The Role of the Thoracic Surgeon in Lung Cancer Care
In this episode, Dr Rizzo interviews Leah Backhus, MD, MPH, about the role of the thoracic surgeon in lung cancer care, including how the screening environment and the advances in surgical techniques, especially bronchoscopy and minimally invasive techniques, have impacted patient outcomes.
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Leah Backhus, MD, MPH, is a surgical oncologist, thoracic specialist, cardiothoracic surgeon, and an associate professor of cardiothoracic surgery at Stanford Hospital and Chief of Thoracic Surgery at the VA Palo Alto (Palo Alto, CA).
Albert A. Rizzo, MD, is the chief medical officer of the American Lung Association and a member of ChristianaCare Pulmonary Associates (Newark, Delaware).
TRANSCRIPTION:
Speaker 1:
Hello and welcome to Critical Observations in Pulmonary Medicine led by the Chief Medical Officer of the American Lung Association, Dr Albert Rizzo. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.
Dr Albert Rizzo:
Hello, and thank you for listening today. Today I'm speaking with Dr Leah Backhas. Dr Backhas practices at the Stanford Hospital and is Chief of Thoracic Surgery at the VA Palo Alto in California. She trained in general surgery at The University of Southern California and in cardiothoracic surgery at the University of California Los Angeles. Her surgical practice consists of general thoracic surgery with a special emphasis on thoracic oncology and minimally invasive surgical techniques.
Thank you, Dr Backhus, for speaking with me today. To begin, will you please briefly tell our listeners how you were drawn to thoracic surgery and what your current role at the Stanford Hospital in California involves?
Dr Leah Backhus:
I was drawn to surgery even as a middle schooler. I just thought it was pretty cool. The human body was like a puzzle and it seemed to me that surgeons were the ones trying to put the pieces of the puzzle together and take them apart and reconnect them and that sort of thing. So, the technical aspects of surgery, at least theoretically as much as a middle schooler can conceptualize it, were intriguing to me. And in fact, I actually wanted to be a neurosurgeon. I didn't know a whole lot about the body. I didn't have any physician mentors or anything in my family or in close proximity. So I made this stuff up as I went along, asking people along the way.
But it wasn't until my third year of medical school that I decided that surgery was really going to be the move for me and specifically not neurosurgery. So, I went ahead and applied for and matched into general surgery. And then it wasn't until I was a second-year general surgery resident that I sought out thoracic surgeons and went into the lab. So, exposure is everything, honestly.
Dr Albert Rizzo:
Exactly. Yeah. Great, great. Well, we're glad you ended up where you are. And what do you currently do at Stanford Hospital? What is your role there?
Dr Leah Backhus:
At Stanford, like most academic places, cardiothoracic surgery is broken down into cardiac and thoracic, and congenital for the most part. In terms of our three divisions, I'm in the general thoracic surgery division and therefore I do not operate on the heart anymore, which is great for me. But I operate at Stanford and I operate and practice at the Palo Alto VA taking care of our Veterans, which is a nice mix of things for me in terms of those two very different and yet similar practice settings and patient populations. So, the lion's share of patients that I see have lung cancer and some esophageal cancer. And then as another side interest, I also do some chest wall surgery and a tiny bit of mesothelioma because there are not very many people that do a ton of it.
Dr Albert Rizzo:
Right, right. Well, that's a great background to have our listeners know what you'll be talking about today. So, I wanted to begin our discussion talking about lung cancer screening. We all know that the uptake of this potentially lifesaving procedure in that high-risk group identified by the USPSTF guidelines remains at a low level, recently quoted at about 5 to 6% nationally. I know you're involved in trying to raise awareness and move the needle on getting more individuals screened. Best practices for the implementation of lung cancer screening include input from a multidisciplinary team. Could you describe the role as you see it, of the thoracic surgeon on this team? And as a follow-up, do you feel it's a role that many of your colleagues embrace?
Dr Leah Backhus:
Lung cancer screening is so important, and it's so much still in its infancy that we have to embrace all models and recognize that all models don't necessarily fit all practice settings, just like any screening initiative. So, I think it's really predicated on the local expertise and ability to do what needs doing. And to that end, it doesn't have to be spearheaded by a pulmonologist. It doesn't have to be spearheaded by an oncologist or radiologist or thoracic surgeon, for that matter. It just has to be someone who is knowledgeable enough in the area and has the bandwidth and time and effort to put into really creating the program. So, there are many models, and there isn't one that is a singular winner.
