Dr. Eric Lim challenges thoracic surgeons to remain relevant with a call to action at the 3rd VATS International conference in London, England
“Act different or watch thoracic surgery die”
With that dramatic shot across the bow, the dynamic and forthright Mr. (Dr.) Eric Lim of Royal Brompton Hospital opened the third VATS International conference. In a lecture entitled, “The Why of advancing minimally invasive surgery,” Dr. Lim put out a call to action to thoracic surgeons around the world, in an effort to remain relevant.
In an increasingly competitive world of thoracic oncology, nonsurgical options like stereotactic radiotherapy, and the developing MRI proton beam therapy are gaining traction for the treatment of early stage lung cancers. These nonsurgical treatments are gaining publicity and popularity due to the efforts of radiation oncologists.
The PCI of Lung Cancer Treatment
Reminding thoracic surgeons of the plight of their cardiac counterparts, Dr. Lim taunted the audience that having superior long-term outcomes does not guarantee success in a consumer-driven market. Public and medical perception is shaped not only by clinical research findings, but by the inherent bias introduced by the authors of these publications. As he explained, this bias, along with a public desire for simplicity, has driven the overwhelming success of percutaneous angioplasty (PCI) and declining rates of cardiac surgery despite well-documented research studies and clear evidence demonstrating the overwhelming superiorityof coronary artery bypass grafting (CABG) for long term survival. Thoracic surgeons must not fall into the trap of complacency and arrogant belief in surgical superiority that has plagued cardiac surgery if we want the specialty to survive.
Dr. Lim has identified three behaviors of thoracic surgeons that are harming the specialty:
Refusal to look at the evidence – thoracic surgeons must be willing to continuously review, understand and accept new clinical evidence and publications. Evolving and emerging treatments have changed many of the cornerstones of thoracic surgery, and core concepts of 1980’s thoracic oncology management need to give way to the increasingly body of knowledge favoring VATS resections, neo-adjuvant treatments, and improved outcomes.
An important caveat to this – is the need for Surgeon led research, and clinical trials to help eliminate the medical bias that has crept into much of the existing literature. Surgeons need to stop allowing other specialties to control the narrative. This is what allowed cardiologists to introduce concepts such as “non-inferiority” when research studies failed to show the benefit of cardiology interventions.
These research trials need to compare surgical interventions with non-surgical treatments. Our inter-specialty debates over which surgical technique need to take a backseat to studies designed to compare relevant outcomes like long-term survival and cancer recurrence if we want to demonstrate surgical superiority over medical treatments. “We need to stop arguing about which surgical technique and favor surgery over other therapies,” Dr. Lim explains.
Refusal to engage with industry – industry drives and funds innovation. If we want to continue to develop wireless technologies, robotics and other innovations for use in minimally invasive surgery, thoracic surgeons must be willing to engage and participate with industry.
3. Refusal to evolve – this is a fundamental problem plaguing thoracic surgery and addressing this issue is the underlying theme of many of the presentations at this year’s course. Dr. Lim has also addressed this refusal to evolve previously. Surgeons need to evolve, and be willing and able to change their surgical practices based on evidence and clinical guidelines. The failure to adopt VATS as the primary surgical approach in thoracic surgery in North America, and Europe despite decades of evidence and clear clinical guidelines favoring this approach is a symptom of this failure to evolve.
The future of thoracic surgical oncology
How will thoracic surgery survive? We already know that surgical excision offers the best long-term outcomes for our patients. But as we have seen, having ‘right’ on your side isn’t enough.
Make surgery the most attractive option
For surgery to succeed, thoracic surgeons need to focus on making surgery safer and more acceptable to our patients. Many patients prefer surgical removal on a philosophical level, but this preference is being eroded by promises of “easy” with SABER and newer chemotherapy regimens.
One of the benefits of surgery versus many of the newer treatments is that surgery is a single treatment versus multiple episodes of care. If we can make that single encounter better for our patients, with shorter hospital stays, less pain/ less trauma and less risk, then surgery will remain the first and preferred treatment option for lung cancer.
A visit to St. George’s Hospital in South London to talk about the state of thoracic surgery in Great Britain.
