A couple months before John Curtis turned 80, he found out he had lung cancer. A nonsmoker, the diagnosis caught him off guard. “I was a little bit disturbed,” he recalls. “Why would this happen to me?” Secondhand smoke was likely the culprit, his lung doctor told him. Luckily, they’d caught the tumor early, and Curtis was a good candidate for a minimally invasive procedure for treating the disease.
When Curtis and his wife met with Dr. Daryl Pearlstein, the surgeon who would perform the operation, Curtis was impressed by how straightforward the procedure seemed. “I had envisioned my whole torso being wide open [during surgery] but he said, ‘No, this would be a lot simpler than that.’ ” On the second day after his surgery, Curtis returned home from Columbia St. Mary’s Hospital. Within a week, he resumed exercising, walking on a treadmill and using a stationary bike. Although he experienced some discomfort over the next few months as his body healed, the pain was minimal. “I compared notes with people who had lung surgery the old-fashioned way, and it was remarkable how much faster progress I was making,” Curtis notes. Best of all, the operation was a success, completely removing the cancer from his body.
The procedure that Pearlstein performed on Curtis – called video-assisted thoracoscopic surgery (VATS) lobectomy – promises shorter recovery times, is far less-invasive and has been proven just as effective as open-chest operations in treating lung cancer. Yet VATS technology is only used in some 15 percent of lobectomies nationwide, notes Pearlstein, a cardiothoracic surgeon on faculty at the Medical College of Wisconsin who practices primarily at Columbia St. Mary’s. The procedure can be challenging to learn and is not available at all hospitals. But as interest and educational opportunities multiply, its prevalence is continuing to grow. “I think it’s the future of thoracic surgery,” says Pearlstein.
Like Night and Day
Unlike some other cancers, surgical removal is the best treatment for lung cancer, with much higher cure rates than chemotherapy or radiation. A lobectomy removes the tumor as well as the portion of the lung in which the cancer is likely to come back. “It’s as if you had a garden, and a weed grew. You can expect that if you pull the weed, another weed might grow in the vicinity,” explains Dr. Christopher Stone, chief of cardiothoracic surgery at the Michael E. DeBakey Heart Institute of Wisconsin. “We know from research that if we can remove the entire lobe containing a lung cancer, there’s a much lower chance of the lung cancer recurring.”
Traditionally, a surgeon performing a lobectomy would make an incision in the patient’s side, cutting between the ribs and through his chest muscle. “You’d actually have to spread the ribs and oftentimes break the ribs so the surgeon could get his hands in the chest and work,” explains Pearlstein. Although the incision, called a thoracotomy, allows for a very good cancer operation, recovering from it can be difficult. Patients are usually in a great deal of pain after surgery, and that pain worsens with every breath, as the movement strains the inflamed tissues. In addition to being distressing, the pain that comes with the procedure can actually inhibit recovery. “People don’t take a deep breath and they don’t cough because it’s so painful,” explains Stone. “When they don’t [do those things], secretions accumulate in the airways and cause pneumonia and collapse of the lung and various other complications.” In the case of elderly patients in particular, pneumonia can be devastating. The invasiveness of the procedure can present problems for obese or otherwise frail patients as well.
By contrast, the VATS lobectomy is far less invasive, requiring only a few small incisions “about the size of a No. 2 pencil,” says Stone. During the procedure, a tiny, high-resolution camera is inserted in the patient’s chest, which projects images from inside the body onto a video monitor. Using the monitor as a guide, the surgeon manipulates small instruments through the incisions to remove the cancerous lobe of the lung. The lobe is sealed in a bag so the cancer cells don’t escape, and it’s pulled through one of the small incisions in the chest.
On average, VATS patients stay in the hospital three days, while patients who have traditional open-chest surgery stay for seven to 10 days. Likewise, recovery tends to be much faster for VATS patients, while thoracotomy patients could experience pain for weeks or even months afterward. “I’ve had several patients who have had a thoracotomy on one side of their chest in the past, and then we’ll do ours [using VATS],” says Pearlstein. “The difference is like night and day in terms of the way they feel and recover.”
The surgery is generally recommended for stage 1 cancer patients whose disease has not spread to other areas of the body. While the surgery marks a profound advance in the field, early detection is still vital. “The key to beating lung cancer is catching the tumor early, like any cancer,” says Pearlstein. “Once you have symptoms, it’s usually not at the curable stage.” In Curtis’ case, his internist first discovered a small spot on his lung during an annual checkup. He wasn’t having any symptoms. After monitoring the nodule for a period of time (lung nodules are relatively common and often benign), his lung doctor ordered a biopsy, which revealed the spot to be cancerous.
