Diseases and Disorders
Lung cancer is the most significant cancer in this country, with over 220,000 individuals diagnosed in the United States in 2011. After decades of rising incidence, there has been a plateau and slight decline in lung cancer since the mid-1990s on the order of 1-2%, possibly due to the effect of declining tobacco cigarette smoking. However, lung cancer in non-smokers is increasing, indicating that the disease is going continue to be a major public health issue for the foreseeable future.
The past few years have witnessed major advances in lung cancer therapy, in surgical technology, personalized chemotherapy, and advanced radiation therapy. In order to offer patients with lung cancer the latest advances in therapy from all disciplines, USC physicians from different specialties come together to see patients in the USC/Norris Multidisciplinary Thoracic Oncology Program. This unique program involves a multi-specialty clinic held weekly where a patient can come and be evaluated by specialists from thoracic surgery, medical oncology, radiation oncology, and pulmonology – all in one visit. The patient’s care is coordinated by a nurse navigator who will streamline the visit and guide the patient through the diagnostic and treatment pathway personalized to his or her specific circumstances. This program eliminates the multiple appointments with different physicians in different locations that are commonplace with care at conventional hospitals, and the program has been extremely well received by patients.
- True multidisciplinary care at the USC/Norris Thoracic Oncology Program that offers “one stop” evaluation by a thoracic surgeon, medical oncologist, radiation oncologist, and pulmonologist. This is one of the few lung cancer clinics of its kind in the United States.
- Experienced nurse navigator for lung cancer who will guide the patient through the diagnostic work up and therapy, as well as coordinate care between the referring physician and the USC physicians
- Lung Cancer Screening Program available for high risk individuals
- State of the art diagnostic technology including endobronchial ultrasound (EBUS), electromagnetic navigational bronchoscopy (SuperDimension®), and CT-guided biopsy
- Minimally invasive lung surgery including video-assisted thoracoscopic surgery (VATS)
- Robotic lung cancer surgery – revolutionary technology for precise resection and lymph node removal. USC is the only academic center in the region offering this on a routine basis.
- Extensive experience in complex lung cancer surgery allowing resection of tumors considered “inoperable” at other hospitals
Mechanism of Disease
The most significant cause of lung cancer is tobacco smoking, which contains over 60 known or potential carcinogens. These chemicals injure the cells of the airspaces in the lungs, and over time can lead to accumulation of genetic changes that lead to cancer development. Greater exposure to tobacco smoking leads to greater risk of cancer development. It is currently believed that the greatest risk is in those individuals who have smoked more than a pack of cigarettes per day for 30 years.
One of the fastest growing segments in the population developing lung cancer is amongst those individuals who have never smoked. This has impacted women in particular. One theory is that women non-smokers who develop lung cancer were passively exposed to second-hand smoke because their spouses smoked or they worked in places where many people smoked.
Lung cancer is notoriously difficult to diagnosis because patients can remain without symptoms for a long period of time while the tumor is growing. This is due to the anatomy of the lungs, which can accommodate large tumors without compromising breathing. Some of the more common symptoms of lung cancer include a persistent cough, coughing up blood, chest pain, or shortness of breath.
To overcome the lack of symptoms and the late stage of diagnosis in many patients, screening for lung cancer is now recommended in appropriate high-risk individuals. The results of a landmark study known as the National Lung Screening Trial was released in 2011. In this government sponsored study, over 50,000 individuals with extensive smoking backgrounds were screened with either a low radiation dose CT scan or a regular chest x-ray. After follow up, those individuals who were screened by CT scans were found to have less number of deaths from lung cancer by 20% compared to those screened with x-rays due to earlier diagnosis of cancers.
Based on the results of the National Lung Screening Trial, the multidisciplinary USC/Norris Thoracic Oncology Program has implemented a lung cancer screening program that utilizes a low radiation dose CT scan with coordination of our lung cancer team and the patient’s primary care physician. Due to the novelty of this research, the findings of the National Lung Screening Trial have not been adopted into national healthcare policies and therefore these scans are not yet covered by regular medical insurance. To take this into account, the USC lung cancer screening program offers these scans at a significantly discounted rate for individuals to utilize this resource.
If a lung nodule or mass is found on radiographic imaging and lung cancer is suspected, a tissue biopsy is usually obtained to confirm the diagnosis. There are several methods of obtaining a biopsy.
- Conventional Bronchoscopy: During this procedure the physician places a thin fiberoptic endoscope into the airways to examine the inside of the lungs. Using this instrument, biopsies can be obtained if the abnormal area is visualized. Otherwise washings or brushings can be obtained in an effort to obtain tissue for diagnosis.
- Electromagnetic Navigational Bronchoscopy (SuperDimension): This special bronchoscope has an extension with a device that works like GPS for your car, and allows the surgeon to reach areas that are not possible with conventional bronchoscopy. The surgeon maps out the area of the lung that needs to be biopsied, and the computer system helps the physician navigate out to the area using the steerable extension of the bronchoscope.[FIGURE]
- Endobronchial Ultrasound (EBUS): This is special bronchoscope with an ultrasound probe built into it, and it allows the surgeon to visualize enlarged lymph node or masses through the airway walls. A special needle can then be passed into the target for sampling.[FIGURE]
- CT guided Biopsy: This procedure is performed by an interventional radiologist who places a needle into the target nodule under direct radiographic guidance.
