Changing the Outlook for Inoperable Lung Cancer

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By David Tom Cooke, MD, as told to Susan Bernstein

The term is “inoperable lung cancer.” It means that the risk of surgery to remove the lung cancer exceeds the benefits of the surgery for a patient. However, it is hard to tell if someone is “inoperable.”

Age is one factor that can slightly increase your risk, but it’s not necessarily prohibitive. I’ve operated on 90-year-olds. Other health problems you have can be a factor, such as impaired lung function. If we remove a lung tumor in a person who already has minimal lung function due to severe COPD or emphysema, that can make surgery risky, for example. There is a growing population of people who fit that description. To be determined that your lung cancer is “inoperable,” you really need to be seen by a thoracic surgeon.

The gold standard for treatment of early-stage, inoperable lung cancer is something we call SBRT, or stereotactic body radiation therapy. It’s high-dose, focused radiation. SBRT is used to try to destroy the tumor. It’s very targeted, and we use special imaging to be very precise with this treatment, typically CT scans. It’s different from traditional, high-dose radiation therapy to shrink or kill tumors. SBRT has potential to cure lung cancer, but it’s not known if it has the same cure rate for patients as surgery. We usually perform one or two SBRT treatments, and then you have routine follow-up for 5 years.

There are some newer experiments going on in this area. It’s thought that radiation can cause the release of antigens, small proteins that activate your immune system. There are studies to see if the combination of SBRT with immunotherapy drugs called checkpoint inhibitors can increase the likelihood of killing and eliminating lung tumors. Checkpoint inhibitors activate one’s own immune system — to remove the “checkpoints” that slow down the immune system — to fight cancer.

Researchers are studying not only the effects of this combination therapy, but how long patients would have to take these drugs. Right now, there have been phase I studies to look at the safety of this SBRT/checkpoint inhibitor combination, as well as clinical trials underway to look at the results of the combination therapy.

Another treatment used in early stages is the use of [local scopes to treat the tumor], such as navigational bronchoscopy. For this treatment, we take a camera attached to the end of a catheter and insert it into the patient’s trachea, or windpipe. Then, either using high-tech guidance tools or combined with a CT scan, we aim the catheter toward the tumor. This is also being done with robotic technology combined with a CT scan to guide the catheter to the tumor, followed by microwaves to kill the tumor, or to locally inject chemotherapy directly into the tumor. There are animal studies being done now to test this type of technique.

There have been recent advances in surgery, so people whose lung cancer was once considered inoperable may become operable. One key factor here is robotic surgery. We can make smaller incisions for less stress on the body. Robotic surgery also allows us to take less lung tissue out to remove your tumor.

There are other new technologies on the horizon for lung cancer treatment. One may be a combination of robotic surgical technology with 3D imaging and heads-up displays in the operating room to carefully guide the surgery. I always use this comparison: If your child is going to the prom, do you want them going in a 1992 Ford Taurus or a 2022 Toyota Camry with all the latest safety innovations, such as blind spot assist, airbags on all sides, and a backup camera? We can use these technologies to greatly increase safety during surgery.

There is another point that is important for the big picture of lung cancer treatment. According to the American Lung Association’s 2021 “State of Lung Cancer” report, over 20% of patients diagnosed with lung cancer did not receive any treatment whatsoever. In addition, Black patients with lung cancer are 23% less likely to receive surgical treatment and 9% less likely to receive any treatment compared with white patients.

Before you have any treatment for lung cancer, it is best to discuss it with a team of doctors, including a thoracic surgeon, because we have so many different options to fight your disease.

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