Online conference: Global Connection — Reconstruction technique in lung cancer

While much of our normal lives are still on hold in many places around the world, particularly in the Americas, it’s still important for us to maintain our connections to the world at large. It’s critical that we remain interested and engaged in the latest advancements and educational opportunities in our specialty.

Pandemic or no, our patients still need us – and conditions like lung cancer don’t take a hiatus just because the world’s attention is directed elsewhere.

With that in mind, thoracic surgeons have moved out of the operating rooms and conference halls – online into virtual conferences and zoom meetings, so that we can continue to provide our patients with most up-to-date and evidence-based practices.

Now some of our favorites, including Dr. Diego Gonzalez Rivas are presenting “Global Connection — Reconstruction technique in lung cancer” live on July 29th, 2020 at 1900 (Hong Kong time). That’s 4 am for west coast viewers like myself in San Francisco or Los Angeles. 7 am for our viewers in Santiago, Chile, noon for our British colleagues and 4:30 in the afternoon for our friends in Mumbai.. So where ever you are, dear readers, set your alarms – and don’t miss this short meeting.

This two hour live-stream will include experts from around the globe talking about advanced reconstruction techniques for surgical resection of late stage lung cancer.

Conference link: Global Connect conference

Guest post: Dr. Migliore and the IV Mediterranean Symposium on Thoracic Oncology

Dr. Marcello Migliore reports on the highlights from the recent Mediterranean Symposium on Thoracic Oncology

A great success the IV Mediterranean symposium in Thoracic Oncologic surgery. One hundred and eighty participants including thoracic and general surgeons, oncologists, and medical students attended the symposium.

thoracic symposium 2
IV Med Symposium in Thoracic Surgery: Speakers and the Students of the Faculty Medicine of the University of Catania

The symposium was organized to pose the basis for new research studies in advanced lung and esophageal cancer. The Rector of the University Prof Francesco Basile pointed out that the symposium is becoming a fixed international scientific appointment of the surgical thoracic community. It was noted that many research and thoracic publications which were done in Sicily in the 50ies and 60ies were only published locally or in Italy, meaning that  many of these very good publications remain unknown internationally.

From the general discussion it was noted that it is necessary to prolong survival in patients with advanced stage lung cancer to obtain a global better survival in patients with lung cancer; unfortunately still today 60-70 % of patients arrive to us with a “non surgical” cancer. Although surgery has been always not considered for stage IV lung cancer, recently, new hope is emerging.

Initially the precious value of radiology and the recent emerging role of immunology confirmed the necessity of a multidisciplinary team to treat this group of patients. New technologies such as HITHOC, the same technique which has been used for mesothelioma, could help to prolong survival in a multimodality therapy in patients with stage IV lung cancer. A recent study  involving 33 patients with advanced lung adenocarcinoma with pleural dissemination that a 6-month, 1-year and 3-year progression-free survival rates for the HITHOC group were 87.0%, 47.8% and 24.3%, while those of surgery group were 44.4%, 33.3% and 0.0%, respectively (1,2) Nevertheless, as for mesothelioma (3) it is imperative not to give false hope, but a “real” hope is mandatory only within a well design study. Surgery for N2 disease remains at the moment under investigation as there are conflictual data, but a single N2 not bulky metastasis could be an indication for surgery without neoadjuvant chemotherapy. Surgery for oligometastasis is feasible but a multidisciplinary decision is necessary, and this is essential when complex surgeries for locally advanced lung cancer is planned; long term survival depend from a well posed surgical indications, and it should not based on personal opinion (4). Advantages of the precision technique has been carefully presented by Michael Mueller from Vienna and Pierluigi Granone from Rome.

Prof Antoon Lerut from Leuven presented the tremendous experience with 3000 esophagectomies with the main conclusion that this complex surgery must be done in centralized centers where experience is present. Although minimally invasive and robotic surgery techniques are feasible by expert hands in some patients with advanced lung cancer, it is evident that randomized trials are necessary before their wider use in clinical practice. Semih Halezeroglu from Istambul presented his experience with uniportal VATS pneumonectomy, and commented that many patients with advanced lung cancer who undergo extended operation do not survive as expected, and therefore some indications should be at least revised to avoid usefulness operations. Finally, the personal feeling is that “individualized” surgery, which seems to be more human to me, for advanced lung and esophageal cancer could become more common in the next years.

thoracic symposium 1
From the left to the right: Prof Luigi Santambrogio, Prof Semih Halazeroglu, Prof Marcello Migliore, Prof Antoon Lerut, Prof Michael Mueller


  1. Yi E, Kim D, Cho S, Kim K, Jheon S. Clinical outcomes of cytoreductive surgery combined with intrapleural perfusion of hyperthermic chemotherapy in advanced lung adenocarcinoma with pleural dissemination. Journal of Thoracic Disease. 2016;8(7):1550-1560. doi:10.21037/jtd.2016.06.04.

  2. Migliore M, Calvo D, Criscione A, et al. Cytoreductive surgery and hyperthermic intrapleural chemotherapy for malignant pleural diseases: preliminary experience. Future Oncol 2015;11:47-52. 10.2217/fon.14.256

  3. Maat APWN et al. Is the patient with mesothelioma without hope? Future Oncology 2015; 11(24s):11-14. November 2015

  4. Treasure T, Utley M, Ian Hunt I. When professional opinion is not enough. BMJ: British Medical Journal 2007; 334.7598: 831.



The Mediterranean IV thoracic oncology symposium

It’s not too late to register for the upcoming Thoracic Oncology Symposium in Catania, Italy.  The symposium is being held April 6th and 7th and is sponsored by the University of Catania and Policlinico University Hospital.

This year’s topic is “Surgery for “advanced” lung and esophageal cancer: New horizons or a false dawn?”  Lectures include a presentation by Dr. Migliore on HITHOC for M1 lung cancer, a discussion on the use of hyperthermia, as well as several lectures on the use of VATS in advanced lung cancer and a segment devoted to esophageal cancer that includes the presentation of research findings by Dr. Toni Lerut based on findings from 3000 esophagectomies.

The full program and registration information can be seen Here.  Potential registrants may also contact Dr. Migliore at

A guest post on last year’s conference is viewable here.


Advances in Thoracic Surgical Oncology

an upcoming conference on thoracic oncology in New York, New York

Mark your calendars and clear your schedules for the first weekend in October!  The Advances in Thoracic Surgical Oncology course is October 3rd – 4th, 2014.


Unlike many of the association conferences  – this conference is not geared at the thoracic surgery specialty or cardiothoracic surgery crowd in its entirety.

