Is ‘Inoperable’ Really the Best Term?

[MUSIC PLAYING] More than 230,000 people in the United States will be diagnosed with lung cancer this year. About 40% of those patients will also find out that their cancer is inoperable. While a diagnosis of inoperable lung cancer is alarming, doesn't mean that it can't be treated.

Various forms of treatment can shrink the cancer, treat symptoms, slow its growth, and extend the patient's life. Joining me is Dr. Joseph Murray. He's the co-director of the lung Cancer Precision Medicine Center of Excellence at Johns Hopkins Medicine. And Dr. Melinda Hsu, she's a thoracic medical oncologist and assistant professor of Hematology and Oncology at the Case Comprehensive Cancer Center at University Hospital's Seidman Cancer Center. Doctors, thanks for joining me.

Thank you.

Well, let's start off with what types of cancer are inoperable. All types of lung cancer aren't inoperable. So which ones are we talking about?

I'll first start off by talking about two main categories of lung cancer that are relevant. One is called small-cell lung cancer and the other is called non-small-cell lung cancer. These two types of cancers are treated in similar, but different ways depending on how advanced they are in the inoperable setting. Small-cell lung cancer and non-small-cell lung cancer can be in the inoperable setting, locally advanced, or metastatic, and this can define what best first treatment is offered to a patient.

Dr. Hsu, how much does location of the tumor matter? Often when we talk about surgery, surgeons have to be able to get at it. Does that matter?

And what about stage? Patients are often used to hearing about the stage of cancer. Does that have relevance as well when we're talking about whether lung cancer is inoperable or not?

Absolutely. Both of those things matter when it comes to whether or not a surgeon can get at the cancer or whether the cancer is operable. The staging system is different for non-small-cell and small-cell lung cancer. But based on the stage, most typically that's how physicians decide whether or not the cancer is operable. So things like the size of the tumor go into the staging, whether or not there are lymph nodes that are involved, and the location of the lymph nodes, as well as whether there's any other sites of cancer in the body, whether that's in the lungs, the other lung, or outside of the lungs. So those three things together help make up the stage and then that usually determines whether or not the cancer is operable or not as well as specific things about the patient.

So taking all that into consideration, Dr. Murray, who's the ideal candidate?

So it depends on what the ideal therapy might be for that patient. In patients who have stage 3 cancers, there's often the opportunity to treat them definitively with things like chemotherapy and radiation together. And when we use a definitive treatment in these settings even when a patient is inoperable, we often have the opportunity to go for a cure if you will. We follow that chemoradiation therapy with immunotherapy to consolidate and offer the best opportunity for that cure for that patient. And this would be for these locally-advanced non-small-cell lung cancers.

How much does a patient's underlying health come into play, Dr. Hsu? Because you could say, well, look, the patient has cancer to begin with. So let's be realistic.

There's always going to be challenges already with lung function, cardiovascular, health. Do we place too much emphasis on that? Or does that really matter when we're talking about inoperable lung cancer?

I think that it does matter. And the reason that I think it matters is when we decide to operate to cure somebody's lung cancer, we're not just trying to cure their cancer, we're also trying to help them live out the rest of their lives without their cancer. And most patients don't want to be tethered to a nasal cannula for oxygen or something like that.

The question that I get from my patients very often who are going to undergo surgery is, am I going to live a normal life? And I think that in our role as oncologists, while we are trying to shepherd our patients through their cancer journey, for a lot of patients, they want to be as normal as possible. And for the patients whose lung cancer is inoperable, we still try to be mindful of the types of treatments that we give them. While, of course, within the confines of standard of care or clinical trials, we still want to personalize their treatment for the patient as much as possible.

Dr. Murray, is inoperable the best word? Because for some people, does that mean terminal in their mind? And is it the right way of thinking about what we call inoperable lung cancer?

It's a great question. Our words have strong meanings, and patients hang their hats on that. I think the use of the term inoperable can be very confusing for patients. And what I focus on is what is the treatment at hand that best fits the characteristics of the stage of their cancer and their personal comorbidities and other health issues that could be a barrier to get the best treatment we can afford them. And the terms I like to use are locally advanced or metastatic cancer and describing to patients how those could be operable, inoperable, or so advanced that systemic therapies are our only options.

Well, Dr. Murray, this brings up the point that we don't want cancer to present when it's advanced. So what do we need to do to diagnose lung cancer earlier?

We have a lot of work to improve how we screen for cancers, and particularly lung cancer in our country. We have guideline-based evidence that supports using low-dose, high-resolution CT scans to scan patients who have a smoking history in specific age groups who are at high risk for lung cancer. But I'll be mindful of the fact that there are many patients who are never smokers who also develop lung cancer, and we are lacking screening strategies for these types of patients.

What I tend to tell patients who show up is that any patient with lungs can get lung cancer. And I do focus, even though screening and risk factors like smoking are quite relevant, on the fact that this is the case and looking retrospectively back in the past with hindsight always makes you want to know why this happened. But I focus on what we should do about it next.

So Dr. Hsu, Dr. Murray mentions the guidelines for smokers or past smokers for low-dose CT. But recent data suggests that less than 10% of people who qualify for that screening receive it. So what do we need to be doing because we want to talk about how do we address inoperable lung cancer? But what we really want to do is prevent it from getting to that stage, and we can do some of that with screening.

Absolutely. And actually those guidelines were expanded recently in 2021 to try to catch more of the population that has a previous history of smoking as well as catch patients at a younger age to try to improve that. And obviously, the data will show us whether or not that's effective. But I think that the conversation actually starts before a patient ever meets an oncologist in terms of screening. And so I think that making sure that the primary care providers are aware of these things in this era of electronic health records maybe even making things like screening orders automatic if patient's smoking history is in the chart.

So it's important to get people screened, get people diagnosed early. And then, Dr. Murray, should a patient get a second opinion if they're told they have inoperable lung cancer? Is that important to do?

I see a lot of second opinion patients myself. So I know that this is frequently happening. And I will say that not all patients can have the means and ability to get a second opinion. I do strongly recommend, even my patients, who I see, to consider second opinion evaluations, particularly if there's questions or concerns about aspects of their own health that might be affecting our recommendations for an operation or not and various therapies or not. And I do have strong advocacy for patients in this regard as I see many patients in second opinion in my own clinic.

How often do you give a different opinion than the physician that originally saw the patient? I know people are thinking that right now when you say a second opinion. But how often do you think it changes the decision making?

So first is standard of care. How might my recommendation differ based on the standard of care recommendations that a local oncologist might be providing and offering? And sometimes it boils down to the individual steps to get the patient to the best and first standard of care option available.

So I may be pushing to do more genomic testing earlier and using things like liquid biopsy to advance that for a patient. And that may be an additional recommendation on top of a great plan from their local team. The other side to look at is what can we afford at a place like Johns Hopkins or in the Cleveland Clinic Hospitals as well beyond the standard of care.

And for clinical trials, this is an option we can afford our patients that a local oncologist may not have access to. And so a big important part of my job is to screen patients before their visit, at their visit, and later to assess whether they would be best served by a clinical trial versus a standard of care. And so if I had to boil down to a number, I'd say that the majority of the time I agree, more than 50% of the time. But I might be adding additional features to guide and personalize the care, just as Dr. Hsu described, to really make that care as best for the patient as possible.

Because getting that diagnosis right of inoperable lung cancer is critically important as one thinks about the next steps. Doctors, I want to thank you for taking time today.

Thank you.

Thanks so much for having us.

[MUSIC PLAYING]