The Future of Surgery for Stage IV Lung Cancer: Dr. Antonoff Shares Hopes, Insights

Mara B. Antonoff, MD, FACS, of the University of Texas MD Anderson Cancer Center, joined Lung Cancers Today to discuss what could be on the horizon for surgery in stage IV lung cancer during the 61st Annual Meeting of the Society of Thoracic Surgeons (STS) in Los Angeles.

“I’m certainly hopeful that we can do some quality-of-life studies and some investigations looking at patient-reported outcomes,” Dr. Antonoff said.

Dr. Antonoff, who spoke during an STS session titled “Surgery for Stage IV Lung Cancer: Getting Surgeons in the Game for Advanced Disease,” explained why it will be important to assess patient-reported outcomes in this setting.

“Ultimately, our goal is to help patients in the way they define having a better life and a higher quality life, not the way we define it,” she said.

There are also many clinical questions that remain to be addressed when it comes to operating in stage IV lung cancer, Dr. Antonoff said.

“In our clinical practice guidelines, while we talk about the fact that patients with polymetastatic disease should be considered there, there are nuances that we need to sort out,” she said. “Some of us are operating in select patients with pleural disease, but we don’t have much data in that space. That’s something we need to sort out. Some of us have done some pneumonectomies in this space. What is the risk-benefit ratio? I think those are things we need to establish,” she said.

Dr. Antonoff explained that “it is our sense that there is inadequate evidence to suggest anything other than a parenchymal-sparing procedure in this case when patients already have systemic disease—unless it’s safer to do an anatomic resection or it’s only feasible to get the main tumor out with an anatomic resection—then we do aim for parenchymal-sparing procedures if possible. But it’s certainly a space where we need more data in terms of nodal evaluation.”

She also explained that although the prognostic benefit of lymph node removal is recognized, it may not affect overall survival in this population of patients, but larger studies are needed to address questions about nodal disease in these patients.

“We have such great bodies of evidence and literature supporting how we should be operating on patients in stage II and stage III disease; they don’t apply in stage IV disease. The cats are already out of the bag. It’s a different disease systemically,” she said.

For example, the “assumption that patients with stage III disease benefit from a lobectomy over a lesser operation doesn’t necessarily mean that that’s true for stage IV disease,” Dr. Antonoff explained.

It’s important to recognize that surgeries for stage IV lung cancer are “more challenging operations,” she said, but there are multiple patient factors to consider.

“This isn’t our historical lung cancer cohort. These are patients who are often much younger, much healthier, who have really fantastic pulmonary function,” Dr. Antonoff said. “For us to be able to really reassess what risk means in this group of patients is meaningful. The most common complications they have are not the same as what we used to see in our patient population that had different demographics, different social history, and different risk factors.”

This makes it critical to understand the risk-benefit ratio of surgery for these patients, as well as psychosocial considerations.

“These quality-of-life metrics, that’s where I would like to see us get some really high-quality social research done on how we’re impacting patients’ quality of life, both negatively and positively, by offering surgery in these spaces,” Dr. Antonoff said.

Hear more on surgery in stage IV lung cancer from Dr. Antonoff in this companion video.