St. George’s Hospital – South London, UK
St. George’s Hospital is one of the largest teaching hospitals in the United Kingdom. In fact, with over 1,000 beds, St. George’s is the largest hospital in London, and one of the largest hospitals in Great Britain. Historically, St. George’s Hospital was the home of several prominent, and important figures in medicine and surgery, including Henry Gray (author of the classic Gray’s Anatomy text, and early anatomist), noted surgeon John Hunter (often called the ‘father of modern surgery’). Edward Jenner, inventor of the smallpox vaccine, also practiced at St. Georges.
The hospital campus itself has an interesting story, after being founded in 1733. Originally located in central London, after several moves and upgrades, it was finally removed to its current location in the working class, ethnically diverse neighborhood of Tooting in South London in 1980. (Hospital services, including the University of London medical school were moved to the Tooting site in multiple stages, starting in 1954.)
All of this makes for a fascinating backdrop for my visit to talk to British surgeons about thoracic surgery in the United Kingdom. The hospital has a dedicated cardiothoracic surgery division, located within the Atkinson Morley Wing (which also houses neurosurgery and cardiology facilities.)
The cardiothoracic surgery division and the subspecialty area of thoracic surgery are well-defined here, with multiple ancillary services such as pulmonary rehabilitation programs and is collectively known as the Chest center. The Chest Center is made up of a multi-disciplinary team which includes two thoracic surgeons, two cardiothoracic surgeons, a pulmonary interventionalist (a pulmonologist specializing in interventions such as bronchoscopy), and a nurse practitioner (known as nurse specialists in the UK). It’s a busy service line, performing over 1100 surgeries per year.
And so, I found myself spending a gray, rainy afternoon discussing the state of thoracic surgery in the United Kingdom with two very fine surgeons from St. George’s Hospital. Like many of the surgeons I have interviewed, they were modest, humble even about the important work that they do for the citizens of Surrey and West Essex counties. As a stranger to socialized medicine and the National Health Service, we started a conversation discussing some of the international headlines discussing thoracic surgery in the UK.
Contrary to recent media reports suggesting a decay in services for British citizens, the surgeons I spoke to (Hunt and Tan) state that thoracic surgery is undergoing a renaissance period over the last few years: the number of dedicated specialty trained thoracic surgeons have actually increased dramatically, and has almost doubled, from around forty surgeons to more than 70. The recent 2011 national audit showed an increase in both percent and total cancer operations and a dramatic decrease in surgical mortality.
This new generation of thoracic surgeons heralds a new, hopeful era for thoracic surgery in Great Britain. These new (and for the most part, younger) surgeons, in turn, embrace newer procedures and technologies for treatment of thoracic diseases. As thoracic surgeons, (versus traditional cardiothoracic surgeons) these doctors have more in-depth knowledge and interest in state-of-the-art therapies for lung cancer and other thoracic conditions. This is particularly important, as here in England, similar to many of the locations I have visited, newer technologies have advanced much quicker than the slower moving bureaucracies such as medical billing and reimbursement. This means that there is often little financial incentive for surgeons to learn, adopt and embrace innovative techniques or even established advancements such as video-assisted thoracoscopy (VATS). The hospitals and the divisions they work for receive greater reimbursement for the larger, more traditional ‘open’ surgeries even if the patients are best served by smaller, minimally invasive procedures.
The thoracic surgeons at St. George’s have managed to circumvent much of this mentality by using existing data from their own program to show the benefits of minimally invasive surgery. Much of this data has been collected as part of the national database called the ‘Blue Book.’ This national audit of surgical practices and outcomes is similar to the Society of Thoracic Surgeons (STS) database, and is entirely voluntary . However, unlike the STS General Thoracic database which is currently poorly attended by American surgeons – the Blue Book is well-populated by British surgeons, with 100% participation .
The most recent data from St. George’s suggests that all of these developments are making a difference. The two thoracic surgeons, Ian Hunt, and Carol Tan are both part of that new generation of innovators, and researchers. They report that they are doing more and more VATS procedures (as part of the 8 – 12 cases they are doing every week). They are doing more and more procedures on older patients – and sicker patients with more advanced cancers – with positive outcomes. The average VATS patient length of stay is 3 days, and even patients undergoing large open traditional cases are going home in five or six days. They have replaced epidurals with PCAs and one time spinal injections to increase patient mobility, and continue to investigate ways to reduce pneumonias and other post-operative complications.
