insider%E2%80%99s-guide…

Here are more links on the subject,
http://cancergrace.org/lung/2013/08/07/asco-lung-cancer-highlights-part…

http://cancergrace.org/lung/2013/08/12/asco-2013-optimizing-radiation-r…

I agree with the great perspectives provided by Jim and Janine -- our moderators for very good reason.

Resectability may be in the eye of the beholder, but there are cases along the spectrum in which some thoughtful and aggressive surgeons might consider surgery feasible and appropriate, and others in which all but the most obscenely aggressive surgeon would favor it. It does come down to a judgment, and Jim is very right to point out that in these situations it's extremely important to seek the input of a well-trained thoracic surgeon who does lots and lots of lung cancer surgery and no heart surgery or gall bladder surgeries in a general surgery practice with some lung cancer here and there. It's also potentially very valuable to get input from several specialists, such as a surgeon, medical oncologist, and radiation oncologist, to see where they converge.

It's important to bear in mind that there is a major gulf between what might be possible and what is a remotely good idea. I can't convey how common it is for patients to get a major surgery that is ill-advised and ends up being only harmful because it's not able to remove all of the cancer without remarkable overall damage. I've heard it said that anything less than a complete resection with absolutely no cancer left behind is nothing more than a big, aggressive biopsy, and that's probably pretty close to a fair statement. Plenty of questionable surgeries are done because the surgeon is overconfident or has a financial incentive or is swayed by the desperate pleas from a patient and/or family that they just want it out. Unfortunately, this very, very often leads to someone just being devastated by a surgery that doesn't do the job but compromises the patient's ability to get the treatment they would actually benefit from.

If anything, starting with chemo burns no bridges and is often a very sensible way to prevent starting with an infeasible surgery.

Good luck.

-Dr. West