Here at Stanford, as in many places, we have a multidisciplinary approach. The lung cancer screening program here has gone through several different iterations, but for the most part, it's being led by thoracic surgeons currently. Historically, it was our pulmonologist and pulmonary colleagues, which was fantastic, and they even set up some mobile scanning units for more remote areas, etc. But most recently, the pendulum has shifted now toward one of my thoracic surgery colleagues who has really been doing the heavy lifting on it.
I do think that the presence of all of those folks is important. You do need to obviously have a radiologist for sure, but a chest radiologist is really accustomed to reading these images and is fully vested with the American College of Radiology screening program. And then of course, your pulmonologist is important because you catch a lot of other things that aren't necessarily lung cancer. And the thoracic surgeon, I think, adds an element of practicality in terms of what are the next steps and potential interventions and putting that all within the appropriate clinical context, which is setting the threshold for when to intervene on someone with a more invasive approach.
Dr Albert Rizzo:
Right. Great answer. And aside from the role on the multidisciplinary team, how do you see your role as far as the surgeon in the shared decision-making process? To me, that's a concept that's almost ingrained in surgical education because surgeons help guide patients through decision processes involving weighing the benefits and risks of surgery as well as alternative treatments that may be options for them. Your thoughts on shared decision-making?
Dr Leah Backhus:
You're right in that it's very much woven into the fabric of surgical training to be able to guide patients through making some of these difficult decisions. Obviously, other medical providers do the same thing, but oftentimes, the surgical discussions are surrounding interventions with much higher stakes. So yeah, we are well trained to do that.
I do think that it requires a whole lot of nuance in terms of how it's done, weighing the risks and benefits, etc. And really, when you're talking about an intervention such as a biopsy or a surgical resection, for instance, that conversation has to happen with the surgeon or with the practitioner that's actually doing the intervention. Sometimes we can get a little bit ahead of ourselves.
For instance, in my world, I see lots of early-stage patients who are often weighing the pros and cons of surgery versus radiation treatment for their primary cancer intervention, and I stay in my lane, so to speak. I don't try to venture too far into the realm of describing and detailing what their course of radiation would look like because that's not fair to the patient, and I don't want to introduce my biases. So, I try to limit my conversation for the most part to the area that I have expertise in, but I always offer patients the option to go and speak to the radiation oncologist directly if they have very specific questions. So, it is a nuanced process, and I do think that the surgeon is well-positioned and well-trained to be able to do that well.
Dr Albert Rizzo:
Right. During my training in pulmonary medicine, much longer ago than I'd like to admit, case conferences with thoracic surgeons usually involve some decisions around surgery or no surgery, lobar resection for a cure, or no resection, and almost always patients had mediastinoscopies. Can you speak to the changes in the philosophy of lobar vs wedge vs segmentectomy, as well as the changes that have occurred in the technology over the last several decades? And here I'm thinking about the development of minimally invasive and robotic techniques as well as the extension of bronchoscopic techniques with EBUS and navigational capabilities.
Dr Leah Backhus:
Yes there hasreally been an explosion, and you yourself know this as well, in terms of advances in techniques and technologies and in the people who are actually performing them. It's a much more heterogeneous group of folks. It certainly does not fall exclusively under the realm of pulmonologists or thoracic surgeons, or even interventional radiologists. There is a lot of crossover.
So, when it comes to the diagnostic part of things, I say that the pendulum has shifted heavily in favor of bronchoscopy and other minimally invasive means of acquiring tissue. And that's really an important piece when we're talking about the potential for neoadjuvant treatments and genomic sequencing, etc, that having tissue ahead of time to aid in your decision-making is really critical and just puts more emphasis on the fact that we need to have tried and true techniques to do that. So bronchoscopy, robotic bronchoscopy, image-guided bronchoscopy, etc, has made tremendous strides in that.
We have a fantastic relationship here at Stanford with our interventional pulmonologists. They're really incredibly skilled such that I can't recall a patient that I've sent that they weren't able to obtain tissue from. They're just that good. And having that information going into surgery is incredibly useful. At this point, we don't do mediastinoscopies for every patient. We were doing mediastinoscopies for patients who were at high risk for having occult mediastinal or for clinically suspicious mediastinal nodes.
