Chest Wall surgery

the John Wayne principle and my love of thoracic surgery

Occasionally, here at thoracics.org, we get comments about our various topics. Sometimes, we are even scolded for our enthusiasm for thoracic surgery by people who often misunderstand enthusiasm and genuine interest in advances in the field, and patient care for callousness. It’s not callousness, it’s the very opposite – it’s a sincere desire to better the lives of our patients thru surgery.

As the editor-in-chief, I don’t have to explain my love of thoracic surgery, but I often like to. I think it brings an otherwise clinical and somewhat dry sounding specialty alive. That’s essential to attract new clinicians to the field, and to drive innovation. We should want our surgeons, our clinicians and staff in thoracic surgery to have a passion for their work.

So today, I’d like to talk about what inspires my passion, and my continued interest in advances in thoracic surgery. Part of this editorial is related to a recent conference I attended with a lecture by Dr. Michael Harden of Australia, but we will talk more about Dr. Harden later.

First, we need to talk about John Wayne, the legendary actor of the classic westerns.

John Wayne has always been a hero of mine – and a reminder of my childhood. Before Netflix, Video-on-demand, VHS or even large cable networks, John Wayne was a staple of weekend television. Along with my father, we would sit in the living room and watch John Wayne films like “Rio Bravo”, “Hondo” or “The Man who shot Liberty Valence”. For the most part, as a Barbie-loving little girl, I could care less about the movies – it was a chance to spend time with my dad, who worked long hours most of the time. Except for “The Shootist.”

That movie, with it’s depiction of an aging, cancer-stricken gunslinger immediately grabbed my interest way back then, and even to this day, still makes me cry. Sometimes, I tear up just thinking about it.

More importantly, this film, (in a round-about way ) ultimately inspired some of my love of thoracic surgery. While readers familiar with the story already know, in John Wayne’s final film, his character is suffering from stomach cancer. As, in real life, John Wayne later died of stomach cancer. He died in 1979, three years after the film was completed. But if you ask anyone about John Wayne, they don’t mention his stomach cancer – they mention his lung cancer. So, I grew up thinking he died of lung cancer.

It wasn’t until I was well into adulthood that I found out that he survived lung cancer, and ultimately died of something else. It was even later, in 2004, during my training in cardiothoracic surgery that one of my older attendings mentioned John Wayne’s lung resection for a stage 3B cancer that prompted even more interest (by this point, google and the internet made it easy to satisfy this curiosity.)

John Wayne was larger than life, and his surgery was too..

That’s when I learned that not only did John Wayne have an extensive lung cancer requiring chest wall resection (that resulted in a complete cure) back in 1964, but that he received the kind of operation that many modern day patients are denied.

If he was alive today, he would need a surgeon like Dr. Michael Harden.

That’s because despite all of these modern day advances, (or maybe because of them), many patients with large bulky tumors, and local invasion (of ribs, spine, chest wall etc) are never even referred to thoracic surgeons in the first place. These patients are shunted to thoracic oncologists and radiation therapists where they receive systemic chemotherapy or radiation instead, despite the fact that our ability to resection these large, locally invasive tumors has greatly advanced since the early 60’s.

Not every thoracic cancer patient with advanced disease can or should have thoracic surgery. Many of these patients are frail, have distal/ widespread metastatic disease or other criteria that may make them ineligible for surgical resection. But often, for patients outside of very large academic centers, their cases aren’t even presented for surgical consideration.

Surgical success despite old-fashioned recovery techniques

A surgical resection like John Wayne’s in 1964, was a massive undertaking, and the risk of death from surgery was not insignificant. There were considerable hurdles to recovery related to all aspects of his care. H was a heavy (5 pack a day smoker), and the knowledge that cigarettes were linked to lung cancer was just beginning to seep into the public’s awareness. The vascular implications and other complications of smoking were not well known.

Bedrest was often prescribed for lengthy periods of convalescence post-operatively, which contributed to pneumonia, blood clots and disability – all the things that now prompt an almost fanatical zeal for us to get our patients up and out-of-bed as soon as possible after surgery. It’s not amazing that surgeons were able to perform this operation in the early 1960’s, there were many, many great surgical advances back then, but it is somewhat amazing that he was able to survive his post-operative course given many of the factors I’ve mentioned above.

But he survived – thrived even, and went back to making some of the best films of his career. His lung cancer never returned, and he lived another 14 years after that. That’s better than the average long term survival rates for most of our advanced cancer patients who receive chemotherapy or radiation.

For me, John Wayne’s recovery and surgical treatment has sparked a number of questions:

Shouldn’t the rest of us receive the opportunity to at least be considered for surgical resection?

Who is eligible for chest wall resection and these other large scale resections? What are our modern day options? What are the short and long-term outcomes?

Who should perform it? Where should patients go?

It’s been over 15 years, and I am still following the research, attending conferences and interviewing surgeons to best answer those questions.

-K. Eckland, ACNP-BC, MSN, RN

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