VATS and Surgical Management of Thoracic Malignancies

February 02, 2021

Information

January 31, 2020

Yale Cancer Center

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00:00Support for Yale Cancer Answers
00:02comes from AstraZeneca, dedicated
00:05to advancing options and providing
00:07hope for people living with cancer.
00:10More information at astrazeneca-us.com.
00:14Welcome to Yale Cancer Answers with
00:16your host doctor Anees Chagpar.
00:18Yale Cancer Answers features the
00:20latest information on cancer care by
00:22welcoming oncologists and specialists
00:24who are on the forefront of the
00:26battle to fight cancer. This week,
00:28it's a conversation about the
00:30surgical management of thoracic
00:32malignancies with Doctor Andrew Dhanasopon
00:33Doctor Dhanasopon is an
00:35assistant professor of thoracic
00:37surgery at the Yale School of Medicine,
00:39where Doctor Chagpar is a
00:42professor of surgical oncology.
00:44Andrew, maybe we can start
00:47off by you telling us a little
00:50bit more about what it is that you do.
00:54Thoracic surgeons operate on the chest
00:56most commonly cancers within the chest,
00:59but we take care of patients
01:01with both malignant and benign
01:03conditions within the chest.
01:05The majority of our patients
01:07tend to be lung cancer patients,
01:10and so that tends to be the
01:13majority of our practice.
01:15Lung cancer seems to be
01:19pretty prevalent. Is that still the case?
01:22Yes, this is still the
01:26case due to smoking history.
01:30And it is the number one cause of
01:33death by cancer in the United States.
01:37And it is the second most common
01:40highest incidence of cancer for both
01:43men and women.
01:46And when you think about that,
01:48often on this show,
01:50we talk about all kinds of different
01:54modalities that people use to treat cancer,
01:57whether it's surgery or whether it's
01:59chemotherapy or whether it's radiation.
02:02How many patients actually, or
02:05what proportion of lung cancer
02:07patients actually are treated with
02:10surgery? Is that the majority,
02:13or is that a pretty low number
02:16compared to the total number of
02:19patients who are diagnosed each year?
02:23The number of patients who are
02:26eligible for surgery is not the
02:29majority of patients, however, as
02:32we detect more and more lung cancer
02:35through lung cancer screening,
02:37more patients are identified earlier
02:39in the disease process and thus are
02:43eligible for surgery as a treatment.
02:45As a surgeon, I guess
02:49I am a little bit biased,
02:51but I often think that when
02:54patients are eligible for surgery,
02:57it's often a good thing because
03:00we're often treating people for
03:02curative intent. Is that right?
03:05Yes, and that's the same
03:07for lung cancer as well.
03:09Surgery for lung cancer typically is
03:12most helpful for patients who are in
03:15their early stage of lung cancer.
03:18And so historically talk a little bit
03:22about how lung cancer was managed
03:26surgically.
03:27Sure, lung cancer had been managed
03:30with what's called a thoracotomy.
03:33And a thoracotomy is a large
03:36incision on the side of the chest,
03:40usually about 6 inches or so long and
03:45through that skin incision the access is
03:49in between the ribs and those
03:51are spread open in order to
03:54access the lung and the lung
03:56cancer to remove the tumor.
04:00And so tell us more. I mean,
04:02it sounds like that's a pretty big operation.
04:05You're in the hospital
04:07and somebody is making this large cut
04:08in your chest and spreading ribs
04:10and taking out part of your lung.
04:13What does that feel like or look
04:15like from a patient perspective?
04:17How long are you in hospital?
04:18Does that mean that you're
04:20on a breathing tube?
04:21Does that mean that you're in ICU?
04:24Give us more of a sense of
04:27what that looks like.
04:30Sure, so overtime up till modern day when
04:35patients require thoracotomy incision
04:38for their lung cancer the hospital stay
04:43is usually between three to five days.