This course, offered by the internationally famous Memorial Sloan Kettering Cancer Center in New York, New York is focused on the use of thoracic surgery in modern cancer treatment, particularly in the treatment of lung and esophageal cancers*.

As a world-famous academic and cancer research center, Sloan Kettering has hundreds of educational offerings for practicing physicians, nurses and other health care professionals as well as Fellowships and doctoral programs in specialty focus areas.

The event is hosted by Dr. David R. Jones, a thoracic surgeon and recent transplant from the University of Virginia in Charlottesville, Virginia.  Dr. Jones is the Chief of Thoracic Surgery, and the Surgical Director of the Thoracic Oncology Program at Memorial Sloan Kettering Cancer Center.

To register for this event, click here

*More information on the lectures and presenters was not available at this time.  (I hope to add more details as we get closer to the event).

Pleural fluid cytopathology

How to prepare a proper specimen for pleural fluid cytology & cytopathological analysis.

Pleural Fluid Cytopathology

Pleural fluid analysis is more than a typical ‘rounds’ question for interns and students.  This fluid contains important indicators of disease status.  Who among us hasn’t memorized pH levels, glucose and protein values?  (For a discussion on transudate versus exudate effusions, see the Medscape article by Jeffrey Rubins below.)

While pleural fluid analysis can be used to assist in the differential diagnosis of multiple conditions; pleural fluid cytopathology is often ordered when a more sinister condition like metastatic cancer is suspected.  Therefore, it is especially important for clinicians to ensure that pleural fluid cytopathology samples are collected, and sent in the most efficient and effective manner possible.  While there are few written guidelines regarding this process, here are some helpful tips based on interviews with several pathologists and the available literature.

Biopsy is best but fluid analysis is still helpful

While the gold standard for diagnosis is always tissue biopsy (in this case pleural tissue biopsy), this does not mean that cytopathological analysis is completely unnecessary.  In many cases, this fluid analysis gives a first look that aids in the diagnosis and staging of disease.  It is particularly useful for patients undergoing thoracentesis procedures, particularly when thoracentesis is performed in lieu of a more invasive procedure such as VATS (which allows for direct tissue biopsy.)

But do I still need to do a biopsy if the fluid analysis is negative?

However, there is often a catch-22 in the use of pleural fluid pathology which can lead to some confusion among patients and providers.  This catch-22 is related to the sometimes variable reliability of pleural fluid cytopathology for diagnosis of malignancy.  This means that the results aren’t always accurate.  As anyone in thoracic surgery can tell you, there have been numerous times when the fluid analysis results are reported as negative (for malignancy) even when the surgeon is (literally) staring at a pleural tumor in the operating room.  This means that a negative pleural fluid cytopathology result can not be used to rule out malignancy.

However, when the fluid is positive, it may save the patient from an additional procedure*.

Cytology versus cytopathology

“Cytology” is the generic term for the study of cells.  Cytopathology is the actual pathological investigation of free cells and tissue fragments, often for the diagnosis or treatment of cancer.

When used clinically, cytopathology is often used to distinguish between other more basic studies of bodily fluids or tissues.  This in-depth cellular examination is more critical in many cases than basic pleural fluid analysis.  This examination may include identification of immunological factors and tumor markers.  This is one of the tests that clinicians use to try and answer the question,“Is it cancer?”.  However, the answer is not always as straight forward.

Reliability and Predictive Value

This question is difficult to answer due to sometimes variable prognostic value of the fluid itself.  Even under the best of circumstances, reliability of this test (like most diagnostics) is less than 100%.  Different studies calculate the accuracy of pleural fluid analysis at detecting cancer vary wildly;anywhere from 10 to 80% has been reported in the literature with false negatives as the most frequent error (when discussing sensitivity and specificity). However, poorly prepared specimens may contribute to false results as well.

Ensuring optimal results by obtaining proper specimens

 Over the years, during different discussions with multiple pathologists as well as laboratory technicians, a common theme has emerged regarding the use of pleural fluid for pathology analysis.  Several of these individuals remarked that obtaining an accurate diagnosis was often difficult due to improper or suboptimal preparation of the pleural fluid, in addition to characteristics of the fluid itself.  What constitutes a ‘proper’ or ‘optimal’ pleural fluid is still (among lab technicians and pathologists) up to debate, but here are some general guidelines:

1. Send it all.

Due to the nature of pathology analysis which replies of the presence and identification of malignant cells within the fluid itself, a larger fluid specimen provides for a better sample.  When thoracentesis/ VATS or other drainage is being performed, and this yields 2 liters of fluid – send all two liters.  Don’t select out the first 25ml in a urine specimen cup, send it all.

There are no set guidelines for the amount of fluid necessary for cytopathology analysis. While malignancies have been successfully detected in amounts as small as 4ml, the rationale behind providing larger samples has been explained as ‘increasingly the likelihood of detecting the presence of cells indicative of malignancy’.

While the amount of fluid needed is currently up for debate among pathologists, sending too little fluid may result in a missed diagnosis, whereas an overabundance of fluid is more of an inconvenience to lab technicians.

Be sure to include the last frothy bits, which often contain more sediment/ cellular material than fluid recovered at the beginning of the sample.  (The content of this fluid may even vary due to the patient’s position – which is another reason to take a larger sample.) In a conscious patient, this may mean several minutes of discomfort, but encourage patients to take deep breaths, and cough so that as much fluid as possible can be removed.  (In patients with very large effusions, this may be a lengthy process as ‘short breaks’ are taken during the procedure to accommodate for fluid shifts.  This brings us to # 2.

2.  Keep it fresh: Talk to the lab about whether you should consider adding an additive like heparin or EDTA to your sample at the time of collection to prevent the degradation of cells.  Depending on when / where your sample is collected and sent – there may be significant delays in the processing of the collected sample.  Many pathologists report that after 4 hours there are significant changes in untreated pleural fluid kept at room temperature.

Consider this as you gather your sample;

–          Did you leave it in the patient’s room for the nursing staff to deliver?

–          Is it possible it may sit for several hours before arriving to the lab?

–          Is the lab well-staffed or will the fluid sit waiting for analysis by overworked, and stressed employees at a lab that may be inundated with many more urgent requests?

Guzman et al. (1992) and other researchers found that with the addition of EDTA to pleural fluid specimens, tumor cells were easily identified even after four days of storage.

Even if your facility doesn’t provide EDTA for your specimens, it’s a good bet that sending a syringe full of fluid from the bottom of a week-old pleurovac is probably not your best bet.

3.  Eliminate errors: Don’t make them guess!

Always personally label fluid and tissue samples completely with the patient’s name, reference number (as used by your institution), body site (ie. Right pleural space) as well as the ordering clinician’s name.  Include your phone number if you want to be called with the results or questions.

