Reviewed March 2021 to maintain the latest information in treatment and research.
An interview with Joshua R. Sonnet, MD, Chief of General Thoracic Surgery and Director of The Price Family Center for Comprehensive Chest Care, Lung and Esophageal Center.
Thoracic surgery covers such a wide range, what's new in surgical care? What fields have seen breakthroughs?
Think of thoracic surgery as falling into three different buckets: lung, mediastinum [part of thoracic cavity containing the heart, thymus gland, portions of the esophagus and trachea], and the esophagus in general. Also, there’s the chest wall. And basically on every front, we continue to get better at minimally invasive surgery. Applying minimally invasive surgery to basically every stage of lung cancer, be it early or late. We are diagnosing every abnormality and problem earlier, of all three of those modalities, and are able to intervene and cure earlier.
And for those that we are not able to, or have issues with, and we don't find early, we have exciting new therapies based on immune responses or genetics that enable us to treat patients that were previously untreatable. On every front, thoracic surgery is making remarkable and profound progress.
In terms of diagnosing earlier, are there new methods of diagnosing? Are tests more sensitive or is it all about early intervention?
Diagnosing earlier—we're much more reliant on lung screening CT scans. So anybody with a history of smoking anywhere within their lifespan or significant exposure to smoking should get a screening CT scan. And a CT scan almost once a year to keep up with what’s going on. That’s across the board, smokers or somebody that has a personal history of lung cancer themselves, even if they weren't a smoker, it makes them a higher risk.
In addition to that, there is a group of patients who are never smokers, a large group of patients, in particular women who have never smoked yet do develop lung cancer. But CT scan and x-rays are being used for so many other modalities that by serendipity we're finding them early as well.
Within this group of never smokers, specifically the rise in lung cancer in women, are there other factors, perhaps environmental factors that could play a role?
We don't have any absolute proof of environmental factors in the lung cancer we’re seeing in non-smokers. We think that they might've been there, though it's not clear.
Let’s jump to esophageal, is there anything new within those minimally invasive approaches that we should touch on?
For esophageal cancer, there are major advances in minimally invasive approaches, with cancer and non-cancer. For cancer, what was considered novel, minimally invasive esophagectomy, where we do it without any big holes and do it completely minimally invasively is now completely routine. We've probably done over 400 here at Columbia. And, the decrease in morbidity or problems related to the surgery and pain is rather remarkable.
So, it took what still is a very large operation and made it significantly less toxic to the patient. And people feared the surgical component. What was once the question of, ”Should we treat it with surgery or chemo and radiation?” is no longer really relevant. Now, I don't think we have to fear the surgical component because we know patients can do so well, so quickly. And basically, it's opened up the operation for sicker patients and older patients.
Wow. So, there are more people now that have the option for surgery because of this surgical approach?
Correct, and with the comfort that they can do extremely well. And the surgery, the experience and recovery from the esophagectomy procedure does not have to be life-changing—except to cure cancer.
Is there anything specifically that you would want people to know? Maybe those reading this who don't necessarily know how routine this has become?
I want them to know that patients requiring esophagectomy, within weeks of the operation, can be back home eating with their family without a dramatic change in their lifestyle, and they can still do quite well.
Amazing. On the non-cancer side of esophageal care, what should we know?
Paraesophageal hernia or hernias where the stomach is up in the chest, that as well used to be a feared operation. Many people who present with this are in their 80s or 90s and doctors shied away from sending patients for this operation because they thought it was bigger than the problem. But now we can basically do a giant paraesophageal hernia, where the entire stomach is in the chest, as an outpatient surgery 80 to almost 90 percent of the time.
And there is no reason a patient's age should make them suffer from such a condition nor should they put it off for fear that the operation is worse than the disease. It’s remarkably well-tolerated by all ages. And it should be seriously considered for anybody with large paraesophageal hernia or even a small paraesophageal hernia.
Do you see patients with this condition who didn't know that this was an option?