04:48And patients are usually in a step
04:51down unit for monitoring their vital
04:54signs and the majority of the hospital
04:57stay is making sure their pain is
05:01well controlled so that they can
05:03deep breathe well and cough well
05:06and recover after such a big operation.
05:11But I understand that now,
05:14just like many surgeries we think
05:18about gallbladder surgery that used
05:20to be done with a big cut as well.
05:23Where now it can be done with
05:263 little holes and some cameras.
05:30What many people in the lay
05:33public call little telescopes
05:34where the gallbladder can be
05:37removed through tiny incisions,
05:39has lung cancer surgery
05:41progressed to that point?
05:43Yes, absolutely,
05:45so that's minimally invasive lung
05:48surgery starting in about the 90s,
05:51there was the progress in terms of
05:55minimally invasive instrumentation.
05:56Just as you had mentioned
06:00for Gallbladder surgery,
06:01these laparoscopic instruments
06:03were modified for the chest,
06:06and so what that looks like
06:09today is usually a camera
06:13and it's usually about a 5 millimeter
06:17or less than half an inch in diameter
06:21that gets projected onto
06:24a typical HD screen in the OR
06:28through one incision and there
06:31are three other small incisions,
06:33again, usually quite small,
06:36about a centimeter and through these
06:39total of four incisions we use that
06:43technique to remove lung cancer,
06:45where previously we had done a thoracotomy.
06:51So it sounds like that would
06:53potentially be much easier
06:54on patients, much less pain.
06:56So what does that picture look like?
06:59I mean, do patients go home sooner?
07:04It doesn't sound like you'd need to
07:07spread ribs and those kinds of things,
07:11so pain is a contrasting picture to
07:14what that looks like as
07:16opposed to a thoracotomy.
07:18Sure, so when patients undergo
07:20this type of surgery called VATS
07:23or video assisted thoracoscopic surgery
07:27because of the smaller incisions,
07:30patients do have less pain.
07:33They do recover in the hospital
07:36and at home much more easily,
07:39and their quality of life and a
07:42return to work is sooner as well
07:46and from a variety of studies
07:49that have been done overtime
07:52this has shown to be the case compared
07:55to open thoracotomy cases and
07:58so, whereas thoracotomy patients
08:00spend about three to four days
08:04in hospital, in a step down,
08:07what happens to patients who are
08:10treated with vats usually does
08:13result in a reduction of the
08:16hospital stay from one to two days,
08:20depending on various other factors.
08:22But the reduction in the hospital
08:25stay is usually from reduction in pain.
08:34If we take a step back and we think
08:37about it from the health care system,
08:40Is 1 procedure cheaper than the other?
08:43I mean, I can see that you know
08:47thoracotomies likely have increased
08:49costs due to increased length of stay,
08:52but on the other hand there's
08:55capital equipment and technology
08:57that adds up to cost as well.
09:00Have people looked at
09:02differences between vats and
09:04thoracotomy in terms of cost?
09:06Yes, there have been several
09:09studies and the general
09:11conclusion from these is that because of
09:15reduced hospital stay,
09:19the minimally invasive approach,
09:23is less costly.
09:26But as you were saying,
09:28the hospital of course has to
09:31invest in the capital upfront,
09:33and this is also similar
09:37to another minimally invasive
09:39instrument, the robotic approach.
09:41Again, there is investment upfront on
09:44the hospital and the health system,
09:48but overtime there is reduced cost.
09:52For patients, when patients
09:54are looking at paying out of
09:58pocket for these procedures,
10:01or if they have a particular percentage
10:04that they have to pay in terms of
10:07copays and those kinds of things,
10:09is there a difference in terms
10:11of patient cost as well?
10:14I actually do not have a good idea on
10:18the cost from the patient standpoint.
10:22I do believe that as the healthcare
10:25system has savings on this that it
10:28would get passed on to the patient,
10:32but I I don't know.
10:34Yeah one would
10:36certainly imagine so and
10:39VATS procedures now have become
10:41fairly widely accepted, right?
10:44So most insurances should cover
10:46VATS procedures just as
10:48they would thoracotomies?
