Peter Goldstraw, MD, FRCS: The Role of the Thoracic Surgeon in Lung Cancer

Peter Goldstraw, MD, FRCS is the incoming President of the IASLC (International Association for the Study of Lung Cancer). In this interview at the 14th Annual World Conference on Lung Cancer 2011 in Amsterdam, he not only discusses the importance of the thoracic surgeon in the treatment of lung cancer, but also the importance of the IASLC for doctors, nurses and advocates around the world.

The Group Room at the 14th Annual World Conference on Lung Cancer (WCLC) was made possible, in part, by:

 

VIDEO TRANSCRIPT

Selma R. Schimmel, Founder & CEO, Vital Options International:

This is Selma Schimmel for The Group Room at the 14th World Conference on Lung Cancer, WCLC, organized by the IASLC, the International Association for the Study of Lung Cancer; we are in Amsterdam.  Right now we are joined by the President of IASLC, Professor Goldstraw.  How are you?

Peter Goldstraw, MD, FRCS, Current President, IASLC:

I am well, thank you.

Selma R. Schimmel:

I’m so pleased to get to see you again.  And, you are a surgeon, which is a very distinctive position now for a surgeon to head this organization.  You are honorary consultant in thoracic surgery at the Royal Brompton Hospital in London, you’re Emeritus Professor of Thoracic Surgery at the Imperial College in London and now you are the President of IASLC.  How does a surgeon land up at the helm of this organization?

Peter Goldstraw:

Well, we are a multimodality organization.  We put a great deal of focus on that.  We’re also a global organization.  I suppose, to be fair, I came to the attention of our membership who elected me as president through the work we did with the TNM staging project over the last 12 years.  This was a new departure for the IASLC and I think the bodies that do administer the TNM classification worldwide appreciated the work we did in the IASLC and the enormous database we produced so that the staging classification is now more closely tied to prognosis than it’s ever been before.

Selma R. Schimmel:

For the sake of our viewers, can you explain the acronym?

Peter Goldstraw:

The TNM classification was devised by a French surgeon back in the 1940’s.  It basically takes the characteristics of the primary tumor, this is the T-factor, and with advancing local tumor it goes from T1 to T2, to T3, to T4.  It also looks at the extent by which the tumor has spread through the regional lymph glands, and these are the lymph nodes or the N-factor.  And so, if there was no extension to the regional lymph nodes this is N0 (N zero), and then slightly more extent into the higher lymph nodes, it’s N1, N2, and N3.  We then have the M-factor, which is the metastatic spread of a cancer dissemination to distant lymph nodes or to other organs such as the brain, the liver and the bones.  And when we’ve assigned a numerical value to the T, the N, and the M, we can put this together in a group of TNM groups which assigned to a stage.  So your stage is derived from the individual T, N, and M categories.

Selma R. Schimmel:

The staging of lung cancer is very particular.  Explain how staging then corresponds with the selection of therapies.

Peter Goldstraw:

Well, staging is designed to inform the patient and the doctor about the prognosis of the patient.  It tells us how far the tumor has spread.  This doesn’t always equate with early versus late disease, it’s a biological snapshot of where the tumor is when the patient presents.  And obviously, this is one but not the only factor which determines the best treatment to offer a patient.  And so, surgery being a very localized modality, we tend to take the patients with the lower stage disease, certainly stage 1, stage 2.  With the more advanced, stage 4, there would be very little role for surgery.  And when we get into stage 3, that’s where we have a dialogue through our multidisciplinary teams to see if there are patients, unusual patients, in the main who could still benefit from surgery.

Selma R. Schimmel:

One of the fundamental roles now of surgery really deals with the fact that you’re looking at all these different mutations and before a patient can even start treatment it’s typically the surgeon that will obtain a tissue sample for the pathologist to help define if a patient has one of these mutations because that will impact a therapeutic choice.

Peter Goldstraw:

I think surgeons are very well aware of that responsibility, that in obtaining tissue for diagnosis, we now have to try and get as much tissue as possible to do elaborate molecular studies on them.  But at the same time, our pathologists have made great advances in making maximum use of whatever tissue we can get from them.  So the patients can be reassured that our pathologists have developed very good processes, which get the maximum amount of information from the minimum amount of tissue.

Selma R. Schimmel:

Professor Goldstraw, how has the role of the thoracic surgeon changed over your career, from earlier on to where we are today?