We do frequently get patients whose symptoms become too much that it becomes basically life or death, and they've been told for years not to consider the operation because it's fraught with so many problems. And that may be true at non-specialized centers, but at centers like ours where we're used to handling such a case, it is relatively routine. And that misunderstanding creates the problem of large paraesophageal hernia because we should take care of it sooner rather than later.
Talk to us about lung disease and lung transplant—how have your approaches to treatment changed?
Patients with lung disease are sucked right into a multidisciplinary approach where the first caveat is, what can we do to keep the patient from being transplanted? That's the first and foremost goal. So whatever expertise is needed to keep them from being transplanted, whether it's the treatment of their interstitial lung disease with an ILD specialist or a specialized rheumatologist, or an immunologist, we'll do whatever it takes to keep them from transplant.
If they should need transplant, the ability to transplant them and keep them alive longer continues to improve and has improved dramatically over the last 10 years, with decreased immunosuppression and better treatment of the lungs.
A recent breakthrough in the lab at Columbia made the news this summer, where they were able to take damaged donor lungs that would have been rejected, keep them alive, and cycle blood through them to repair them. How far down the line is that research from practice?
You know, it’s a future probability. It’s not live-action right now, and a bit far down the line. The concept of improving lungs either with blood or other material is probably what's going to happen. Now “we can repair lungs” is on the horizon. And centers like ours that have the capability—which is called ex-vivo lung surgery—are still trying to assess and/or repair lungs on site presently. And the ability to do that should rapidly improve in the next few years.
What would that mean for lung transplant? Would that change the process of getting a donor organ, decreasing or potentially eliminate the shortage?
It'll decrease the shortage. And ultimately, it will allow us to pretreat the lungs so that they're not only better as lungs, but a better fit for those patients. We may ultimately see personalized lung transplant, where the donor lung is personalized to the recipient so that there is either no need for rejection medicine or decreased medicines. That is far in the future, but that is the ultimate goal. When I say far in the future, it's easily within 10 years.
Avoiding those side effects of this lifetime medication would be dramatic. And our progress in bridging patients, the sick patients with lung transplant with ECMO, or artificial lung support, continues to expand. So, we can have patients that are on artificial lungs basically for months, if need be, and keep them alive until they get the lung that fits them.
And I should mention that we continue to push the envelope with patients who are on the artificial lung, where they are awake, walking, and talking. With the goal that in near future, we get them out of the intensive care units, and hopefully further in the future back home.
Wow. So you’re essentially creating time until there's a proper lung for that person? Is the artificial lung being used more and more this way?
Correct. You know, it is happening because of the shortage, and particularly the shortage exacerbated by Covid where there are not as many donors. We routinely are transplanting patients off the artificial lung every month.
How does the Covid pandemic affect transplant in this way?
It’s across all organs. If you think about it, people are staying home and doing less and being seen less by fewer doctors, that's one cohort. There are fewer tragic occurrences like car accidents. And then a lot of organ donation is an interaction of hospitals with the patients and their families when they're sick in the hospital. Because of the restrictions on visiting, I think that is significantly down too.
One of the tragedies of the pandemic that is talked about but still under-appreciated is how many people with other different diseases and problems are not being treated as best as they can. I hate to say neglected but it's just they're overshadowed by what's going on. It’s one of the big unforeseen complications of Covid.
Does that affect lung and chest care even more? Do you find people are more apprehensive to seek care for these conditions?
People in the New York, New Jersey area are pretty good about it right now. They know that in general hospitals are probably safer than supermarkets. We're good at protecting patients during the peak of the pandemic. And we're good right now. For me in fact, when I go to the hospital, I feel it's my safe haven. I feel safer here than when I'm out in public.
Let’s jump to Chronic Obstructive Pulmonary Disease (COPD) and emphysema.
There are some medical improvements in the different medications available for COPD and emphysema. Surgically, we continue to break barriers in the surgical treatment of emphysema with lung volume reduction surgery. Which we know is one of the few interventions that can improve survival and quality of life for emphysema. We're probably one of the world leaders, and we do that two ways.
