The Voice
Spotlight on surgery as a treatment for lung cancer
Many people are familiar with surgery to replace a knee, or remove an appendix, but people aren’t as familiar with lung cancer surgeries. Here, we’ll explore when lung cancer surgery is used, the different types of lung cancer surgery, and what the experience can be like as a patient.
Lung cancer is most often treated with surgery when it is detected early – at stage 3A or earlier. If the cancer is found before stage 2, typically, local options such as surgery will be the first and most effective option. At stage 2, surgery will still be the primary treatment but will likely be followed by other treatments such as radiation and chemotherapy. After stage 3A, lung cancer would not be treated with surgery.1
A surgeon who specializes in procedures for lung cancer patients is called a thoracic surgeon. Dr. Jessica Donnington, a thoracic surgeon in Chicago, has discussed how doctors decide what type of surgery a patient needs. “We define our surgeries for early-stage disease in two ways. One, how much lung we take and two how we get through the chest wall,” Dr. Donnington explained.2
She went on to address surgery for early stages of the disease, saying “the standard answer for patients with stage 1 or stage 2 disease is that we do a lobectomy. That’s [removing] one third of the lung on the right or half the lung on the left.”
Doctors usually prefer to take as little lung tissue as possible, and Dr. Donnington explained that, “for patients with very small tumors, less than two centimeters, that sometimes something called a segment or segmentectomy works, and that is a portion of [the] lobe.”2
However, when doctors remove tumors, they have to balance wanting to be minimally invasive with wanting to be thorough and effective. “You have to take all of the lymph nodes and all of the blood vessels that go to that region to ensure you don’t miss any cancer cells, which may have spread,” Dr Donnington said.2
Lung surgeries can involve removing even more tissue at the advanced stages, as Dr. Shanda Blackmon, of Texas explained to Mayo Clinic. “My patients with advanced lung cancer are often surprised to learn that they can have an entire lung removed,” Dr. Blackmon said.3
She went on to add that the recovery times for various lung cancer surgeries vary widely based on how invasive or intensive the surgery is.
“If you had a small part of your lung removed, you might be able to stay overnight in the hospital and go home the next day,” says Dr. Blackmon. “However, if you have an entire lung removed, you may need to stay in the hospital for a week or two. If you have a complication, you might need to stay longer.”3
There are primarily two ways thoracic surgeons perform surgery. One is known as a thoracotomy, which is what you might think of as a traditional lung cancer surgery. It involves a surgeon making an incision 8 to 10 inches long, between a patient’s ribs.
The other way is called minimally invasive surgery. Over the past 20 years, doctors and researchers have developed a minimally invasive technique called video-assisted thoracic surgery, or VATS. This procedure only requires a small incision—usually between 1 to 3 centimeters—and can be done either with traditional instruments or with robotic assistance to remove lung tissue.
In a typical VATS procedure, the surgeon uses long instruments and a tiny camera to operate through the small cuts, watching everything on a 2D screen. With robotic-assisted thoracoscopic surgery (RATS), the setup is a bit different—the surgeon sits at a console and controls robotic arms that offers a high-definition, 3D views and enhanced precision.
Both approaches are safe and effective, and the choice between them often comes down to the surgeon’s training and preference. So far, studies show that VATS and RATS provide similar outcomes when treating early-stage lung cancer. Generally, VATS and RATS surgeries have been described as, “it hurts less, the recovery is faster, and people get back to their normal self so much better.”2 According to Dr Blackmon, the less invasive nature of VATS procedures really does make a difference. “I’m a big proponent of minimally invasive surgery.”3
Dr. Thomas Bauer at Hackensack Meridian Health in New Jersey provided a view of how robotic assisted surgery works. As he explained, “the surgeon sits at the console next to the patient in the operating room and controls the instruments, including a 3D high-definition camera. The instruments have wrists which can move the same way that my hand moves.” He added, “The camera and instruments were placed through small incisions between the ribs. The surgeon removes the lung tissue through one of the small incisions.”4
What is the experience like for patients?
For a traditional lung cancer thoracotomy, the hospital stay is between 5-7 days. One lung cancer patient, Jennifer Toth, spoke candidly about recovering from her lung cancer surgery to remove her entire lung. “The first few days… can be scary and challenging and affect your mind, body, and spirit,” she said. She added that there were also relatively minor things, like unexpected pain in her shoulder and arm when she woke up, because her left arm was placed above her head for most of the nine-hour procedure. She also described loss of appetite and constipation from the pain medication.5
Perhaps surprisingly, Toth described her chest tubes as more painful than some of the incisions.5 Chest tubes are in place for drainage after a thoracotomy for 1 to 5 days, depending on the extent of the surgery. Additional concerns include scarring from the incisions and may deal with fatigue and infection as well.6
According to the Lung Cancer Foundation of America, it’s common for patients to experience pain in their chest area. Many patients also experience temporary breathing issues due to swelling. To help resolve this issue, patients are given a small breathing device after surgery called an incentive spirometer. It is a handheld device used to help patients take slow, deep breaths to keep their lungs healthy and prevent complications like pneumonia or atelectasis.
Along with physical symptoms, there can be an emotional toll, as well.
“Far too often, I see patients who have gone through surgery, and they’re recovering, but they still have moments when they feel very alone,” said Dr. Blackmon. She recommended support groups and ongoing medical monitoring.3
The five-year period after lung cancer surgery is critically important. Surgical resection remains the standard treatment for early-stage lung cancer. However, according to the National Library of Medicine, the recurrence rate after surgery is unacceptably high, ranging from 30% to 50%. Key risk factors identified include surgical procedure, TNM staging, lymph node involvement, body composition, and tumor characteristics. Despite extensive efforts, accurately predicting the likelihood and timing of recurrence remains a significant challenge.7 However, with early stage, with no sign of spread, the cure rate can be greater than 85%.
Although lung cancer surgery can be challenging, one of Dr. Bauer’s patients, William DiStefano, was encouraged by recent developments in surgery and kept the focus on returning to everyday life.
“When Dr. Bauer explained how the robotic surgery worked and that I would be a candidate, I felt very at-ease. Within a couple of weeks, I was back doing what I loved (working in his garden) and feeling pretty good,” DiStefano said.4
Sources:
- Types of Lung Cancer Surgery: What to Expect and How to Lower Your Risk for Complications | U.S. News
- Thoracic Surgery For Early Stage Lung Cancer | Lung Cancer Foundation of America
- Lung cancer surgery: Types, recovery and survivorship | Mayo Clinic Comprehensive Cancer Center Blog
- Understanding Minimally Invasive Lung Cancer Surgery | American Lung Association
- Lobectomy: My Story | LungCancer.net
- Surgery | Lung Cancer Foundation of America
- Predicting Postoperative Lung Cancer Recurrence and Survival Using Cox Proportional Hazards Regression and Machine Learning | Cancers