On the actual order, or lab requisition, provide additional information including patient symptoms, and pertinent history (ie. 63 year old with 40+ pk years of smoking, and history of asbestos exposure in Navy shipyards, now presents with pleural effusion, chest pain and 25 pound weight loss.)  Provide any special instructions as needed.   This allows the pathologist examining the patient’s specimens to correlate clinical history, symptoms and other available diagnostics with cellular findings and stains.

4.  Now do it again.  If the patient develops a second pleural effusion, go ahead and send that fluid too – particularly if the first sample was non-diagnostic.

*Depending on the patient’s clinical status/ symptomology.  As mentioned in a previous post, many patients with malignant pleural effusions may undergo additional procedures at some point in time for palliation of symptoms.


 American Society of Cytopathology – a great resource for interested readers.  The website also contains a ‘virtual slide atlas’ which includes case studies and several slides showing pleural fluid cytopathology. Click here for the case study of a 60 year old with pleural effusion.

Antonangelo L, Capelozzi VL. (2006). Collection and preservation of the pleural fluid and pleural biopsy. J Bras Pneumol. 2006;32 Suppl 4:S163-9. Portuguese.  These Brazilian authors from the University of Sao Paulo discuss the proper collection of pleural fluid specimens.  In this article, the authors make recommendations for the collection, storage and examination of pleural fluid for a variety of laboratory and microscopic tests.

Brandstetter RD, Velazquez V, Viejo C, Karetzky M. (1994). Postural changes in pleural fluid constituents. Chest. 1994 May;105(5):1458-61.

Guzman J, Arbogast S, Bross KJ, Finke R, Costabel U (1992).  Effect of storage time of pleural effusions on immunocytochemical cell surface analysis of tumor cells. Anal Quant Cytol Histol. 1992 Jun;14(3):203-9. No free full text available.

Porcel JM.  (2011).  Pearls and myths in pleural fluid analysis. Respirology. 2011 Jan;16(1):44-52.  Porcel advocates for smaller volumes, but an ‘inadequate sample’ should never be a reason for a missed diagnosis.  He also advises the addition of an additive if there are any anticipated delays (4+hours) in specimen processing.

Salyer WR, Eggleston JC, Erozan YS. (1975).  Efficacy of pleural needle biopsy and pleural fluid cytopathology in the diagnosis of malignant neoplasm involving the pleura. Chest 1975 May, (5) 536-9.  Classic article on the predictive value of pleural fluid cytopathology. A  pdf of Salyer et al is available here.

Rubins, J. (2013).  Pleural effusion workup.  From Medscape/  Pleural Effusion Workup pdf version.

Additional Resources

Shidham, V. B. & Falzon, M. (2010). Serous cavities.  Chapter 3 in  Diagnostic Cytopathology: Expert Consult: Online and Print (2010).  Grey & Kocjan (Eds).   Elsevier Health Sciences.

The Stigma of Lung Cancer

Medscape interviews Dr. Schiller regarding the stigma of lung cancer, as a ‘deserved disease.”

There is a new interview over at Medscape that examines the stigma of a diagnosis of Lung Cancer.  During the interview, Dr. Joan H. Schiller, MD,(Chief, Division of Hematology/ Oncology at the University of Texas Southwestern Medical Center, Dallas, Texas) discusses her work in examining biases and attitudes regarding lung cancer and patients with lung cancer.  Most importantly, the study included participants who work in the medical field (doctors, clinicians etc).

To participate in her ongoing study, click here for the Lung Cancer Project.

Doctors as study participants

Lung cancer patients aren’t just stigmatized by friends and neighbors.  They are also shamed by some of the very people that are supposed to take care of them; doctors, nurses and other healthcare personnel.

For example, this well-known Oncologist  expresses concern that “CT scans will be used as a crutch by smokers” that will give smokers a false sense that medicine can ‘fix’ problems caused by smoking.

While I certainly understand that as an Oncologist who sees advanced stage cancers in her practice every day – she may be emotionally exhausted and disheartened by the amount of smoking-related cancers in her practice, I think that ANY diagnostic technique that allows us to find/ and diagnose cancers at early stages – when there is a better chance for successful treatment – is not a crutch*. In truth, even with early detection only a tiny fraction can be “cured.”

I doubt that any smoker says, “Oh, well.. I can smoke because they can always do a CT scan..”   Of course we should encourage smoking cessation – in all our patients, but shaming, stigmatizing and punishing our patients who have a history of tobacco use is counter-productive and unworthy of us as health professionals..

As we discussed in a previous post, the stigma of a lung cancer diagnosis is a distinct entity in comparison to other cancers, and causes divisions among lung cancer patients themselves (former smokers versus never-smokers).

With lung cancer as the number one cancer killer in the United States, as well as new screening recommendations for the early detection of lung cancer being endorsed by several major health agencies and organizations – it is time we tackle this stigmatization and marginalization of people with lung cancer.

* I do agree with her recommendations for smoking cessation, and using taxes from cigarette sales to pay for CT scans.. Or maybe some of the tobacco settlement funds.


“The Stigma of Lung Cancer” – Medscape article by Joan H. Schiller, MD, Alice Goodman, MA.

Suzanne K Chambers, Jeffrey Dunn, Stefano Occhipinti, Suzanne Hughes, Peter Baade, Sue Sinclair, Joanne Aitken, Pip Youl, Dianne L O’Connell (2012).  A systematic review of the impact of stigma and nihilism on lung cancer outcomes.  BMC Cancer. 2012; 12: 184. Published online 2012 May 20. doi: 10.1186/1471-2407-12-184.  Review of previous studies on stimatization, and quality of life outcomes in patients with lung cancer.

Janine K. Cataldo, Thierry M. Jahan, Voranan L. Pongquan (2012). Lung cancer stigma, depression, and quality of life among ever and never smokers.  Eur J Oncol Nurs. 2012 July; 16(3): 264–269. Published online 2011 July 30

Janine K. Cataldo, Robert Slaughter, Thierry M. Jahan, Voranan L. Pongquan, Won Ju Hwang (2011). Measuring Stigma in People With Lung Cancer: Psychometric Testing of the Cataldo Lung Cancer Stigma Scale.  Oncol Nurs Forum. 2011 January 1; 38(1): E46–E54. doi: 10.1188/11.ONF.E46-E54. Scale and survey measuring stigma & shame, isolation, discrimination and smoking among patients with lung cancer using a tool adapted from HIV stigma studies.

Ping Yang (2011).  Lung Cancer in Never Smokers.  Semin Respir Crit Care Med. 2011 February; 32(1): 10–21. A general overview of lung cancer in never smokers as well as the stigma of lung cancer in this group.