We do it without surgery—with endobronchial therapy, endobronchial valves that can mimic the surgery without any cutting. And we also have new surgical techniques where we can do surgery on the lungs without ever making an incision on the chest. We go through the top of the belly, so you don't have any rib pain, or anything. And we have found that our patients can get the benefit of lung surgery without having the pain, and with remarkably quicker recovery.
Amazing. What’s new in the treatment of pulmonary fibrosis?
The medical treatment of pulmonary fibrosis continues to be a very exciting field where we now have drugs, at least two new drugs within the past couple of years, that can actively treat it. So now patients have a medical option to keep them from needing transplant.
These medicines can slow down the progression and don't absolutely cure it if it's the classic interstitial lung fibrosis. But if we find it and diagnose it early, it can slow it down long enough. Those patients can live full and long lives with the medicine that's for the most part non-toxic.
Is it fair to say that one of your goals is to keep patients from needing surgery as long as possible across the board? It sounds like that’s a hefty part of the advancement across the field.
Absolutely. If we can cure somebody or take care of somebody without surgery, that's the preference. But if not doing surgery is going to mean not the same cure rate, not doing as well, then we're going to apply surgery or surgery-like treatments where they can get curative treatment. But with little morbidity and mortality.
So for instance, for lung cancer, we used to routinely do what’s called a lobectomy for lung cancer where we take a lobe of a lung. Now, we almost rarely do it. Instead, we do what's called segments or sub-lobe resection. And we've found that we can take out almost any segment of the lung using minimally invasive techniques with the same cure rate while preserving a lot of lung function. It’s been a huge advance.
You know, this is why it’s very important for patients to seek out centers that have what I would call a strong bench. Experts of every field sitting on that bench that are ready to jump in and win the game. And everybody is happy to play their role to help that patient, regardless if it's a big role, an early role, or a late role.
Speaking of roles, what role do genetics play in the treatment of lung disease?
It’s probably not genetics in the way you expect, but personalized medicine. In that, we tissue-type every lung cancer extensively. No matter how big or small the lung cancer is, the genetics are completely worked out so that every possible treatment, whether it's immunotherapy, which we're world leaders in, or personalized medicine with treatments focused on the genetic subtype of the cancer are not only available but routine for every cancer patient here.
We were the beginning and the leading clinical trial for immune treatment of lung cancer. So at Columbia, we have multiple options available for the immune treatment of lung cancer.
Are these immune treatments all part of the same approach of keeping people from needing surgery as long as possible?
Actually, no. To tell you the truth, most immune therapy is not curative in itself, but it will enable somebody that maybe wasn't curative to become curative, enabling us to do surgery where we didn't have that option before.
How about other non-lung thoracic conditions? What should we know?
You know, there’s a big dearth in the lack of understanding in doctors and patients that treatment of the diaphragm is available. And issues with the diaphragm are respiratory failure, albeit non-lung based. We have minimally invasive surgery, or electronic pacing of the diaphragm, that can take somebody that's in respiratory failure and on ventilators from a diaphragm not working despite good lungs and convert them to a patient that doesn't need a ventilator. And we're one of the few centers in the country with a diaphragm center focused on that.
What are you most optimistic about?
I think one of the most exciting things is the continued early detection and treatment of lung cancer. Right now it's by CT scan. In the future, it may be by breathalyzer. And as we get better and better at diagnosing it earlier, we're going to start treating it without surgery at all, by microwave ablation from inside the airway and treatments like that.
With microwave ablation, we're not there yet on a wide-scale basis but we'll steer catheters into parts of the lung where we used to just be able to diagnose the cancer by putting a needle into it. And wherever we diagnose, we can put a little probe that will actually burn the cancer from the inside and cure it.
So, the future is basically doing detection and treatment at the same time?
Exactly. I would hope that in a short amount of time, we'll say five to seven years, we’ll be able to screen, diagnose, and treat on the same day. And that’s the goal—to screen, diagnose, and treat all within the same day.