Surgery for early lung cancer: what you need to know

Lung cancer can be a daunting diagnosis, but the good news is that many who have undergone screening or other early detection programme are diagnosed in these early stages where treatment intent is curative.

What is early stage lung cancer?

Currently, I consider lung cancer to be in an early stage when it is less than 4cm in size and no lymph nodes are involved and no disease outside the chest. In this setting, there are many treatment options available for you including upfront surgery, radiotherapy or ablation. In general, no systemic treatments such as chemotherapy are required.

Regarding radiotherapy as an option, two trials suggested survival with radiotherapy is better in early stage lung cancer, however the studies were small and closed prematurely as they could not recruit enough patients to complete.[1] There are no results to confirm the medium to long term findings, highlighting the difficulties in the interpretation of incomplete clinical trials.[2]

Is surgery the best option?

Whilst there have not been any high quality research comparing surgery with no surgery, the vast majority of patients with early stage lung cancer who are fit and well will choose surgery as the principal treatment option. This is because the cancer can usually be removed with reassurance that it is completely out and detailed information on the cell type and biomarker profile can be conducted with more accuracy compared to radiation where we remain unsure how much cancer remains and where biomarker testing will be done on much smaller size specimens.

Types of surgical procedures

Surgery to remove your lung cancer in the early stage setting can be as simple as removing the cancer itself using a wedge resection (suitable for cancers less than 2cm and no lymph nodes involved) or a segmentectomy, which removes an anatomical section of the lung itself. Larger tumours (more than 3cm) usually require removal of a lobe of lung (lobectomy) to ensure complete removal and reduce the risk of the cancer returning.

Benefits of minimal access surgery

If you decide to have surgery for early stage lung cancer, I conducted VIOLET, a large clinical trial of over 500 participants that revealed less pain, shorter hospital stay, and less complications when the operation was performed using keyhole surgery.[3] The evidence shaped my current approach using one keyhole to perform the entire operation. Moreover, my further studies also show less pain and better mobility in the first year after surgery compared to operations where more than one keyhole was used.[4]

Whilst single incision keyhole surgery is my standard approach, some patients may not be suitable (if there is a safety concern or to ensure complete cancer clearance), in which case I will either add more keyholes or change to an open incision to complete the procedure.

What to expect before and after surgery

Once you have agreed to surgery, we will conduct a series of blood tests, heart trace, a chest-x-ray and review of your medications. This is often undertaken by the preassessment team to screen for any disorders that may need attention before the operation.

On the day of surgery, you will be admitted in the morning, change into hospital gown, and I will meet you to let you know of the likely timing of your operation. In general, we ask that you do not eat anything after midnight the day before your operation, and you will be allowed to drink a glass of water every hour until we send for you.

Most patients will be suitable for day case surgery and allowed home (with or without a drain) as long as your pain is controlled and you feel well and confident. The aches and pains may take 3 months to recover, and we will issue you with painkillers and advise you how to slowly come off with time. Please note that some painkillers can make you very constipated, so you need to ensure you are well hydrated and mobile, and if necessary we can also give you medication to help your bowels (laxatives).

We will see you in clinic usually a week later to review your progress and inform you of the results of the operation, and if all is well, we will discharge you from clinic back to your referring doctor.

What are the outcomes?

In general, complete resection of all cancer (what we can see and what we cannot see) is achieved in 98% of operations[3] and if the lymph nodes are not involved, then no further treatment is required. If the lymph nodes are found to be involved then we will usually recommend additional systemic treatment (chemotherapy) to reduce your risk of death by 20%.[5]

After surgery for early lung cancer, we can expect cancer to return within 5 years in a wide reported range of 8-30%[6-7] and that’s why continuing surveillance is important. This is usually performed by CT scanning every 6 months.

Why choose Professor Eric Lim?

I have extensive experience with single incision keyhole surgery (since 2010) with excellent clinical outcomes, leading on how surgery for lung cancer can be optimally conducted. Much of the advice in global guidelines have been based on my work, that can be tailored to you personally.

Have you or a loved one been diagnosed with early-stage lung cancer? Book a consultation with Professor Eric Lim to explore your surgical options.

References

1. Chang JY et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. The Lancet Oncology. 2015;16:630-637.

2. Treasure T et al. SABR in early operable lung cancer: time for evidence. The Lancet Oncology. 2015;16:597-598.

3. Lim E, et al. Video-Assisted Thoracoscopic or Open Lobectomy in Early-Stage Lung Cancer. NEJM Evid 2022;1(3). DOI: 10.1056/EVIDoa2100016

4. Lim E, et al. Outcomes of single- versus multi-port video-assisted thoracoscopic surgery: Data from a multicenter randomized controlled trial of video-assisted thoracoscopic surgery versus thoracotomy for lung cancer. JTCVS Open, Volume 19, 296 - 308

5. Lim E, et al. Preoperative versus postoperative chemotherapy in patients with resectable non-small cell lung cancer: systematic review and indirect comparison meta-analysis of randomized trials. J Thorac Oncol. 2009 Nov;4(11):1380-8.

6. Saji H, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. The Lancet, Volume 399, Issue 10335, 1607 - 1617

7. Altorki et al. Lobar or Sublobar Resection for Peripheral Stage IA Non–Small-Cell Lung Cancer. N Engl J Med 2023;388:489-498