A Chapple, S Ziebland, A McPherson (2004).  Stigma, shame, and blame experienced by patients with lung cancer: qualitative study.  BMJ. 2004 June 19; 328(7454): 1470. doi: 10.1136/bmj.38111.639734.7C   UK study looking at the stigmatization of patients with lung cancer. Some of the statements in the article by patients being interviewed are quite marked, as well as the dramatic isolation of these patients from friends, families and neighbors.

JML Williamson, IH Jones, DB Hocken (2011).  How does the media profile of cancer compare with prevalence?  Ann R Coll Surg Engl. 2011 January; 93(1): 9–12.  The role of the media in the public’s perception of cancer, and over/ underrepresentation of certain types of cancer in the UK.  (Article does not specifically mention lung cancer).

Rory Coughlan (2004). Stigma, shame, and blame experienced by patients with lung cancer: Health promotion and support groups have a role.  BMJ. 2004 August 14; 329(7462): 402–403. doi: 10.1136/bmj.329.7462.402-b  short comment.

Recommended reading: Advances in Lung Cancer

this 2012 article by Hannon & Yendamuri explains the newest methods and modalities of treating nonsmall cell lung cancer (NCLC) as well as the importance of accurate staging for diagnosis and evidence-based treatment.

A layperson’s guide to “Advances in Lung Cancer,” by Hannon & Yendamuri

In addition to providing links to the full article text, we have also provided a highlighted pdf version  – with additional notes, links and information contained in this post.

What is staging?

Staging is the diagnostic process of determining how much/ how far cancer has spread.  Staging usually involves several tests and procedures such as PET/CT scans, mediastinoscopy or bronchoscopy (with endobronchial biopsy).  Some of these tests may have been done at the time of initial diagnosis.  Others will be done as part of the work-up after doctors suspect or have diagnosed lung cancer.

More about mediastinoscopy:

Mediastinoscopy as explained by Dr. Carlos Ochoa

WebMd article on mediastinoscopy

when mediastinoscopy is done with a camera, it is called video-assisted mediastinoscopic lymphadenectomy (VAMLA)

Transcervical extended mediastinal lymphadenectomy: is an extended version of a traditional mediastinoscopy, allowing for more extensive lymph node dissection.

article at CTSnet

The jury is still out on whether the newer technologies are superior to traditional mediastinoscopy. The most important thing is for a patient to have a mediastinoscopy-type procedure for accurate tissue diagnosis.  The more lymph nodes sampled – the more accurate the staging.

This procedure may be combined with other procedures like bronchoscopies with needle biopsy (EBUS) to be able to sample more nodes from more locations in the mediastinum.  (Each procedure samples a different area of the mediastinum.)

Why is staging important?

Staging provides doctors and patients with information about the extent of cancer present.  Is the cancer in a small area of the lung alone?  Has it spread to the lymph nodes?  Is there distant metastasis to other organs?

Knowing the answers to these questions will determine the course of treatment (surgery versus chemotherapy alone, surgery plus chemotherapy/ radiation).  Staging also gives us information about anticipated or expected survival – which is important for patients to know when deciding on treatment options.

Lung cancer 101 – article on staging of lung cancer, small and non-small at

Non-small cell lung cancer staging – National Cancer Institute. Also have information about the diagnostic testing used for accurate staging.

Staging is done, now what?

Once the cancer has been staged accurately, doctors can begin to discuss treatment options.  Treatment options can include surgery, chemotherapy and radiation.  Surgery is usually the most effective for early stage cancers (IA to IIIB in most cases).  More advanced cancers may require chemotherapy regimens or palliation alone.

Treatment Modalities discussed in Hannon & Yendamuri:

Brachytherapy – this is a type of radiation treatment that is implanted into the patient at the time of surgery.

American Brachytherapy Society (ABS)

Radiation therapy – has a section on brachytherapy

Single port thoracic surgery – archives for related posts on single port thoracic surgery

Robotic surgery – posts on robot surgery and the DaVinci surgical system.

Dr. Buitrago and robotic surgery – with short YouTube clip

Dr. Mark Dylewski – master of robotic surgery

Dr. Weksler – robotic surgery

The Davinci Robot

Awake thoracic surgery with Dr. Mauricio Velaquez

Palliation – including treatment for malignant pleural effusions

What is palliative care?

Reference article:

Hennon, M. W., & Yendamuri, S. (2012). Advances in lung cancer.  Journal of Carcinogenesis 2012, 11:21.

Dr. Mark Hennon and Dr. Sai Yendamuri  are board-certified thoracic surgeons, and assistant professors of thoracic surgery at the State University of New York – Buffalo.  They currently practice at the Roswell Park Cancer Institute in Buffalo, New York.

CT scans for the early detection of lung cancer: new recommendations

Article re-post on the newest recommendations for screening guidelines for early detection of lung cancer. Second in a series on lung cancer related topics as part of Lung Cancer Month.

As reported in multiple journals – a large, randomized study showed a significant mortality benefit from periodic low dose CT scans for the early detection of lung cancer in high risk individuals.  Since this data was published, the National Comprehensive Cancer Network has begun recommending annual CT scans in high risk people.  (High risk is defined as 55 – 74 years of age with 30 or more pack years of smoking*.)  Since lung cancer screening is independent of symptomatology, this allows lung cancer in asymptomatic patients to be discovered – at earlier stages (which hopefully allows for more effective [i.e. surgical resection] treatment.

However, this recommendation is not without its detractors (due to cost, radiation exposure, etc.) as discussed in the article below.

Article re-post from

Screening for Lung Cancer Based on ‘Strongest Evidence’

Zosia Chustecka

November 17, 2011 — The brand-new guidelines from the National Comprehensive Cancer Network (NCCN), the first to be published by a national advisory group, strongly recommend the use of low-dose computed tomography (LDCT) screening for select individuals at high risk for the disease. For the target group of heavy smokers 55 to 74 years of age, regular annual LDCT scans are recommended.

This is a category 1 recommendation, which is based on high-level evidence (i.e., a randomized controlled trial) and uniform NCCN consensus that the intervention is appropriate.

“A category 1 recommendation is very uncommon,” said Arnold J. Rotter, MD, from the City of Hope Hospital in Duarte, California, who was one of the members of the NCCN panel that wrote the  guidelines. “The vast majority of clinical medicine wouldn’t be considered category 1,” he told Medscape Medical News. “Both mammography and colonoscopy, commonly performed cancer screenings, are only category 2A per the NCCN,” he pointed out.

For high-risk individuals, the recommendation is the strongest that it can be because it is based on a large randomized clinical trial, Dr. Rotter explained.