Recent changes within the national health service have sometimes made this more difficult. Patient privacy and new public health policies make investigational trials more cumbersome and time-consuming, but it doesn’t dampen their enthusiasm.
I can’t talk about St. Georges and Thoracic Surgery without further mentioning the surgeons that help make St. George’s Hospital the top #2 or #3 institution in the UK for patient care. As I’ve mentioned, Mr. (Dr.) Ian Hunt, FRCS, MD is a humble sort of gentleman. He is also an enthusiastic, friendly and fascinating interview.
In just 2010 and 2011 alone, he was involved in at least six research papers published on two continents (see below). These papers span the spectrum of thoracic surgery topics – from metastasectomy in colon cancer to cryoablation for chest wall pain, to thoracic trauma and the use of video mediastinoscopy.
I haven’t seen him operate, but he has the qualities that seem universal and essential in the make-up of outstanding modern surgeons . One of these qualities is relentless pursuit of academic and surgical knowledge. This pursuit has led Mr. Hunt across three continents and several countries, as he travelled to Alberta, (Canada), New Zealand and the United States for education and training that was not available in the UK. He has a keen interest in pursuing research and answers for the conditions that plague his patients the most; surgical resections for advanced cancers, mediastinal surgery and chest wall reconstructions, thoracic trauma, mesothelioma and airway disease. He is also interested in research and predictive tools such as the ThoracoScore (used to predict post-operative mortality – similar to the Surgical Apgar .)
His colleague, fellow surgeon, Carol Tan joins us during the interview. She came to St. George’s Hospital several months after Ian Hunt, and together they have been instrumental in creating a ‘atmosphere of change’ at St. Georges. We spend a few minutes talking about epidemiologic patterns of lung diseases. In comparison to other geographic areas, urban London sees more seasonal empyema patterns related to parapneumonic infections, but less chronic diseases such as tuberculosis and opportunistic fungal infections. We discuss how the use of long-term antibiotic therapy regimens has complicated the identification and diagnosis of causative organisms. We also discuss her interests in the treatment of pleural disease and St. George’s surgical programs for myasthenia gravis (in conjunction with spine surgeons) and the benefits of unconventional transcervical approaches instead of median sternotomy. Both Mr. Hunt and Ms. Tan also talk about the increasing use of ‘co-surgeons’ in the operating room, the advantages of this practice and how this is changing surgery.
Together, we discuss the Davies article and how this skewed view of the roles of pulmonary medicine and thoracic surgery mirrors many of the conflicts in cardiology and cardiac surgery . We also discuss how referral patterns and timing of referrals also affects surgical outcomes and the co-dependency among specialists.
Before the end of the interview, we also talk about another faucet of thoracic surgery (that is near and dear to my heart): the use and role of nurse practitioners in thoracic surgery. Unfortunately, Caroline, the nurse specialist in thoracic surgery at St. George’s is unable to join us today. But maybe another day.
 “Please make the article about thoracic surgery, and what we do, not about us,” Mr. Hunt requests. In response, I have done so, but will give brief mention of both Mr. (Dr.) Ian Hunt and Ms. (Dr.) Carol Tan at the conclusion of this article, to give readers a better idea of the speakers qualifications and background.
 This refers to surgeons specifically focusing on thoracic surgery, as opposed to traditional cardiothoracic surgeons who are dual specialized, or general surgeons (who have omitted specialty training) but may perform thoracic procedures.
 This seems to be a fairly common situation in medicine, around the world. Influence of conversion on cost of video-assisted thoracoscopic lobectomy, Eur J Cardiothorac Surg. 2010 Jan;37(1):249-50; author reply 250-1. Epub 2009 Dec 5.
 Learning these techniques often comes at considerable expense, and inconvenience for many of these surgeons – who may have to travel to North America, Hong Kong or other large centers specializing in minimally invasive surgery for fellowships or periods of extended training.
 While entirely voluntary, there is a stigma attached to surgeons who do not participate under the assumption as to the reasons why they do not want their hospital, thoracic surgery program and individual surgeon data disclosed to the public.
 The British Blue Book is not specific to thoracic surgery only. Several other specialties such as orthopaedics contribute to this database. However, the cardiothoracic specialty is overseen by the Society of Cardiothoracic Surgery.
