Advice Pls! VATS vs. Open Thoracotomy (7cm 77 y.o.)? SoC vs. Clinical Trial?

[hopejunkie]

My 77 y.o. father has been recently diagnosed with stage IIb (T3N0M0) with no visible mets to LN or brain. However, the tumor is large, nearly 7 cm. (We will hopefully receive tumor marker info by Monday but Drs. suspect he's EGFR+ given that he's a non-smoker, Asian and the "look" of the tumor w/CT.) We were initially assessed at UCSF where they strongly recommended neoadjuvant tx (likely Targrisso if he's EGFR+) in hopes of downstaging the Ca and wiping out micro metastases prior to the open thoracotomy. (Proof of concept appear compelling however, this is not standard of care and thus, he'll be part of a clinical trial.) We sought a second opinion at Stanford where they've recommended surgery first (50-75% chance that VATS is possible!) followed by adjuvant therapy. This is standard of care for a resectable tumor and per NCCN Guidelines. We wanted to reach out to this forum for feedback on two questions: (1) What are pros vs. cons and other thoughts about deciding if to follow standard of care or participate in a trial; (2) how important (or not) is the particular type of surgical procedure used - particularly VATS vs. open thoracotomy for this size tumor. Any thoughts/suggestions would be greatly appreciated.🙏❤️

[judg69]

Hi again Hope, I am 70 now , but have miraculously beat the odds and survived 9 years since lobectomy of my upper right lobe. Your questions are identical to what I was faced with , having IIIA/IIIB lung cancer. 1) My decision was standard of care, as I did not want any possible issues or setbacks from a trial. 2) My surgeon stated that open thoracic and VATS both had comparable results, but that occasionally one consideration or another might favor one surgical type over the other. I expressed my desire for open thoracic surgery if there was any debate, and that is what we moved forward with. Again, best wishes to both you and Dad, judg69

[JanetteR57]

I had upper left lobectomy by thoracotomy in Dec 2010 and a 7cm adenocarcinoma removed - at the time EGFR targeted treatments were only available on clinical trial but my tumour tested negative. My specialist lung surgeon told me chemotherapy didn't respond to my rare type of mucinous bronchoalveolar carcinoma (now reclassified by IASLC as invasive mucinous adenocarcinoma). Mine was also T3N0M0. Since that time the tumour size under the UK National optimum lung cancer pathway would have offered me adjuvant chemotherapy to mop up any risk of cells still circulating. However the pandemic changed that option for many as the risk of contracting covid in hospitals by regular chemotherapy visits was more likely than the 5% risk recurrence improvement odds being covered by adjuvant chemotherapy. Recent trial data on targeted therapies and immunotherapy for patients is quite compelling - especially as we now have more patients with stage iv surviving longer as a result of them. however stage 2b (which T3 is) SOC in the UK is still surgery and in the UK VATS has overtaken open surgery but patients consent to open so that in the event of the surgeon having to convert, consent has already been obtained. I was back at work and swimming by the end of March 2011. Access to the tumour is usually what determines the type of surgery used - as some tumours may appear more accessible from imaging but once inside, things might be slightly different. I was simply happy for it to be removed and then any follow on treatment - which in my case was 'active surveillance' to be determined afterwards. However there was really little choice back then especially if not EGFR mutated. Clinical trials are essential for the research/medical community to learn more about what might need improving in clinical pathways and so every patient who takes part is doing the world a favour - but as with any research, there are no guarantees either way. Incidentally VATS has been given to much older patients (80s and 90s) in the UK if they're fit enough for surgery. There are some specific EGFR positive groups in the US and UK so feel certain that they may have more specific information as lung cancer these days is treated in a much more clinically personalised way now the research has revealed so many variations and types of response to treatment. unsure if this helps but good luck to your father whatever he decides.

[hopejunkie in reply to JanetteR57]

Dear Janette: Thank you again for taking the time to share your experience and insight. We will know more by next week re: his EGFR status along with other genomic results which will refine treatment options... Sending you hugs and wishes for continued good health!!❤️🙏

[JanetteR57 in reply to hopejunkie]

Thank you... x

[Feelingblessed2013]

In July 2013 my upper left lobe was removed through vats. I was stage 2b, had 2 very small (under 3 cm) tumors in that lobe. My surgeon told me that they may have to do an open thoracotomy, but would try for vats first. He said vats is less invasive, less post op pain, easier/faster healing. I had the upper right lobe removed through vats surgery April 2018, that time I was stage 1a. I will be 65 in November.Surgery is still considered the "gold standard" of treatment for lung cancer, whenever that option is available.

I sometimes wish I had been offered alternative treatments simply because missing 2 lobes, and having emphysema in the 3 remaining, isn't fun, but it is what it is. I am greatfull that surgery was an option for me, because its been eight years since my first diagnosis, and I'm still here.

My last CT scan was 2 weeks ago, and I'm still ned.

[hopejunkie in reply to Feelingblessed2013]

Dear Katherine: Thank you for your sharing your story - very inspiring. Congratulations on a clean scan!! Sending you well wishes for more clean scans to come and continued good health. ❤️🙏

[Feelingblessed2013 in reply to hopejunkie]

Thanks. Please let me know how your dad is doing, how you are doing? Your father is very lucky to have you.

[hopejunkie in reply to Feelingblessed2013]

Oh... Thanks for asking, Katherine. I'm exhausted, overwhelmed and so terribly scared. I know I need to "take care" of myself but all I can think of is "lung cancer."

[Feelingblessed2013 in reply to hopejunkie]

It's a hard road to travel, but you are stronger than you think you are. I know its not easy but try to remember, you need to take care of yourself, so that you are able to take care of your dad.