These high-risk individuals are defined as adults 55 to 74 years of age with a 30 pack-year or more history of smoking tobacco (i.e., smoking 1 pack a day for 30 years), even if they have stopped smoking within the past 15 years.

This is the same as the inclusion criteria for the National Lung Screening Trial (NLST), which was halted early last year after showing a significant lung-cancer-specific mortality benefit. An interim analysis from this trial showed that screening heavy smokers with LDCT significantly reduced deaths from lung cancer, compared with screening with chest x-ray. In the LDCT group, the reduction in lung-cancer-specific death was 20%, and there was a 7% reduction in all-cause mortality, Dr. Rotter noted.

“This was a large randomized clinical trial and it provides the strongest level of evidence that can be obtained,” Dr. Rotter emphasized.

The answer is yes.

“The question of CT screening for people at high risk for lung cancer has been answered, and the answer is yes,” he told Medscape Medical News. “Of course, further research can be done to clarify the optimal timing, size, criteria for follow-up, and many other details, but the crucial issue of lung cancer mortality has been answered in the affirmative,” he said.

The  guidelines recommend regular LDCT screening for another group of high-risk individuals — those who are slightly less-heavy smokers (a 20 pack-year or more history of smoking) but who have an additional risk factor, such as cancer history, lung disease history, family history of lung cancer, radon exposure, and occupational exposure. This is a category 2B recommendation for LDCT screening. It is based on lower-level evidence and NCCN consensus, but not  uniform consensus (as in category 2A), which signifies that there was some debate about this recommendation.

Concern Over How to Proceed

Earlier this year at the World Lung Cancer Conference in Amsterdam, the Netherlands, lung cancer experts heaped praise on the NLST results, but at the same time expressed concern about how to proceed with this finding in clinical practice. Who should be screened? How often? What should be done about unclear findings? How should intervention be minimized for patients who turn out not to have lung cancer? One issue specific to lung cancer screening is that the lung is a vital organ, so biopsies carry a greater risk than biopsies of other organs that are screened for cancer, such as the breast, cervix, and prostate.

More recently, at the Tenth Annual American Association for Cancer Research International Conference on Frontiers in Cancer Prevention Research, experts declared that lung cancer screening is “not yet ready for prime time.”

There are a number unresolved issues with respect to CT screening for lung cancer, said John L. Field, MA, PhD, BDS, FRCPath, director of research at the Roy Castle Lung Cancer Research Programme, University of Liverpool, United Kingdom. “These need to be resolved before a national screening program can be implemented in any country,” he said at that meeting.

“These issues include defining optimal risk populations, cost effectiveness, and harmonization of CT screening protocols; the whole area of work-up techniques is still an open question,” he explained. In addition, “optimal surgical management…screening intervals, and screening rounds” must still be defined for Europe, he noted. There are several European studies  ongoing, including the NELSON (Nederlands-Leuvens Longkanker Screenings Onderzoek) trial.

I don’t know quite what their beef is.

When asked about these opinions, Dr. Rotter said: “There is tremendous push back from all of academia about cancer screening. I don’t know quite what their beef is.” This applies to all screening, he said, including mammography for breast cancer, colonoscopy for colon cancer, prostate-specific antigen testing for prostate cancer, and LDCT scans for lung cancer.

“Eliminating screening and depending on improved chemotherapy to optimize health for the population does not make sense to me,” he said.

Part of the issue is that some of the early evidence supporting these interventions came from nonrandomized clinical trials, Dr. Rotter said. This was the case with lung screening, he admitted, and was the main criticism directed at the International Early Lung Cancer Action Program (I-ELCAP) study, headed by Claudia Henschke, MD, which Dr. Rotter was involved in during the early years.

The I-ELCAP study showed that lung cancer can be diagnosed with LDCT at a much earlier stage than usual, he explained. Without screening, 85% of lung cancers are diagnosed at stage III and IV; only 15% are diagnosed at stage I.

The I-ECLAP study inverted this staging, so that 85% of lung cancers were diagnosed at stage I, he said. “But this wasn’t a randomized trial, and that was an issue,” he acknowledged. And some researchers suggested that some of the early-stage lung cancers were indolent.

“Our overwhelming experience in every area of cancer is that people with earlier stages do better and have better survival,” Dr. Rotter said. There was pressure from the research community to prove that lung-cancer-specific mortality could be reduced with LDCT screening, so the huge NLST, funded by the US National Cancer Institute, was launched. There was some controversy over the comparison of LDCT with chest x-ray; some researchers questioned whether the use of chest x-rays was ethical in light of the benefits already documented for LDCT.

Now that the NLST results are in and are overwhelmingly positive for lung cancer screening with LDCT in high-risk individuals, there should be an end to these debates, Dr. Rotter said. “I think that the antiscreening groups are struggling to find a way to minimize these very significant findings,” he added.

“I believe that lung screening is ready for prime time,” Dr. Rotter said. “In fact, the recommendations are conservative; they limit screening to only the highest-risk group,” he noted, in contrast to screening for other cancer types, which is aimed at all people.

Not a Test, Part of a Process

Lung cancer screening should not be conducted in isolation, Dr. Rotter emphasized. It should be part of a multidisciplinary program with primary care doctors, pulmonologists, radiologists, thoracic surgeons, medical oncologists, and pathologists, as specified in the NCCN guidelines. In addition,  smoking-cessation counseling should be an integral part of the  screening process, he noted.

This sentiment was echoed by Michael Unger MD, FACP, FCCP, director of the pulmonary cancer detection and prevention program and of the pulmonary endoscopy and high-risk lung cancer program at the Fox Chase Cancer Center in Philadelphia, Pennsylvania.

Screening is not a test but a process.

“I maintain that screening is not a test but a process requiring a multidisciplinary approach with adequate resources for appropriate follow-up and algorithms of the best available additional tests and procedures,” Dr. Unger told Medscape Medical News. “Without this, it is a financially driven sham that exploits public ignorance; it has some personal benefits but also potential damage.”

Dr. Unger was on the panel of experts that authored the  NCCN guidelines. “By definition, it is a consensus, and is not necessarily a rigorous, methodologically strict, and categorically graded guideline. Thus, it has strength and weaknesses,” he said. However, he added, the results from the NLST randomized controlled trial “are solid.”

“The consensus recommended proceeding with the process of screening in a specific high-risk population that, essentially, is not different from the population criteria for inclusion in the NSLT study,” he said.

Dr. Unger agrees that there are many unanswered questions. “For example, assuming a negative study on initial and repeat LDCT in a subject 57 years of age: Do we stop (and if so, on what basis) or continue until age 74? Or should we do it every 2 years? If so, what is the evidence?”

