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VATS and Surgical Management of Thoracic Malignancies

February 02, 2021
  • 00:00Support for Yale Cancer Answers
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  • 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.
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  • 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.
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  • 13:55mammogram beginning at age 40 or
  • 13:58earlier if they have risk factors
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  • 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.