And now, for the most part, we send those patients for EBUS. Now if they have a negative EBUS, but they still have a very high clinical suspicion, we do still follow that with a mediastinoscopy. However, if your EBUS is able to secure the diagnosis of your mediastinal staging, then that's really helpful and you will also have avoided a mediastinoscopy for that patient. So, it's pretty neat to have that in our armamentarium.
And then, of course, the minimally invasive approaches that we have in surgery have just exploded as well. I tend to do all of my minimally invasive lung resections robotically at this point. There's no data to report the superiority of robotics over VATS or VATS over robotics. They're pretty equivalent in the appropriate hands of a skilled surgeon. But either one of them is incredibly beneficial compared to open techniques, to minimize the length of stay and length of recovery, particularly when you're talking about someone for whom surgery is not their only intervention and treatment, that they may need to go on and get adjuvant therapy. It's important that they have expeditious and yet safe surgery, so they can move on to the next stage of their care.
Dr Albert Rizzo:
And as far as the philosophy of lobar vs wedge vs segmentectomy, are there more lung preservation philosophies than before as far as trying to attain a cure?
Dr Leah Backhus:
Yeah, I'd say that's still in evolution, honestly. And segmentectomy, for the most part, is thought to be superior to wedge resection for various reasons. Wedge resection is not really considered sound oncologic surgery and offers very little advantage over stereotactic radiation. The main benefit of segmentectomy over wedge resection or SBRT is the fact that you get more lymph nodes harvested for both therapeutic and diagnostic purposes. So, I would not equate a segmentectomy to radiation, but with wedge resection, it gets really difficult to tease those two apart in terms of outcomes. We do salvage surgeries as well, but for the most part, I'd say, if you took a national sample, still by and large, lobectomy is still considered the standard of care. But that is certainly up for debate and is currently being debated in several ongoing trials.
Dr Albert Rizzo:
Aside from the role of the CT scan, are there still other imaging developments that may be helpful to the radiologist or the thoracic surgeon such as nuclear medicine scans? Do they help at all in this setting?
Dr Leah Backhus:
Yes, there are nuclear medicine scans, as in PET scanning, which is pretty standard at this point to assist with the clinical staging of a patient. It would be considered substandard care for a patient with lung cancer or suspected lung cancer to not have had a PET scan to complete their clinical staging.
There are also some advances with regard to the way in which PET scanning is done that can help discern metastatic lesions from others. For instance, prostate, you do the = PET scan andPSMAprostate-specific PET scan, which can be really helpful in terms of guiding your decision-making towards extensive surgical resection. For instance, if you know that you're dealing with a metastatic lesion versus a primary lung cancer, that's incredibly helpful information to have upfront. So yeah, it's absolutely considered the standard of care.
Dr Albert Rizzo:
So one of the main drivers for lung cancer screening is to shift the stage of lung cancer diagnosis to an earlier stage, which is potentially a curative state. Unfortunately, in clinical practice, many patients with metastatic stage four disease present, and it's now recognized that this is a heterogeneous group. And despite all being characterized as stage four, some patients will have a high disease burden, whereas others will have isolated metastatic lesions. And I believe in the 2017 update, the TNM staging, there was a reclassification of the metastatic disease into M1a, M1b, and M1c because they had different median survivals. Can you describe this classification and how, if it has at all, changed the thoracic surgeon's involvement and approach to stage four disease?
Dr Leah Backhus:
You already somewhat started to describe it. In general, metastatic disease is not really considered to be surgical. It's not really considered to be resectable, not necessarily because of the metastatic lesion that you're looking at, but because of what it's indicative of, that you're now in a systemic cancer situation and you really require systemic solutions and treatments to address it.
But M1a would be patient with malignant pleural effusion or pericardial effusion. In general, those are not considered resectable. Surgery plays a role only in palliating those patients for the most part, but the palliation themselves can be quite meaningful in terms of preserving life, ironically, and in preserving the quality of life, first and foremost. And then you have M1b, and M1c, which are types of distant metastatic disease.