Another important point is that in the United States, where lung cancer screening is already being offered at some centers, the process is not covered by medical insurance companies, Dr. Unger noted. “Patients are asked to pay (around $300 to $350) out of pocket…. This might introduce the problem of disparities.”

For the time being, Dr. Unger sees lung cancer screening as more of personalized rather than a population-based approach. “We are dealing then with 2 issues — medical practice and public policy,” he said. [article end].

* How to calculate pack years:  pack years are the number of years smoking multiplied by the amount of cigarettes (ppd) per day.  For example, a person who smokes two packs per day for 15 years would have 30 pack years – same as someone who smoked 1 pack per day for thirty years. When trying to calculate years smoking (if patient isn’t sure) – take the age of the patient and assume initiation of smoking at the age of 15 to 20.  It is rare for mature adults to start smoking.

Update: 25 May 2012: The American College of Chest Physicians and the American Society of Clinical Oncology (ASCO) recently released lung cancer screening guidelines recommending low-dose CT scans.  These guidelines were endorsed by the American Thoracic Society.   These guidelines recommend yearly CT screening for smokers and former smokers 55 years and older with heavy smoking habits.  More about the pros and cons associated with these guidelines can be found here.

Additional Resources

A blog by a thoracic surgeon discussing the effect of Japan’s long standing lung cancer screening program (which dates back to the 1940’s).

National Comprehensive Cancer Network – screening recommendations.

Updated:  3/24/2012 : More on the screening guidelines as presented at a recent cancer conference in Florida.  NCCN annual conference presentation, March 2012

Ferketich AK, Otterson GA, King M, Hall N, Browning KK, Wewers ME.  A pilot test of a combined tobacco dependence treatment and lung cancer screening program.  Lung Cancer. 2011 Nov 14.

Note:  article re-posts are for the benefit of readers who do not have subscriptions or access to medical journals.

The Pearl Ribbon

the social stigma of lung cancer and the ‘pearl’ ribbon campaign

Everyone knows about those darn ‘awareness’ ribbons… Red for HIV/AIDS, pink for breast cancer..  But since November is Lung cancer month – I’d like to address the hypocrisy of the lung cancer ribbon(s) and our [society’s] treatment of patients with lung cancer.  While not specifically endorsed by the American Lung Association, there is a division within the ribbon awareness campaign – the gray ribbon versus the pearl ribbon.  For the uninitiated, gray is for smokers (or people who apparently deserve cancer) while the pearl ribbon is reserved for non-smokers (such as Dana Reeves.)  This isn’t just about ribbons – after all, few people even know that these specific ribbons exist.  It’s about the social stigma that surrounds lung cancer from all sides; from medical professionals, the media, family and friends of patients and the patients themselves.

The irony of this is that; this sense of responsibility or health (social) justice does not extend across the spectrum of health conditions; no one assigns the shame of untreated sexually transmitted infections to people suffering from infertility, or cervical cancer, nor should they.  Though it’s impossible to ignore the link between obesity and diabetes (thus heart and vascular disease) no one assigns blame or personal responsibility to the hundreds of millions of obese people with diabetes.  Will cell phone users feel the stigma if they develop brain cancer?  Doubtful.  While smokers, and smoking have become a handy target for social scorn – these other groups are fairly safe for scrutiny.  Why?  My guess is because while the pool of smokers diminishes every year (for multiple reasons), the huge numbers of people with an STD history, obesity or cell phone use (after all, who doesn’t use a cellular phone?) makes these groups immune to serious scrutiny, or discrimination.  Nowadays, smokers pay higher health insurance and life insurance rates, and can lose their jobs for smoking.  But when is the last time that a BMI of 40 or a diagnosis of diabetes increased someone’s co-pay*?

More disturbingly, this distinction divides us at a time when we need to stand together; to gain media attention (and research dollars.) Anyone (and everyone) facing lung cancer needs love, care and support. While many people may make distinctions to try and come to terms with a difficult diagnosis, at the end of the day – we need to erase these self-imposed boundaries, unify and make our voices heard:  Lung cancer is the number one killer of women in the United States – but breast cancer receives most of the money and all of the attention.  If even a fraction of the money designated for breast cancer research could be raised and directed towards lung cancer research for detection and treatment – regardless of smoking status, thousands of lives could be saved.

*Arizona is attempting to impose penalties on Medicaid recipients for both smokers and the obese in an attempt to salvage the struggling social program, but this is less about personal responsibility than a cost-saving maneuver.

Additional References:

American Lung Association – no one deserves lung cancer.

Lung Cancer Research

Lung Cancer Partnership

National Cancer Institute

The Stigma of Lung Cancer:

Cataldo, JK et. al. (2011). Measuring stigma in patients with lung cancer: psychometric testing of the caltaldo lung cancer stigma scaleOncol Nurs Forum. 2011 Jan 1;38(1):E46-54.

Chapple A, Ziebland S, McPherson A. (2004). Stigma, shame, and blame experienced by patients with lung cancer: qualitative study.  BMJ. 2004 Jun 19;328(7454):1470. Epub 2004 Jun 11.

LoConte NK, Else-Quest NM, Eickhoff J, Hyde J, Schiller JH.  Assessment of guilt and shame in patients with non-small-cell lung cancer compared with patients with breast and prostate cancer.  Clin Lung Cancer. 2008 May;9(3):171-8.

Schönfeld N, Timsit JF. (2008).  Overcoming a stigma: the lung cancer patient in the intensive care unit. Eur Respir J. 2008 Jan;31(1):3-5.

Lung Resection in the Elderly – the Harvard/ Keating experience

a new article published in Cancer, and summarized at Medscape talks about the importance of Lung Resection for long-term survival in Lung Cancer.

Re-posting an article on the benefits of early surgical intervention on elderly patients with early stage lung cancers from This is a nice article summarizing the research study conducted by Dr. Nancy Keating at Harvard Medical School in Boston, MA.  A link to the original research abstract is here, but no free full-text available.

This article that highlights the importance of surgery – even for patients that primary care physicians and others may not immediately think of as great surgical candidates (frail elderly, COPD, other illnesses.)

Unfortunately, they didn’t address WHO was doing the surgeries – was it thoracic surgeons in high resection geographic areas (on the higher risk patients) as is often the case?  Were surgeries in the areas with lower resection rates more likely to be done by general surgeons who are less experienced in operating on more frail thoracic patients?  [all thoracic patients are frail to some decrease given the nature of the condition – so specialty trained thoracic surgeons are usually much more experienced in caring for these patients].  It would have been nice to know.