. The qualities of outstanding modern and historical surgeons differ greatly. One of the most important qualities in surgeons past was fearlessness. These surgeons often endured failure after failure (patient deaths) before developing effective surgical techniques. As you can imagine, this quality of fearlessness would now be seen as recklessness – and would not be a desirable trait in modern surgeons for many reasons.
 As we discussed previously, Davies work ignores much of the existing research that demonstrates conflicting results to their opinions – including their own research which failed to confirm their propositions.
 The Surgical Apgar scoring system by Gwande predicts post-operative mortality and complications by measuring 4 intra-operative factors.
Ms. Carole Tan, MD, FRCS(C) is a board-certified thoracic surgeon. She joined the Chest Center at St. George’s Hospital in 2010. She is currently the principal investigator for PulMiCC (pulmonary metastasectomy for colorectal carcinoma.)
Ms. Tan’s clinical interests include the treatment of pleural disease, specifically malignant mesothelioma, which we have talked about on previous occasions at Cirugia de Torax. In fact, she has been widely published in this area (see bibliography below.) Prior to coming to St. George’s Hospital, Ms. Tan was the surgical coordinator for the multicenter MARS trial (on the surgical treatment of malignant mesothelioma).
Zakkar M, Tan C, Hunt I. Is video mediastinoscopy a safer and more effective procedure than conventional mediastinoscopy? Interact Cardiovasc Thorac Surgery.
Tan C, Treasure T, Utley M. Reply to D’Andrilli and Rendina. Eur J Cardiothorac Surgery.
Bliss JM, Coombes G, Darlison L, Edwards J, Entwistle J, Kilburn LS, Landau D, Lang-Lazdunski L, O’Brien M, O’Byrne K, Peto J, Senan S, Snee M, Spicer J, Tan C, Thomas G, Treasure T, Waller D. The MARS feasibility trial: conclusions not supported by data – Authors’ reply. Lancet Oncol 2011;12(12):1094-5.
Tan C, Barrington S, Rankin S, Landau D, Pilling J, Spicer J, Cane P, Lang-Lazdunski L. Role of integrated 18-FDG-PET-CT in patients surveillance after multimodality therapy of malignant pleural mesothelioma. J Thorac Oncol 2010;5(3):385-8. Treasure T, Waller D,
Tan C, Entwisle J, O’Brien M, O’Byrne K, Thomas G, Snee M, Spicer J, Landau D, Lang-Lazdunski L, Bliss J, Peckitt C, Rogers S, Marriage Nee Denholm E, Coombes G, Webster-Smith M, Peto J. The Mesothelioma and Radical Surgery randomised controlled trial: The MARS feasibility study. J Thorac Oncol 2009;4(10):1254-8.
Tan C, Gleeson F, Treasure T. Malignant pleural mesothelioma.In: Hunt I, Muers MM, Treasure T, eds. ABC of Lung Cancer, pp 25-8. WileyBlackwell, April 2009.
Utley M, Gallivan S, Jit M, Paschalides C, Tan C, Treasure T. Can patients progress modeling inform the management of cancer patients? In: Brailsford S, Harper P, eds. Operational Research for Health Policy: Making better decisions. Proceedings of 31st Annual Conference of the European Working Group on Operational Research Applied to Health Services, pp 243-252. Oxford, UK, Peter Lang, 2008.
Tan C, Treasure T. UK surgical trials in mesothelioma. Lung Cancer in Practice 2007;3(2):8-9.
Pai V, Gangoli S, Tan C, Rankin S, Utley M, Cameron R, Lang-Lazdunski L, Treasure T. How best to manage the space after pneumonectomy? Theory and experience but no evidence. Heart Lung Circ 2007;16(2):103-6.
Davies A, Tan C, Paschalides C Barrington SF, O’Doherty M, Utley M, Treasure T. FDG-PET maximum standardized uptake value is associated with variation in survival: Analysis of 498 lung cancer patients. Lung Cancer 2007;55:75-8.
Faith A, Peek E, McDonald J, Urry Z, Richards DF, Tan C, Santis G, Hawrylowicz C. Plasmacytoid dendritic cells from human lung cancer draining lymph nodes induce Tc1 Responses. Am J Respir Cell Mol Biol 2007;36:360-7