10:50Yes, absolutely.
10:52All insurance companies do cover
10:55VATS the minimally invasive
10:56approach compared to thoracotomy.
10:58So are there any reasons why
11:01a particular patient may not opt for a
11:04vats procedure versus a thoracotomy,
11:07are there patients that you would
11:09kind of lean more towards doing
11:12things as we would say old school.
11:16As you can imagine for the
11:20minimally invasive approach that
11:23requires instrumentation that is
11:25small in order to fit through
11:29these small incisions that we use,
11:33and so vats is used for
11:38relatively straightforward lung
11:40cancer operations. For operations
11:42that are more complicated,
11:45for example, larger tumor or if the
11:49patient has received chemotherapy
11:51and or radiation where there is more
11:56scarring due to those treatments
11:59that does make it more difficult
12:03to use the vats instruments.
12:08It's not totally unreasonable,
12:08but it is certainly easier on the
12:12surgeon to do the operation through
12:15a thoracotomy for those scenarios.
12:18And does it
12:19take special kind of training to
12:22be able to do vats procedures,
12:25or are most lung cancer
12:28surgeons pretty adept at both?
12:32In today's thoracic surgery
12:34practices, almost all,
12:35at least in the United States,
12:38almost all thoracic surgeons
12:40have been trained in vats.
12:42In addition to the traditional
12:44thoracotomy approach,
12:45and so most hospitals
12:47then have this technology
12:49that patients would be able
12:51to avail themselves of.
12:53It's not like you have to go to,
12:57you know some place special
12:59to get that. Is that right?
13:02Exactly most hospitals would have this.
13:05The instrumentation for minimally
13:07invasive vats, yes.
13:10We are going to take a very short break
13:13for a medical minute.
13:15Please stay tuned to learn more
13:18about surgical management of thoracic
13:20malignancies.
13:23Support for Yale Cancer Answers comes from AstraZeneca, working
13:26to eliminate cancer as a cause of death.
13:29Learn more at astrazeneca-us.com.
13:32This is a medical minute about breast cancer,
13:35the most common cancer in
13:37women. In Connecticut alone,
13:39approximately 3000 women will be
13:41diagnosed with breast cancer this year,
13:44but thanks to earlier detection,
13:46noninvasive treatments,
13:46and novel therapies,
13:48there are more options for patients to
13:51fight breast cancer than ever before.
13:53Women should schedule a baseline
13:55mammogram beginning at age 40 or
13:58earlier if they have risk factors
14:00associated with breast cancer.
14:02Digital breast tomosynthesis or
14:043D mammography is transforming
14:05breast screening by significantly
14:07reducing unnecessary procedures while
14:09picking up more cancers and eliminating
14:13some of the fear and anxiety
14:15many women experience.
14:16More information is available
14:18at yalecancercenter.org.
14:19You're listening to Connecticut Public Radio.
14:23Welcome
14:23back to Yale Cancer Answers.
14:26We are discussing the surgical
14:28management of thoracic malignancies,
14:30so Andrew right before the break
14:32we were talking a lot about how
14:35historically lung cancer had been
14:37taken out with thoracotomies,
14:40which are large cuts people needed
14:43to stay in hospital several days in
14:46a in a step down unit and how really
14:49things have evolved towards vats or
14:53video assisted thoracic surgery
14:55where you can use kind of small incisions,
14:59a little camera that can go in and
15:04remove these, ultimately reducing pain,
15:06reducing length of stay and you had
15:09mentioned before the break that
15:12there's yet another technology
15:14in terms of robotic surgery.
15:16Tell us more about that?
15:17The Intuitive company
15:23produced a robotic technology in the 2000s,
15:27and that's what is commonly
15:29known today as the Davinci robot,
15:33so that is another minimally invasive
15:36tool that thoracic surgeons can use
15:40to surgically treat lung cancer.