Surgery Rates tied to Lung Cancer Outcomes in the Elderly

David Douglas (Medscape)

NEW YORK (Reuters Health) Aug 24 – People with early non-small cell lung cancer (NSCLC) live longer if they’re in regions of the U.S. where doctors perform more surgeries for that indication, according to a new study.

The link between higher surgery rates and better survival held true even for frailer patients.

“We found that areas with high rates of surgery tended to operate on older and sicker patients, yet still had better outcomes for early-stage lung cancer than areas with lower use of surgery,” said senior investigator Dr. Nancy L. Keating in an email to Reuters Health.

“These data suggest that areas with lower surgery rates may benefit from higher rates of surgery,” she said.

Dr. Keating, from Harvard Medical School in Boston, said, “Resection has by far the highest chance of cure.”

But, she noted, “It may be that fear of harm (surgeons being concerned about causing poor outcomes) may be leading to relative underuse of this effective treatment.”

“While there are some patients for whom the risks certainly outweigh the benefits,” she added, “those patients may be fewer than some physicians recognize.”

Dr. Keating and colleagues studied a population-based cohort of more than 17,000 Medicare beneficiaries at least 66 years old who were diagnosed with stage I or II NSCLC during 2001 to 2005.

Using Surveillance, Epidemiology, and End Results (SEER) data, they compared areas with high and low rates of curative surgery for early stage lung cancer.

Fewer than 63% of patients had operations in low-surgery areas, whereas more than 79% did in high-surgery areas, according to a July 28th online paper in Cancer.

The high-surgery areas saw more operations on older patients and in those with chronic obstructive pulmonary disease (COPD).

The one-year lung-cancer-specific mortality rate was 12% in the high-surgery regions and 17% in low-surgery. The adjusted odds ratio for each 10% increase in the surgery rate was 0.86. There were similar findings for all-cause mortality.

Original article reference information:

Cancer. 2011 Jul 28. doi: 10.1002/cncr.26363. [Epub ahead of print]. Improved outcomes associated with higher surgery rates for older patients with early stage nonsmall cell lung cancer.  Gray SW, Landrum MB, Lamont EB, McNeil BJ, Jaklitsch MT, Keating NL.

SITS lobectomy with Dr. Diego Gonzalez

Discussion of a case report by Gonzalez, Paradela, Garcia & Dela Torre (2011) of a lobectomy by single incision thoracoscopic surgery.

Since there’s been quite a bit of interest in single-port thoracoscopic surgery (SITS) here at Cirugia de  – I’ve added information about SITS lobectomy.  British surgeons, Rocco et. al  had previously reported the outcomes of several wedge resections by uni-port (SITS) back in 2004 but this is the first case report that I’ve seen for lobectomies via this technique*.

Gonzalez et al. in Coruna, Spain published a case report of a lobectomy by SITS.  The authors note that they have performed three cases by this technique at the time of article submission (November 2010).

As expected, the authors reported decreased post-operative pain and parathesias when using this technique.   They also reported that while visibility is more limited with this approach, they feel that it is less problematic for surgeons already accustomed to, and familiar with double port lobectomies.  This approach, in their experience, is best used for lower lobe lesions due to difficulties accessing and maneuvering for bronchial resection for upper lobectomies.

* If you’ve seen other published reports – please send the citations to the site.

Update:  25 July 2011

I contacted Dr. Gonzalez to inquire about his surgical experiences since the publication of the article this past March.  Dr. Gonzalez reports that he and his colleagues (Dr. Mercedes De la Torre and Dr. Fernandez) have continued to practice SITS for lobectomies and other thoracic procedures, and that he is now using it for the majority of his cases.

Dr. Gonzalez states that many of his patients are discharged earlier (POD 2 or 3) and are experiencing less post-operative pain.  He is planning future studies to demonstrate this.

Dr. Gonzalez website

I expect we’ll be hearing more about Dr. Gonzalez and his partners in the future.

Note: Dr. Chu in Beijing, China has also published cases in the literature with single port lobectomies.


Gonzalez D., Paradela M., Garcia J. & De la Torre M. (2011). Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg. 2011 Mar;12(3):514-5. Epub  2010 Dec 5. (free full-text article with photographs).

Rocco,  G.,  Martin-Ucar, A. & Passera, E. (2004).  Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726-728. (free full text aricle with color photographs).

Mailbag: Cancer Treatment Centers of America & Lung Cancer

Cirugia de Torax answers one of the most frequently received email inquiries regarding lung cancer treatment and the Cancer Treatment Centers of America.

Update:  in March of 2014 (almost three years after our original post), the Cancer Treatment Centers of America announced the addition of a thoracic surgeon, Dr. Johnathan Kiev to their staff at the midwestern campus in Zion, Illinois.  

Here at Cirugia de, we receive quite a bit of email about lung cancer, and lung cancer treatment.  A significant portion of this email concerns questions regarding the efficacy and treatments available at the Cancer Treatment Centers of America – a commercial, for-profit chain of hospital facilities that advertise ‘holistic’ and specialized cancer treatment.

The company currently has four hospitals, spread across the United States (Philadelphia, PA, Arizona, Oklahoma and Illinois with additional facilities scheduled to open in 2012.)

This organization is particularly well-known due to a series of television advertisements with various actors making statements such as “when I woke up from surgery, my surgeon said I had cancer.  He had no compassion” etc, etc.  These commercials tend to be emotionally exploitative (in my opinion), but I thought I would investigate some of the treatments offered for thoracic cancers due to the volume of inquiries.

However, when perusing the information available on-line, including surgeon profiles – it was readily apparent that despite offering a wide range of therapies and information targeted at patients with lung / esophageal/ and other thoracic cancers – there are no board-certified or specialty trained thoracic surgeons currently working for this organization.  The majority of surgeons listed are general surgeons, with a few head and neck surgeons.  In fact, there are only 2 general surgeons at each facility (as well as a plastic surgeon at each facility – listed under ‘breast surgeon’.)

This hospital chain – doesn’t offer thoracic surgical procedures despite advertising heavily for these patients. (Some of the terminology used on their website is vague – but lobectomies, lung resections, esophagectomies are not specifically mentioned.) The website alludes to this fact – in one small section – stating that ‘we’ll give you treatments when others can’t” or at least the assumption that the centers are only treating advanced (late stage) lung cancers is expressed.  But on another section of the site, they advertise diagnostic modalities for diagnose lung cancer – so it’s not the most open/ easily understood website from the patient perspective.

So – to answer previous inquiries, “What about the Cancer Treatment Centers of America?  Is that a good place to go for lung cancer?”

Short answer:  No. (or at least not yet.)

