As the Greek philosopher Heraclitus observed, all things change. Certainly, the history of surgical treatment of patients with lung cancer is an example. There is both more and less.

LESS

For the consideration of “less” there is the consideration of the amount of lung the thoracic surgeon removes when operating for lung cancer. The first operations for lung cancer, beginning with Evarts Graham’s seminal procedure in 1933, were for the thoracic surgeon to remove the entire lung harboring the cancer. This pneumonectomy was the operation of choice for technical reasons. It was easier and safer for the surgeon to tie off the hilum of the lung, the area that contains all blood vessels and the bronchus (breathing tube), than to attempt to separate the lobes that are subunits of the lung. This operation cured some patients but at the cost them half their total lung function which frequently left them permanently short of breath and limited in their activities.

Soon thoracic surgeons learned how to safely carry out the process of separating these lobes (two on the left and three on the right) from each other so that a surgeon could perform a lobectomy, removal of a lobe. Lobectomy soon became the “standard” operation for lung cancer. When staging (determining the extent of the cancer) shows the cancer is confined to a lobe and does not find any spread of the cancer the cure rate of a lobectomy is the same as a pneumonectomy and leaves the patient with more lung and the expectations of a higher quality of life as breathing capacity is maximized. More recent experience has shown that it is safe to remove even less than a lobe when conditions are right, thus preserving even more functioning lung and protecting the quality of life even more. This is called precision surgery and consists of a segmentectomy (a lobe is constituted by several segments) or an operation called a wedge resection which ignores anatomic divisions and removes a wedge of lung as one would cut a wedge of pie. This precise undertaking affords the same cure rate as lobectomy but is predicated on the accuracy of staging so the surgeon can be confident all the cancer is contained in the segment or wedge.

MORE

During my residency and most of my practice years, medical treatment for lung cancer, consisting of a small number of chemotherapy drugs, was only modestly effective. These drugs, along with radiation, prolonged life only days to weeks for most patients and frequently caused unpleasant side effects. This situation has improved. There are more and more effective chemotherapeutic drugs, efficacious immunotherapy agents, and drugs which help by interfering with cancer metabolism. And complications and noxious side effects are less onerous than before. This means that patients with advanced disease are more likely to have their life prolonged and enjoy better quality of it. In addition, many studies-which are ongoing-are showing that adding these agents, before and/or after an operation, to the treatment regimen of a patient undergoing lung resection can improve survival. This latter effect is presumably due to the eradication of small and not clinically evident cancer cells remaining after an operation, either in lung tissue or lymph nodes (known metastatic disease remains a contraindication for surgery).

At the same time radiation therapists have developed techniques that have increased the efficacy of their intervention. By focusing the radiation beam very precisely the malignant cells are more likely to be eradicated with less damage to surrounding tissues. This means that radiation treatments also can be combined with surgery and the modalities mentioned above to increase the likelihood of complete cancer eradication.

The ideal treatment algorithm should take into consideration both all the possible permutations of surgery, chemotherapy, immunotherapy, and radiation and the order in which each should be applied. Treatment of an individual must be individualized as we learn more from studies comparing treatment regimens.