Innovative Procedures for Lung Cancer: Part I

My hospital sponsors an annual thoracic nursing conference, which often focuses on oncology nursing as well. This year I was asked to speak at this conference about what is new and upcoming in the treatment of lung cancer. My first thoughts were that not much has really happened in lung cancer treatment for a while, so I was going to have to struggle to find “new and innovative” treatments. However once I began my research, I was pleased to find that there are new therapies evolving. Some of the background information I found was startling. For instance, of the top four cancer types in regards to new cases and deaths annually—breast, prostate, colorectal, and lung—there are a much larger number of both new cases of lung cancer and deaths as a result of lung cancer.

There were about 185,000 new cases of breast cancer with about 41,000 deaths in 2008. In comparison, there were 215,000 new cases of lung cancer with 162,000 deaths. Although 29% of all cancer deaths can be attributed to lung cancer, less federal money is spent per patient death than any of the other cancers mentioned. Whereas about $25,000 per patient death is spent on breast cancer research, only about $1,400 per patient death is spent on lung cancer research. Less than 5% of the National Cancer Institute’s $4.8 billion budget is for lung cancer research and the Centers for Disease Control and the Department of Defense had no money earmarked for lung cancer in 2008. Given those statistics, it’s amazing to me that we’ve made any progress in the treatment of lung cancer at all.

One of the difficulties with lung cancer treatment remains that the vast majority of patients present with disease is locally advanced or metatstatic at diagnosis. According to the Surveillance, Epidemiology, and End Results (SEER) data from the National Cancer Institute, patients with immediately resectable disease accounted for only 16% of the cases, whereas 45% presented with stage IV disease. One of the hurdles that I recently read about is that lung cancer carries an additional stigma along with it and is therefore often “hidden.” Unlike breast cancer for which the patient is often seen as the victim, the patient with lung cancer can be seen as having brought in on themselves. This may be only one reason that patients with lung cancer do not seek treatment until they are often in the end stages of the disease.

Nevertheless, there have been amazing advancements in the treatment of lung cancer. Two areas I would like to focus on are: 1) the use of brachytherapy as an adjuvant to thoracic surgery; and 2) the use of some newly approved targeted agents for the treatment of lung cancer.

This blog will continue to focus on brachytherapy and surgery, and I will address the targeted therapies in the next blog, so stayed tuned.

Thoracic surgery is often used for patients who present with stage I, II, or IIIA lung cancer. A lobectomy is the option most often used because of the improved outcomes and decrease in recurrence. However, if a patient’s pulmonary status precludes them from having a lobectomy, a wedge resection is often performed. The outcomes have historically been much poorer with the wedge resection including a higher incidence of recurrence and lower survival. The addition of brachytherapy to a wedge resection has decreased the rate of recurrence over wedge resection alone or wedge resection followed by external beam radiation.

There are two main forms of brachytherapy used. One uses a seed impregnated mesh and the other uses afterload catheters for the placement of adioactive seeds. The radioactive isotope most frequently used is I¹²¹ however, I¹²⁵ has also been used.

The procedure that utilized catheters is performed via video assisted thoracic surgery (VATS) procedure. Three catheters are placed for the purpose of loading the radiation seeds. The brachytherapy at a biological dose of 5000 cGy is then delivered twice daily for four consecutive days. After the final delivery of brachytherapy, the catheters are removed and the patient is discharged to home. Although the results of this procedure are promising it is not without risk. The patient must be hospitalized with radioactive precautions taken for 4 days following the procedure. When the patient is discharged, the patient and family are instructed on radiation precautions since the patient remains radioactive.

The alternative treatment uses a mesh that has been embedded with radioactive iodine sutures. The sutures are intricately spaced so that a dose of 10,000—12,000 cGy. The mesh is then placed over the resection to include a 2cm margin over the stable line. This technique has also shown to decrease the incidence of recurrence. Because of the lower doses used, the patient is not considered radioactive therefore no special precautions need to be taken.

Lung cancer treatments are evolving and changes are being seen every year. Next time we’ll talk about targeted therapies and the recent drugs in our arsenal against lung cancer.