Detailed answer:  As we’ve discussed before, the best long-term outcomes for lung cancer are obtained via surgery.  The first stop after a lung cancer diagnosis should be to see a thoracic surgeon.  After a discussion of your particular circumstances (stages, burden of disease etc.) your thoracic surgeon will be better able to determine whether surgery is an option.  Until this determination has been made, all other therapies/ holistic treatments/ supplements/ etc. should be considered secondary.  These are not the best first-line treatments for someone with surgically manageable disease.

Only after this determination – should/ could patients consider receiving additional or adjuvant treatments in facilities such as the organization mentioned above.

please note – Cirugia de does not dispense or provide medical advice, and does not answer individualized/ specific medical or surgical questions.  Questions should be general in nature.  Replies are for basic consumer education, and none of the information provided on this site should be considered in lieu of a medical consultation with a board certified health care provider. 

Additional information –

1. Commercial – a particularly vague ‘cancer’ commercial emphasising holistic / ‘alternative’ treatments.  As a nurse, this specific commercial is rather offensive to me.

2. Cancer treatment center of america – website

Intrathoracic Hyperthermic Chemotherapy (Hithoc) in advanced non-small lung cancer: the Nara Experience

As part of a continuing discussion of HITHOC (Hyperthermic IntraThoracic intraOperative Chemotherapy), today we are talking about the results of a small study conducted at the Nara Medical University, School of Medicine in Nara, Japan.

As part of a continuing discussion of HITHOC (Hyperthermic IntraThoracic intraOperative Chemotherapy), today we are talking about the results of a small study conducted at the Nara Medical University, School of Medicine in Nara, Japan.

While the study is small (just 19 patients in three groups), it’s important because the patients involved all had advanced lung cancer, with malignant pleural effusions or disseminated disease discovered at the time of surgery. This is important, as readers know, because lung cancers are often diagnosed late, (after patients develop malignant effusions), and that the prognosis for patients with malignant effusions is grim.

Population: 19 patients.

Notably, the treatment group C consisting of seven patients (which received no intrathoracic thermic treatment) who were treated during an earlier period (2001 – 2003). Group C had an average age of 64. Essentially a control group.

The remaining patients were treated during 2006 – 2008 and are divided into two groups;

Group A which received hyperthermic (hot) saline infusion with a 30 minute dwell time – consisted of seven patients.  This group was also older (average age 72).

Group B, consisting of five patients who received hyperthermic chemotherapy (cisplatin) infusion into the chest cavity with a 30 minute dwell time.

Note: Infusion in this post refers to instillation of fluid into the chest cavity, not an intravenous treatment.    All patients received post-operative adjuvant chemotherapy.

The grouping of A and B serves to distinguish whether the mechanism of treatment is related to the application of heat alone, or the application of heated chemotherapeutic agents.  Current theories about the effectiveness of HITHOC suggest that the heat of the chemotherapy allows the drugs to penetrate more deeply into the tissues compared to application of chemotherapy alone, but requires studies such as this to support this theory.

Interestingly, the pre-operative staging of these patients differed significantly from intra-operative findings with 8 patients diagnosed with early disease (stage I), five patients with stage II and only six patients as stage IIIA pre-operatively.  (Presence of a pleural effusion denotes stage IV).  Malignant effusions were not seen during pre-operative workup. (It is not uncommon to find more advanced cancer at the time of surgery.)

Surgery: All of the patients underwent a VATS procedure (video-assisted thoracoscopy).  The majority of patients of patients (16) underwent surgery to remove the primary lesion (cytoreductive surgery) with ten patients undergoing lobectomy and six patients undergoing wedge resection.

Intra-operative findings:  16 patients found to have malignant effusions, 10 patients with disseminated disease.

Results: No intra-operative/ post-operative deaths.

Group A (hot saline group): no deaths during follow-up period, with a median follow-up period of almost 20 months.  No recurrence of pleural effusions.

Group B (heated chemotherapy group): 4 deaths in follow-up period; median survival time was 41 months, one patient with recurrent pleural effusion 26 months after treatment.

Group C: (VATs alone): 5 deaths (during follow-up period) median survival 25 months, 4 patients with recurrent pleural effusions (average time to recurrent effusion: 3 months).

While this study is too small (with only five patients receiving intrathoracic chemotherapy) to generalize the results – it should prompt researchers into conducting more studies and trials into the use of hyperthermic intrathoracic chemotherapy in patients with late stage lung cancers.

The decreased incidence of pleural effusion in the treatment groups (A and B) is important also for quality of life issues.  However, these findings are also limited by the small study size.

I have written to Dr. Naito (corresponding author on this article) for further comment and information.


1. Kimura, M., Tojo, T., Naito, H., Nagata, Y., Kawai, N., & Taniquichi, S. (2010). Effects of a simple intraoperative intrathoracic hyperthermotherapy for lung cancer with malignant pleural effusion or dissemination. Interactive Cardiovascular & Thoracic Surgery 2010, April, 10 (4); 568 -71.  (linked to pdf).

Lung cancer patients die awaiting surgery

the health care crisis hits home: prolonged waiting times for patients with lung cancer results in the deaths of several patients in Canada – and this scenario is projected to be repeated in the USA and Europe due to surgeon shortages and limited access to health care.

In disturbing news from Canada, as reported by the Vancouver Sun in April 2011, as part of an ongoing court case, an estimated 250 lung cancer patients died awaiting surgery due to prolonged wait times. In this case, the thoracic surgeon, Dr. Ciaran McNamee had previously complained to hospital administrators at Capital Health in Alberta, Canada about the prolonged waiting times patients were experiencing due to insufficient operating room facilities. For his patient advocacy efforts, Dr. McNamee was fired, and slandered as experiencing ‘mental health issues.’ Dr. NcNamee also alleges that other doctors who complained about the problem were also punished or paid off to keep silent about the problem while their patients suffered.

While in this case, the prolonged wait times were caused by insufficient operating room facilities, in the future the problem may be more directly related to the lack of thoracic surgeons themselves.

May 13, 2011

I admire Dr. McNamee for his convictions and patient advocacy in the face of serious repercussions.  I wrote to him at Brigham Womens & Childrens Hospital in Boston, where he is now a professor of surgery as part of the thoracic surgery program to extend an invitation to submit a guest post.  (He specializes in esophagectomies along with VATS which are two subjects we always like to hear more about here at cirugia de torax.)

October 30, 2011 – the Calgary Herald updated this story among controversy over the original comments by Dr. McNamee and his successor, Dr. Tim Winton.

March 2, 2012 – The Vancouver Sun reports that the Canadian politicians continue to argue over the issue but do very little to address these allegations and the shortage of health care services affecting Alberta residents.