In the 1a, there's also, includescontralateral lung metastasis, which is a little bit of a controversial area. So, if you've got a patient who has, say, bilateral lower lobe nodules, is that patient really considered to have M1 disease or are they considered to have synchronous primary tumors? And that gets really nuanced, and we spend a whole lot of time talking about those patients and trying to give them the benefit of the doubt. They shouldn't have any other sites of disease, first of all, so those two areas need to be the only sites clinically observable. And then we painstakingly have to stage them, stage their brain with dedicated brain imaging, and then stage the mediastinum to make sure that there are no mediastinal nodal diseases.
It is not unheard of, but certainly less common and less likely, for a patient to have a contralateral metastasis without any other nodal involvement. So, if we see two isolated tumors that are contralateral to one another, but there is no evidence of either hilar or mediastinal lymph nodes, we would give that patient the benefit of the doubt and not classify them as M1, and instead, classify them as synchronous stage one tumors. And if you do that right and correctly, those patients actually can do quite well.
And then you have patients who have distant metastases like M1c, and again, the role of the surgeon is really... distant extrathoracic metastases like bony mets, liver mets, and adrenal, the two distant sites for which there is an exception in terms of still offering surgery potentially for patients would be brain mets, so isolated brain mets or isolated adrenal, occasionally, sometimes the isolated liver, if they can be eradicated with local ablative therapies, either CyberKnife for the brain or any sort of ablative or resectional interventions on the liver and, or adrenal. Bony metastases are difficult to address and are usually treated with systemic therapy alone or with spot radiation to symptomatic metastases.
Dr Albert Rizzo:
Great. So, with lung cancer patients living longer due to earlier stage diagnosis and certainly the explosion of treatments with targeted therapies and immunotherapy, follow-up very often finds recurrent disease at some point. Can you talk about the role of a thoracic surgeon in helping direct a surgical intervention at some point in time for these cases?
Dr Leah Backhus:
For recurrences?
Dr Albert Rizzo:
Right.
Dr Leah Backhus:
Yes, I'd say the surgeon's practice in general is heavily weighted towards early-stage disease and contradistinction to medical oncologists' practice, which is heavily weighted towards advanced disease. So in the thoracic surgical practice, most of our patients are not going to recur, which is great, but they also heretofore had not been a whole lot of recommendations with regards to any adjuvant therapies. And so their oncologic home was with a thoracic surgeon because they never see an oncologist, they're not getting any systemic treatment, and so they live with you for the duration of their surveillance.
And ongoing surveillance after initial treatment for lung cancer is my passion, if you will. It's where I've done most of my research. So we're still trying to define honestly, what is the best way to do the surveillance on these folks. I have a strong bias, and I feel like the biggest threat that they face is not necessarily the recurrence, and certainly, once you get after two years it is not. It's more of the risk of a second primary lung cancer, particularly for patients who have ongoing risk exposures for those patients who may not have quit smoking or have ongoing environmental exposures. Obviously whatever it was that set the patient up to develop their initial lung cancer is still in place and therefore they have lots of lung parenchyma that remains at risk.
Dr Albert Rizzo:
So your surveillance after initial surgery is what, yearly, six months? Or what do you define as your surveillance?
Dr Leah Backhus:
I'd say most people still follow the NCCN guidelines, which heretofore had been this one size fits all thing, which was that everyone should just get a CT scan every six months, then it was every six months for the first two years, most recently is every six months for the first three years, followed by annual after that for two more years. But it's also broken down further by whatever was your primary treatment, if it was radiation versus surgery, and whether or not you had chemo. So the guidelines are starting to introduce some of the nuances there.
These recommendations, however, are all based on consensus and the preponderance of the literature that is out there, which is very sparse and not necessarily very high quality either. So it's not the best evidence and then therefore the recommendations are not necessarily the best either They're only as good as the evidence they're based upon.
Dr Albert Rizzo:
That's right. Right. So you may have touched on this next question a bit earlier, but the goal of lung cancer is certainly a cure. We know that can't always be the case. And can you tell us how a thoracic surgeon can sometimes help palliate a patient with advanced disease? And here I'm thinking about what you mentioned earlier, the pleural effusions. Particularly, what's the best way to manage some of these malignant pleural effusions that tend to recur in patients?