Pushing the Envelope
Despite the advantages the VATS lobectomy offers over other methods, it’s not available everywhere. In fact, when the procedure was introduced in the early ’90s, it was controversial. Many doctors couldn’t believe you could do an effective cancer operation this way and had doubts about its safety, recalls Pearlstein. He studied under the surgery’s founder, Dr. Robert McKenna, who developed the technology to make the operation more widely available – namely, to patients who “could tolerate getting that portion of the lung removed, but just couldn’t handle the incision,” explains Pearlstein.
In 2006, a study of 1,100 patients treated with VATS demonstrated the procedure’s safety and efficacy, as well as its speedier recovery times. “It established the VATS lobectomy as the operation to do for lung cancer,” says Pearlstein.
Still, the procedure is available only at select hospitals and cancer centers, largely because the technique is so specialized. “If all a surgeon has done is open surgery, no matter how complex, learning advanced videoscopic surgery is like learning how to operate all over again,” says Pearlstein. In addition to the time and energy that training requires, the procedure may also present something of a generational divide. “The newer generation of surgeons who grew up with video games are much more comfortable manipulating their hands while looking at a screen,” notes Stone. “Some of the more senior surgeons have had a harder time adapting to that technology.” Still, there is a tremendous desire to learn, Pearlstein says. He and his partners at the Medical College will begin teaching the procedure this year to surgeons from around the country.
Meanwhile, doctors are continuing to find new uses for VATS technology. “We’re starting to do more complicated lung surgeries this way for tumors that are not necessarily at stage 1,” says Pearlstein. The procedure may also be used for treating esophageal cancers, chest diseases and complicated chest infections, as well as for performing lung biopsies.
Anytime a new medical procedure is touted in the media, doctors tend to worry that their patients will request it, regardless of whether it’s been proven. But with the VATS lobectomy, Stone says, “We’re using new technology to perform a tried-and-true procedure.” Pearlstein hopes that within five years, as many as half of all lobectomies across the country will be performed using VATS, up from just 15 percent right now. His teaching efforts will likely play a significant role in driving up that number. “Any thoracic surgeon who is willing to dedicate the time and energy will be able to develop these techniques,” he notes. Having performed the procedure more than 500 times during his fellowship and in his practice, he’s eager to share his knowledge. “I believe in it so strongly,” he notes. “I see how much better patients do.”
Caroline Goyette is Milwaukee Magazine’s monthly health columnist.
Health Tips
A roundup of the latest health wisdom
New knee, new lease on life. For older patients with severe wear-and-tear arthritis, total knee replacement not only improves knee mobility, but also overall physical functioning, notes Arthritis and Rheumatism. Compared to those who hadn’t had surgery, knee replacement surgery patients improved significantly in several capabilities: bathing themselves, completing housework, shopping, lifting weights up to 10 pounds and walking two to three blocks.
Write down a plan for pain. American Family Physician recently released recommendations on treating chronic pain, suggesting physicians create a written treatment plan for each patient. The plan should include objectives for success, any additional diagnostic tests needed, psychological and physical symptoms, and nondrug treatments and medications. Treatment should then be adjusted to meet the patient’s needs.
New female condom quieter during sex. A Food and Drug Administration advisory panel unanimously recommended approval of a new version of the female condom that is much cheaper – and less noisy – than the existing version. The current female condom costs about $3 to $4 each, is made of sheets of polyurethane with welded rings at each end, and is noisy, making a snap, crackle and pop, according to one panel member. The newer version is made of synthetic rubber and uses a simpler manufacturing process. The FC2 female condom, made by Female Health Co., has been approved for use in most other countries. It may be available in the U.S. by summer.
Widely used drugs may impair memory in men. A class of drugs used for conditions such as diarrhea, asthma, lung disease and Parkinson’s disease was associated with poor memory in older men with high blood pressure, according to the Journal of the American Geriatrics Society. The study focused on anticholinergic drugs, which include atropine, Cogentin, Detrol, Extendryl and Levsin. More research should determine if the findings are true for older people without high blood pressure and for women.
New recommendation for breast cancer. Women with locally advanced breast cancer, including inflammatory breast cancer, should be treated with Herceptin (trastuzumab) with chemotherapy prior to surgery. That’s according to a study reported at the 31st Annual San Antonio Breast Cancer Symposium. Compared to women receiving chemotherapy alone, the relative risk of cancer recurrence was almost cut in half by using Herceptin with chemo. In fact, researchers state that the combination prior to surgery should be standard treatment for women with locally advanced HER2-positive breast cancer.
– Scott R. Weinberger