15:44Tell us more about
15:47this because the whole concept of
15:50you know robots doing your surgery
15:52for some might seem really high tech
15:56and really innovative and for others,
15:59might seem really kind of frightening
16:02because you kind of like the idea
16:05of a human actually being there
16:07to manage your cancer.
16:10So how exactly does this robot
16:13or robotic surgery work?
16:15Is it really like there's
16:18a small little robot
16:20that goes in there and does your surgery
16:24during robotic lung cancer cases?
16:27We have the robot arms at the
16:30patients table and a few feet away
16:34the surgeon sits at a console
16:37where they view the images from
16:40the robotic camera and they use
16:44an instrumentation to remove the
16:47robotic arms that way so the surgeon
16:50is certainly in the room next to
16:53the patient with the robotic arms
16:56at the patient doing the
16:59actual work inside the chest. So
17:02the important key is that the surgeon
17:06is really the brain operating
17:09the robot and the robot's arms.
17:12These robots are not
17:14operating independently of
17:16a surgeon who is there, is
17:19that right?
17:21Absolutely, the robot is not autonomous.
17:24The robot in each and every movement is
17:28directed by the surgeon.
17:30So why is this any different
17:34then where
17:37you're still working with instruments.
17:40Looking at an image on
17:43a screen, both are certainly
17:46minimally invasive
17:47approaches with the robotic technology.
17:52Formed through four small incisions,
17:55each are between 8 to 12 millimeters in size
18:00and there there is an additional incision.
18:05A small incision that's made for
18:08the assistant at the bedside to
18:12assist during the operation as well.
18:15So both certainly do result in less pain
18:19in the postoperative period then and
18:24open thoracotomy,
18:25the main advantages for the
18:28robotic approach is number 1,
18:30the improved visualization because of
18:33the robotic camera and the technology
18:37that went into developing that
18:40it does give you a 3 dimensional
18:44view of the surgical field.
18:46Sort of like you were actually
18:49inside the chest looking at
18:52these structures and doing
18:55the surgery that way.
18:57In addition to that,
18:58it's certainly more ergonomic as well,
19:01and if it's easier on the surgeon,
19:04that certainly helps the operation
19:06go well and for the patients that
19:09have a better outcome.
19:13So you know I can appreciate that
19:17the camera is a little bit better.
19:21The arms are a little bit better
19:24in terms of their ergonomics and
19:27potentially the degree to which they are
19:31flexible in moving in various directions,
19:34which can make the operation
19:37easier to perform.
19:39But there must be added cost
19:42to this whole system
19:45over VATS which as you mentioned,
19:48is pretty universally available.
19:51Certainly
19:51the robotic system has a greater capital
19:55costs for the hospital for the health system.
20:01And in addition to the actual tools,
20:04the actual robot and the consoles there
20:07does need additional training
20:10on the side of the staff as well.
20:14For example, a person at the bedside
20:18being another surgeon or resident
20:20physician assistant to assist
20:22and in addition to that person
20:25of course, the nursing staff
20:28in the room to help set up the
20:32robotic instrumentation for the
20:35operation and not to mention in scenarios
20:38where an acute issue needs to be dealt with,
20:43the whole team needs to be aware of
20:46how to maneuver things so that they
20:50could be dealt with without the robot,
20:54and so there are
20:59many things that are required for
21:04a surgeon to perform robotic thoracic
21:09surgery as part of their practice.
21:13One of the ideas behind the
21:19technology is also to allow surgeons
21:24who have perhaps not trained in vats
21:29to be able to perform a minimally
21:33invasive approach a lot easier.
21:38As both the vats approach and the
21:41robotic approach do have learning
21:44curves associated with them,
21:47the learning curve from open thoracotomy
21:50to robotic approach is an easier
21:53minimally invasive approach to learn.
21:57And so from the patient's standpoint,
22:00if you compare vats to robotic surgery,
22:04is there any difference in terms of
22:07length of stay or pain, or return to work?
22:13There have been and continue
22:16to be studies looking at this.
22:19And other factors as well.
22:22For example, the length of state there is
22:26a trend towards decrease length of stay.