Dr Leah Backhus:
Yeah, the malignant pleural effusions, they're interesting because I'd say that we do not see the vast majority of them.I feel a little bit disheartened by that because the patients that we do see often have been instrumented several times before they actually wind up coming to see a surgeon. And I'm not sure why that threshold is so high. And whether that threshold is being set by the oncologist or the pulmonologist or the primary care doctors or who it is that is actually treating the malignant diffusions with repeated thoracentesis, versus having a much more expedited track to getting in to see a thoracic surgeon or a pulmonologist or an interventional radiologist, whoever it is, that can actually palliate the effusion.
The main ways of palliating, one would bethoracentesis, which often needs to be repeated, the other is obviously with an indwelling catheter, a tunneled indwelling catheter, like a PleurX catheter, which the patient can accommodate drainage at home. And then the most definitive is a pleurodesis procedure. And that's the main benefit, if you will, of a surgeon intervening in these cases because we can do any or all of them.
So if it really should just be managed via thoracentesis, we're able to do that. But we're also able to take patients to the operating room, evacuate the effusion completely in a very controlled setting, assess the lung for its ability to re-expand, and then either place a PleurX because the lung is trapped and therefore they're going to have a chronic space, or do a pleurodesis procedure such that they wouldn't need any additional interventions in the future. So it's one-stop shopping, that's what I tell patients.
Dr Albert Rizzo:
But do you recommend they see the surgeon earlier rather than later?
Dr Leah Backhus:
Well, I do because it can actually work against you. So every time you do a thoracentesis, if there's a little bit of blood that gets in there, and even if there isn't, you can still set the patient up for starting to form adhesions and now you've got loculations, and so then your repeated thoracentesis attempts are going to be less likely to succeed. And then that makes for more difficult surgery later when we're trying to recreate one singular pleural space to either place a catheter in or to try to create pleurodesis.
Dr Albert Rizzo:
Right. So with the changing landscape of lung cancer care because of screening, improved therapies, and certainly longer survival, as well as the development of some diagnostic and therapeutic technology, as we mentioned earlier, what are some of your thoughts on what is on the horizon for thoracic surgery in lung cancer?
Dr Leah Backhus:
I think we were continuing to exploit the ways in which we can do things minimally invasively to help expedite recovery. There's a lot of movement in the enhanced recovery after surgery pathways, or ERAS pathways, to help get patients back and out of the hospital and back to their lives or to their next step in their treatment process faster and in better shape, so that they're able to tolerate some of the more chronic treatment interventions that may be down the road for them.
I think that there is going to be a whole lot more collaboration with our oncologist when it comes to considerations of who needs to be treated neoadjuvantly, heretofore, that's always just been those stage 3a patients. For the most part, those were our main shared patients when it comes to neoadjuvant therapy. For adjuvant therapy, our stage two patients are always referred, but we really didn't have to interact with oncology upfront for anyone other than the rare stage 3a patient.
And nowadays, not only are we interacting with the 3a patients, but we're also interacting with the patients who have even 1b disease for some indications. So, stage Ib and stage II also can be considered, and that's going to require a big paradigm shift in terms of how thoracic surgeons think about their patients and need to consider delaying surgery, and how it is that we nuance that conversation with our patients who otherwise come in to see you. When you come to see the surgeon, for the most part, you're ready for surgery and want surgery. And then to have someone say, "Hang on. Just a second. Actually, we're not going to do surgery right away. Even though you're resectable right now today, we're going to roll the dice a little bit and give you this immunotherapy, and hopefully, it's going to work great because it's worked great in lots of people. And then we take you to surgery." Well, what if it doesn't work great? Well...
Dr Albert Rizzo:
It's a tough discussion, I'm sure.
Dr Leah Backhus:
Yes, exactly.
Dr Albert Rizzo:
Well, I really want to thank you for your time today. Are there any other parting thoughts you have?
Dr Leah Backhus:
No, I'm glad you're doing this. I think it's a fantastic effort to get more information out there. Dissemination of knowledge is key, particularly when it comes to those really low uptakes of lung cancer screening in our country. We've got to do better, and that's across the board, let alone our most vulnerable and marginalized populations.
Dr Albert Rizzo:
Absolutely.
Dr Leah Backhus:
We've got a lot of work to do to get up to 70%, like for mammography and colon cancer screening.
Dr Albert Rizzo:
Right. Well, again, thank you very much for your efforts today and also for your efforts in raising awareness. I know you work with the Lung Cancer Roundtable nationally and look forward to seeing you again in those venues.
Dr Leah Backhus:
Yes, absolutely.
Speaker 1:
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