Thoracic surgeons: innovate or perish

There is an old adage: if it ain't broke, why fix it?

If you have been operating the same way with the same results over the last 5 years, then you are guilty of not improving the specialty. Many wonder why we should have a constant need to "innovate" and keep pushing ourselves out of our comfort zones and possibly to the detriment of clinical care? The answer is survival.

If we do not continue to improve, I predict thoracic surgical oncology (the bulk of our work) will become as extinct as surgery for tuberculosis by 2030.

In the treatment of lung cancer, leaps and bounds have been made in targeted treatment and immunotherapy mainly for the treatment of 80% of patients with systemic disease. Surgery is currently a principal modality for 20% with local disease and the minority are offered radiotherapy as first line or as an adjunct to chemotherapy.

Well, that is until the publication of Chang et al [1] now challenging surgery as first line treatment. To the surgical skeptics of this paper, you really have no voice - evidence talks, opinion walks. 

But good grief, have you seen what's on the horizon? Proton beam therapy, MR linac consortium for real time MRI guided radiotherapy in the leading transatlantic cancer centres.

Surgery will lose out, not because it is inferior - in my opinion it will be exceedingly difficult to use energy to get the same degree of local cancer eradication as opposed to placing the cancer in a bucket.

We will lose out to an inferior treatment because the perception of radiation treatment is more acceptable to the patient in relation any reported reduction in efficacy (its ironic that Chang et al reports superiority of radiotherapy). Surgery will lose out mainly because competitors are extremely well-funded multinational corporations improving radiation technology with deeeeeep pockets to market, advertise and conduct clinical trials.

So, if you are still operating like you have done, not improved on length of stay then the perceived acceptability of surgery like you will remain stagnant whilst the competitors race on to claim the rest of the 20% of the market share. 

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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.