- Surgical Biopsy: When more tissue is required or if other diagnostic tests fail, sometimes the thoracic surgeon must remove that portion of the lung containing the nodule. This is usually done in a minimally invasive manner. Sometimes this operation can be both diagnostic and therapeutic at the same time.
Once the diagnosis of lung cancer has been made, the next crucial step is to stage the disease. This determines how extensive the cancer is and see if has spread to the lymph nodes or other distant organs. The stage helps guide the treatment. Staging is typically done with CT scans or an integrated PET/CT scan. Often a brain MRI is done as well. Through these studies, the physician can measure the size of the tumor, assess its location, evaluate if there might be tumor spread to lymph nodes in the central portion of the chest (the mediastinum), and determine if other organs are affected.
Surgery is the mainstay of therapy, and it is important that a dedicated thoracic surgeon with a focus in lung cancer evaluate the patient because resectability of a tumor is often a subjective decision that takes into account experience and knowledge of state of the art therapy. Thoracic surgeons at USC commonly operate on patients who have been turned down at other hospitals. Thus, even patients who are deemed “inoperable” at other centers may benefit from consulting with the lung cancer team at USC. Moreover, the use of robotic technology and minimally invasive procedures is allowing surgeons to operate on older and sicker patients because the physiological impact is significantly lower with these techniques.
Lung cancer treatment can involve surgery, chemotherapy, and/or radiation. This combination of therapies is known as multimodality therapy, and is characteristic of modern lung cancer treatment. The specific order of treatment and the specific combination of treatment is determined by the patient’s functional status, stage, and tumor characteristics.
Surgical resection usually involves removing the lobe of the lung that harbors the tumor. There are 5 lobes of the lung (3 on the right and 2 on the left) and generally, loss of one lobe is well tolerated by patients. In special circumstances, less than a lobe is removed, or in other cases, the entire lung on one side needs to be removed. At USC, thoracic surgeons utilize minimally invasive techniques to remove the lung cancer. For a lobectomy, this is usually done with the da Vinci® robotic system, a revolutionary way of removing the lobe and the lymph nodes in the chest. It is done through 4 tiny incisions and gives the surgeon 3 dimensional, high-definition vision with articulating robotic instruments that mimic the surgeon’s hands and wrists deep inside the chest. This allows for a better, more precise operation, and results in less pain and faster recovery. This technology has allowed USC thoracic surgeons to operate on patients who would be otherwise too frail to undergo regular lung surgery. USC is the only center in the region that routinely offers this approach for lung cancer, and the surgeons work with expert surgical assistants, anesthesiologists, and OR nurses who have specific training and experience in robotic thoracic surgery.
Another minimally invasive technique used in lung surgery is known as video-assisted thoracoscopic surgery or VATS. USC thoracic surgeons utilize this somewhat older technique as well for simpler procedures such as limited wedge resection of the lung where robotic technology is not needed. This technique also involves making a few tiny incisions in the chest and the use of a video camera and small instruments. For a full lobectomy and lymph node removal, however, our experience has shown that there is an improved ability to remove all of the involved tissue in a more reliable manner using the robotic approach.
Multimodality therapy sometimes allows for resection of cancers that traditionally have not been considered possible. In these cases, the team will administer chemotherapy and radiation first to help control the disease, and then the surgeon is able to perform the operation. Moreover, in some cases lung cancer can also be resected even if it has spread to distant organs; for example, this has been accomplished for patients with metastases to the brain who can undergo a combined procedure to remove tumors from both sites.
When patients are truly not candidates for surgery, our multidisciplinary approach offers patients cutting-edge stereotactic radiosurgery (Cyberknife®) or ablation technology that can precisely kill the tumor in the chest without the need for an operation. Our team has extensive experience in this mode of treatment.
Chemotherapy for lung cancer has come a long way in the past few years, and USC physicians are on the forefront of utilizing novel strategies for their patients. Conventional chemotherapy has not changed much over the decades, but there has been refinement in predicting which patients will respond better to which drugs. By using genetic information from the tumor, USC physicians can determine whether or not chemotherapy is even necessary, and if needed, which drugs to use for maximal effect.
Another area of significant development has been the use of biologic agents or targeted chemotherapy. These novel bioengineered drugs are designed to specifically kill tumor cells with certain genetic mutations, which is a much more precise mechanism of action than conventional chemotherapy. Patients in the USC/Norris Thoracic Oncology Program have access to the latest agents, some of which are available only in clinical trials.
The da Vinci robotic system has significantly cut down on the amount of pain medications that patients require, and hospital stays have been cut down to less than half of what was historically required with traditional thoracotomy or an open incision. For patients who ultimately need additional therapy such as chemotherapy, the lesser physiologic and mental impact of minimally invasive surgery allows patients to undergo their chemotherapy earlier and more completely than patients who have had a traditional operation. This appears to translate into superior survival outcomes as the intended therapy is more successfully delivered.
The option of stereotactic radiosurgery (Cyberknife®) and ablation technology has given frail patients or those too weak to undergo surgery the option of excellent control of the local tumor with non-operative techniques. Short term outcomes have been excellent in such circumstances, and USC physicians have extensive experience in these techniques.
The analysis of genetic data from an individual’s tumor has allowed USC physicians to significantly refine the use of chemotherapy in lung cancer patients with excellent outcomes. Personalizing the patient’s regimen ensures that toxicity and lack of efficacy are minimized. TheThoracic Oncology Program has become a significant referral center in the region for outside oncologists send their patients for complex cases that are not amenable to conventional chemotherapy strategies.