Peter Goldstraw:

We are still absolutely central to the care of early stage cancers and it’s still unfortunately true that it’s the patients who have surgical treatment who have by far the best prospects of cure.  I think the surgical focus that we’ve seen at this world conference really answers your question, that this world conference has probably had more surgical content than any world conference I’ve attended in the last 30 years.  And the focus of that surgical content is to try and do 2 things- maximize the benefit we can offer our patients while minimizing, if you like, the price that the patient has to pay for that prospects of cure.  So we’re constantly looking to expand the proportion of patients who can undergo surgery and we do this in multimodality therapy, making some patients operable who might not have been suitable initially.  We’ve also had a very good paper today showing that you can actually increase the proportion of patients having surgical treatment by actually training and employing more thoracic surgeons.  And that may seem to be self-evident but in fact, it’s never been proven before.  And that these surgeons, if they are appropriately trained as specialists… and that is very important because not all surgeons who do these sort of lung cancer operations are specialists, but if you trained specialists to do the job then not only will more patients get surgery, but your overall cure rate will rise.  On the other hand, we want to reduce the extent of the trauma of surgery to our patients. And we’re doing that, I think, by using minimally invasive techniques, key-hole surgery, even robotic techniques.  We’re also reducing the amount of lung tissue we must remove and matching the amount of lung tissue to the true extent of the disease.  Now, there are lots of tests that we use to try and assess that before surgery, but one of the focuses of this meeting has been on ‘how do we more accurately determine the true extent of the disease at the operation and make sure that the amount of lung tissue is the minimum that will give the patient that prospect of cure.’

As you are aware, there’s been a hot topic here on the value of CT screening in detecting early stage lung cancer.  And so, these measures to reduce the amount of surgery, the amount of lung tissue that we resect, is particularly important in the screen detected lesions.

Selma R. Schimmel:

Mr. Goldstraw, as the President of IASLC, what is your vision?

Peter Goldstraw:

At this time, we not only replace our President but we replace our board and we replace our committees, and so it’s a time of renewal for the IASLC.  And, I think the mission that we’ve set ourselves for the next couple of years has several components.  I think it’s vitally important that we increase our membership.  We want more specialists to become members, we want specialists from more countries, more geographical regions to join our society so we can get our message out wider around the world.

Selma R. Schimmel:

In a country like the United States, where the majority of cancer patients are treated in the private sector, how do we encourage and facilitate the involvement of the community based medical oncologists and thoracic surgeons and the other interdisciplinary team affiliated with lung cancer treatment?

Peter Goldstraw:

Well ideally, we want them to become members of the IASLC.  We realize that there is a limit to how many conferences and how many societies people can belong to, and so we’ve developed a lot of web-based educational products, some of them associated with the staging initiative.  So we’ve got an iPad application for our TNM staging classification so that just walking around going into the multidisciplinary clinic, they have all that information right in front of them.  But we also have web-based seminars so that doctors can have CME accreditation in their office at the time that suits them.

Selma R. Schimmel:

I know that you want to make a mention about the role of nurses and advocates within the IASLC.

Peter Goldstraw:

I think we realized that this is a very important area of our membership.  We could have been criticized in the past for focusing, I think, too much on the medical specialists.  We realize however, there’s a lot of marvelous work being done by our advocacy groups not just informing patients, but also in the vital function of fund raising.  And a lot of our fellows are now funded from the money that’s provided by advocacy groups.  Similarly with the nurses, we are absolutely delighted that at this world conference we’ve got more nurses attending than ever previously.  And our nurses are getting organized, they’re getting formed into an international thoracic oncology nurses forum so there’s a global platform to exchange views and to exchange scientific studies.  We really want them to do that within the context of the IASLC and I think they want that too.  It’s a meeting of minds and we will see at the next world conference in 2013 in Sydney that our nursing colleagues will be there in even greater numbers and they’ll have their own scientific track through that conference.

Selma R. Schimmel:

I know this has to be an enormously exciting time in your career, so I want to congratulate you.  And I want to thank you, also, on the behalf of the advocate and patient community for your keen humanistic sense and the desire really to unite and make this whole circle of care sort of seamless and very cohesive; it’s so important.

Peter Goldstraw:

Thank you.

Selma R. Schimmel:

And congratulations to you, Professor Peter Goldstraw, honorary consultant thoracic surgeon at the Royal Brompton Hospital in London, Emeritus Professor of Thoracic Surgery, Imperial College in London, and now, the President of IASLC.  Thank you again.

Peter Goldstraw:

Thank you.

END OF VIDEO