By Paul Nelson, ANZ-LCNF Thoracic Surgery Lead and Renae Grundy, ANZ-LCNF Deputy Chair & Tasmania Representative
Lung cancer surgery
Surgery is best considered for stage 1 and 2 non-small cell lung cancers. Surgery may also be considered for stage 3A lung cancers but may require neoadjuvant treatment with chemotherapy and/or radiation.
With surgery, five-year survival rates vary between 92% for stage 1A to 53% for stage 2B.
Types of surgery performed depend on the size and position of the tumour in conjunction with the physical status of the patient.
Two common surgical approaches are thoracotomy or Video Assisted Thorascopic Surgery (VATS).
Some centres will also have access to perform robotically assisted lobectomies (RATS).
Common types of thoracic surgery
Pneumonectomy is the removal of the entire lung. It is usually performed to treat large lung cancers located centrally and affect large sections of the pulmonary vein and/or pulmonary artery. Patients need to meet careful selection criteria prior to this surgery as the physiological changes that occur with single lung ventilation are significant.
Lobectomy is the most common of lung surgeries performed to treat lung cancer.
There are three lobes on the right – upper, middle and lower. There are two lobes on the left – upper and lower. During surgery, the affected lobe is removed as well as arteries and veins supplying that lobe. Mediastinal lymph nodes are removed at the time of surgery and are sent to pathology to rule out nodal spread, which may determine the need for adjuvant chemotherapy.
Each lobe is divided into segments which are anatomically distinct from the joining segments. If the tumour is small, less than 2cm, this type of surgery may be an option to preserve as much viable lung tissue as possible. This is often the case in patients with borderline lung function. Associated lymph nodes, veins and arteries are also resected.
Pre-operative work up
It is important to establish if the patient has the functional pulmonary reserve to tolerate the proposed resection to maintain a reasonable quality of life.
Respiratory function tests to establish lung volumes and diffusing capacity should always be performed. A 6-minute walk test is also very helpful and an easy test to perform to assess basic exercise tolerance.
Further tests may be needed if these results are borderline, if cardiac disease is suspected or if pneumonectomy is required. These tests include:
- Cardiopulmonary exercise test
- Cardiac stress test
- Trans thoracic ECHO
Smoking cessation strategies should be discussed as early as possible. Cessation of smoking prior to surgery decreases the risk of post-operative complication and leads to better long-term outcomes in relation to cancer survival.
Radiotherapy for early-stage lung cancer
Surgical resection (lobectomy and lymph node sampling or dissection) is the standard of care for early-stage non-small cell lung cancer. However, in the presence of pre-existing co-morbidities, performance status concerns or patient preference, some patients may be unable to tolerate surgical resection. In these patients, radiotherapy offers a potentially curative treatment option that is associated with less morbidity.
For inoperable stage 1 non-small cell lung cancer, stereotactic ablative radiotherapy (SABR) is the standard of care, having been demonstrated to be superior to conventional fractionated radiation.
Stereotactic radiotherapy delivers ablative doses of radiation, delivering either 48Gy or 54Gy in one to five treatments over a course of one to two weeks. Ablative doses are achieved whilst sparing surrounding lung tissue, by delivering several radiation fields (arcs) from various angles that converge on the target.
There have been no head-to-head trials comparing surgery with SABR in early-stage lung cancer. Trials that have attempted to answer this question have failed to recruit due to referring physicians and patients favouring surgery.
There are phase 2 and retrospective data which suggest similar overall survival to surgery in patients with stage 1 operable non-small cell lung cancer.
Side effects for patients undergoing SABR include fatigue; skin reaction; oesophagitis (depending on tumour location); cough; pneumonitis; and lung fibrosis in the longer term. Stereotactic ablative radiotherapy offers a safer and potentially curative treatment for patients with inoperable stage 1 non-small cell lung cancer.
Prehabilitation for thoracic surgery
Prehabilitation refers to a diverse bundle of care delivered by nursing and allied health professionals that includes exercise, nutrition, smoking cessation, and psychological support. A diagnosis of lung cancer can allow for a teachable moment between health professional and patient, not only with regard to smoking cessation (where relevant) but other healthy lifestyle choices, thus encouraging both physical and psychological wellbeing. Clinical research has established exercise, for example, as a safe and effective intervention to counteract the adverse physical and psychological effects of cancer and its treatment.The aim of prehabilitation, therefore, is to promote healthy behaviours, and thereby health status, during the pre-treatment stage. Ideally, these healthy behaviours will become embedded into daily life.
Enhanced Recovery after Surgery (ERAS) programs have been around for some time and were a model of care initiated by Professor Hendrik Kehlet in the 1990s with a focus on prehabilitation for patients undergoing colorectal surgery. These programs have since been introduced pre-operatively into a variety of other surgeries, including head & neck and lung; however, the pathways may differ depending on the type of surgery. One systematic review which examined seven RCTs, enrolling 486 patients, demonstrated that the implementation of an ERAS program for lung cancer surgery can effectively accelerate postoperative recovery and save hospitalisation costs without compromising patient safety.It is acknowledged that other factors such as early mobilisation and adequate pain management also play a very important role.
- Chang J, Senan S, Paul MA et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage 1 non-small cell lung cancer; a pooled analysis of two randomised trials. Lancet oncology 2015;16:630-77.
- Ball D, Tao Mai G, Vinod S et al. Stereotactic ablative radiotherapy versus standard radiotherapy in stage 1 non-small-cell lung cancer (TROG 09.02 CHISEL): a phase 3, open-label, randomised controlled trial. Lancet Oncology 2019; 20: 494-503.
- Chang J Y, Mehran RJ, Feng L et al. Stereotactic ablative radiotherapy for operable stage 1 non-small-cell lung cancer (revised STARS): long-term results of a single-arm, prospective trial with prespecified comparison to surgery. Lancet Oncology 202; 22: 1448-57.
- Sanchez-Lorente, D., Navarro-Ripoll, R., Guzman, R., Moises, J., Gimeno, E., Boada, M., & Molins, L. (2018). Prehabilitation in thoracic surgery. Journal of thoracic disease, 10(Suppl 22), S2593–S2600. https://doi.org/10.21037/jtd.2018.08.18
- Lukez A, Baima J. The Role and Scope of Prehabilitation in Cancer Care. Semin Oncol Nurs. 2020:150976.
- Cormie P, Atkinson M, Bucci L, Cust A, Eakin E, Hayes S, McCarthy S, Murnane A, Patchell S, Adams D. Clinical Oncology Society of Australia position statement on exercise in cancer care. Med J Aust. 2018 Aug 20;209(4):184-187. doi: 10.5694/mja18.00199. Epub 2018 May 7. PMID: 29719196.
- Melnyk, M., Casey, R. G., Black, P., & Koupparis, A. J. (2011). Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Canadian Urological Association journal = Journal de l’Association des urologues du Canada, 5(5), 342–348. https://doi.org/10.5489/cuaj.11002
- Li, S., Zhou, K., Che, G., Yang, M., Su, J., Shen, C., & Yu, P. (2017). Enhanced recovery programs in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer management and research, 9, 657–670. https://doi.org/10.2147/CMAR.S150500