Why it’s time for a paradigm shift in lung cancer treatment

The numbers are stark, and sobering. More than 2 million people around the world were diagnosed with lung cancer in 2018. Each year, this complex disease is responsible for over 1.7 million deaths. It is the leading cause of cancer deaths [1] globally and accounts for more of these than breast, colon and prostate cancer combined. 

More than 80% of lung cancer patients will survive for at least a year if diagnosed at an earliest stage, compared to around 15% for people diagnosed with the most advanced stage of disease [2].

Today, the majority of patients are diagnosed at a late stage, with a minimal chance of surgical cure. 

New hope on the horizon

Lung cancer screening programs are being implemented around the globe, meaning more patients are being diagnosed, and at an earlier stage. In fact, low-dose CT screening for lung cancer has been shown to detect lung cancer when it is most curable, as well as reducing mortality by 20% compared to screening with standard chest x-ray [3]. Based on the promising results of lung cancer screening trials, coupled with increased public awareness, it is expected that the odds will be flipped worldwide and more patients will be diagnosed with small peripheral lesions with a chance of curative treatment.

This comes with its own challenges. Small peripheral nodules are typically more complex to reach and localize during biopsy and surgery. Standard bronchoscopic biopsy – where a bronchoscope is inserted through a patient’s natural airways and used to reach and identify these tiny lesions – provides a diagnostic accuracy of less than 50% for peripheral lesions smaller than 2 cm, thus requiring follow-up visits and the use of alternative biopsy techniques. 

Treatment for these tiny lesions often comes in the form of open thoracic surgery instead of the less invasive video assisted thoracic surgery (VATS). Open surgery is needed to identify small lesions, which are often located deep in the lungs. Once identified, the whole lobe containing the lesion is removed. Recovery from such a procedure can be considerable – up to a year - with the patient likely to need pain relief throughout.

As a result, many patients with small lesions are monitored only for growth, a sign of malignancy. This ‘watch and wait’ approach can cause patients considerable distress as they face repeat visits to officially diagnose, stage and then treat the disease. A patient pathway – the time from initial detection of an abnormality in the lung to the disease being treated and eliminated – of 100 days is typical, a timeframe that is likely to both aggravate the patient’s anxiety and potentially lead to unexpected growth or disease spread. In Denmark, for example, where the Ministry of Health introduced the Cancer Patient Pathways to improve the diagnostic process and have given an assurance that presenting patients would be seen within two weeks, three-year relative survival of lung cancer patients increased from 11% to 20% [4]. A remarkable result by any standard and the type of leap forward we should all strive to achieve.  

Bronchoscopy procedure performed with Philips advanced imaging.

The impact of new image guidance technology on early detection and treatment

But how can we enable high diagnostic accuracy and quick turnaround to minimally invasive treatment for patients with small peripheral lesions? 

The good news is that more accurate and less invasive methods are being introduced and adopted in clinical practice and are expected to start a new era. These days, even barely visible nodules of just 5mm can be detected and treated through new techniques. Advanced imaging integrated into operating rooms and bronchoscopy suites can be combined with navigation bronchoscopy to achieve high precision diagnosis and fulfill the need to combine diagnosis and staging with minimally invasive therapy in one room.

Here, after a bronchoscope is inserted through the patient’s mouth upon intubation and sedation, high-quality real-time cone beam CT imaging and available software enables the interventional pulmonologist to clearly visualize and outline the lesion. The procedure is guided continually by a combination of cone beam CT with augmented fluoroscopy and electromagnetic navigation bronchoscopy to advance the catheter towards the lesion through the bronchoscope. Once done, its position can be confirmed in real time using cone beam CT imaging. A biopsy tool can be inserted through the catheter to take tissue samples or the same catheter can be used to leave a radio-opaque fiducial marker for minimally invasive surgery. On positive rapid on-site pathologic evaluation or frozen section analysis, the patient can undergo VATS during the same session or benefit from new interventional options like percutaneous and endobronchial ablation. For the latter, the procedure is planned using available software and the ablation catheter can be threaded through that bronchoscope to the tumor under real-time augmented fluoroscopy guidance. Once this is done, the lesion is heated and destroyed using microwaves, avoiding the need for open surgery. The very same cone beam CT also allows us to monitor and confirm in real-time that the procedure was a success.

Philips advanced imaging with Augmented Fluoroscopy technique. The image shows biopsy tools being introduced via a bronchoscope through the airways and directed with high-precision towards the blue- highlighted pulmonary nodule.

Intra-operative 3D cone beam CT image is used to confirm correct positioning and coverage of the ablation probe prior to heating and destroying the tumor.

Several centers around the globe are implementing this pioneering approach with the aim to bypass a long journey to treatment and avoid grueling open surgery for a significant number of patients.

The knowledge and the technology are now available to diagnose and treat lung cancer earlier, more accurately and less invasively than ever. It’s now time to move the needle and make a difference. Will you join us in this journey?