22:31There is a trend towards decrease pain,
22:35but so far nothing that is
22:39statistically significant.
22:41The other factor to consider
22:44is from a cancer operation.
22:46If any of these minimally invasive
22:50approaches are similar or different
22:53than the traditional approach in
22:56terms of cancer survival and so far
23:00both events in the robotic approach
23:02do not have a difference between them
23:06or with the traditional
23:10approach in terms of cancer survivorship.
23:14And is robotic surgery covered by all
23:17insurance the way vats is and would
23:21be the cost to the patient and or
23:24to the hospital system be the same.
23:28Most insurance companies do recognize
23:30robotic surgery and it is covered.
23:34I don't know the specifics of how
23:37the comparison between a robotic
23:40approach versus a vats approach
23:43in terms of the final cost to the
23:47patient.
23:50So how do you make the decision between whether
23:52to offer patients a VATS procedure
23:55versus a robotic procedure?
23:59I think the main thing is from the surgeon
24:04experience and training standpoint.
24:08I think when patients are seeing a thoracic
24:13surgeon and discussing surgical options
24:18mostly, a surgeon has trained and is
24:21comfortable with the vats approach and then
24:25I think that is appropriate of course.
24:28And if they are more comfortable
24:30and have trained in the robotic
24:33approach then that is fine as well.
24:36I think the main thing for
24:39patients to be aware of is that the
24:43thoracic surgeon have some experience
24:45in a minimally invasive approach,
24:48whether it's vats or robotic.
24:50So that their length of stay is less,
24:55their pain is less.
24:57Their return to work is sooner,
25:00and there are also less complications
25:03after surgery compared to the
25:06traditional open approach as well.
25:11Do all hospitals have robotic
25:13surgery or when we
25:16were talking about VATS you had kind of
25:19mentioned that this is pretty ubiquitous.
25:22Most people have trained in vats and
25:25so it would be something that would be
25:28very amenable no matter where you were.
25:32It doesn't sound like that's necessarily
25:34the case for robotic surgery.
25:37Is that right?
25:39Not all hospital systems have the Davinci
25:42technology this is something
25:45that is becoming more common and
25:48my understanding from a financial
25:51standpoint is that the company
25:54does work with the hospital in the
25:58health system to come up with a
26:01suitable plan so that they can offer
26:05the robotic technology to their
26:09patients and to save on the cost.
26:13And that cost savings,
26:16hopefully does get passed
26:18on to the patient as
26:20well, and you had
26:23talked about kind of deciding between
26:26vats versus robotic surgery you
26:29really mentioned that it had to do
26:32primarily with the surgeons comfort.
26:34If surgeons are comfortable with both
26:37techniques and have been trained in both,
26:40are there particular patient
26:42characteristics that would lean
26:44you more one way or another?
26:47Yeah, for the robotic approach
26:52the instruments tend to be longer
26:55and sturdier than the vats
26:58instruments and so for patients
27:01for example, who might be morbidly
27:04obese
27:08it would be easier for the surgeon to do
27:13the surgery robotically versus by vats.
27:18And there are other scenarios
27:21from a tumor standpoint as well.
27:25With the robotic approach,
27:28the ability to do very fine
27:32detailed dissection and surgery
27:35is enhanced compared to the vats
27:39approach due to the improved camera,
27:44improved ergonomics and the ability
27:48for the robotic instrumentation to
27:50have greater degrees of freedom
27:53with the instrumentation,
27:55so for those types of tumors as well,
27:59those are
28:01better performed with robotic versus vats.
28:06Doctor Andrew Dhanasopon is an
28:08assistant professor of thoracic
28:10surgery at the Yale School of Medicine.
28:12If you have questions,
28:13the address is canceranswers@yale.edu
28:15and past editions of the program
28:17are available in audio and written
28:19form at yalecancercenter.org.
28:20We hope you'll join us next week to
28:23learn more about the fight against
28:25cancer here on Connecticut Public Radio.