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 . 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% . A remarkable result by any standard and the type of leap forward we should all strive to achieve.