State of the Union: Lung and Chest Care Today

In this interview, Joshua R. Sonett, MD, Chief of Thoracic Surgery and Director of The Price Family Center for Comprehensive Chest Care, Lung and Esophageal Center, reflects on major advances in lung and esophageal care, innovations in transplant and diagnostics, and the growing reach of minimally invasive surgery—along with what’s next for Columbia’s thoracic team.

Expanding Access, Expanding Care

Let’s start with a broad reflection: how would you describe the current state of lung and chest care at Columbia?

We continue to grow. As with most places, our robotic offerings and techniques have expanded. We offer everything—open surgery, minimally invasive, and now robotic options—depending on what works best for each patient. All our surgeons use robotic technology, or other minimally invasive techniques, depending on what’s best for the patient.

We’ve also completely expanded our section of interventional pulmonology, which is part of the division of thoracic surgery. They work closely with both pulmonary and thoracic surgery, and we’re about to hire our third interventional pulmonologist.

Wow.

That’ll allow us to do more outreach. We’ll have interventional pulmonology and thoracic surgery, plus a thoracic oncology clinic and ORs in Westchester and New Jersey. That’s important too. It’s integral that we continue to deliver our multidisciplinary care wherever we’re practicing and keep that model in place so one team can see a patient and treat them effectively.

Are they able to stay with the same team across locations?

Correct. We have locations in Westchester, and we actively see people in two different offices in New Jersey. We have, in essence, three different offices: two for primary pulmonary and thoracic surgery care, and then with Atlantic Health, we also do lung transplant evaluations and clinics in New Jersey.

Innovative Tests and Tools

Last time we talked, we spoke about how minimally invasive surgery had become routine for esophageal and lung cancer care. Has there been further advancement?

Yes. We’ve evolved minimally invasive esophageal surgery, called foregut surgery. We’re foregut surgeons too.

All of our foregut hernia surgery is now offered as an outpatient procedure because we’ve gotten so good with minimally invasive techniques, whether robotically or laparoscopically. And for esophageal cancer surgery, which used to be one of the most difficult in terms of morbidity and patient impact, we’ve honed it down. It’s much more routine now. The patient goes home, they’re fine, and they can live completely normal lives.

Minimally invasive techniques have transformed esophageal cancer care to be less traumatic in both the short and long term. Eighty- or ninety-year-olds can come in and have a hernia surgery and, if they wish, go home the same day.

Are there other procedures under the lung and chest umbrella that have followed that trajectory?

Yes. At Columbia, we have the busiest Diaphragm Center in the world. We get diaphragm patients from all over the world because it’s not a well-understood issue. There’s still a need for more education. The diaphragm isn’t always respected as an organ that can be treated. Many patients get written off, whether it's for vent failure or other issues, but the diaphragm can be treated. Surgery has become easier and more minimally invasive, and the pacing technology has also dramatically improved.

We’re also one of the busiest centers for thymic cancer and benign thymic lesions like myasthenia gravis. We offer all those surgeries minimally invasively. What used to require a median sternotomy and major impact on a patient’s life can now be done outpatient or with only 24 hours in the hospital.

Are there any new tools for early detection of lung cancer?

Dr. Stanifer runs our lung screening program, which has blossomed. We’re at multiple locations—Hudson, Lawrence Hospital—and within the next year, we should be onboarding a mobile CT scanner to bring screening directly to patients. Lung cancer screening is underutilized, especially for patients who have smoked, and now we’re trying to define which non-smokers should also get CT screening.

Especially with the rise of cases in women who are non-smokers.

Yes, and men too! But we don’t know exactly what causes it. I would hate to scare people. There are some suspicions, but we can’t say lung cancer is increasing in non-smokers so much as more people aren’t smoking. So, when a patient who hasn’t smoked gets lung cancer, it stands out now, whereas before, most people with lung cancer had smoked.

We’ve also evolved enough to sometimes tell a smoker that their cancer wasn’t from smoking—it’s a genetic type, similar to the cancers we see in non-smokers.

What tools are you using to determine that?

It’s radiologic characteristics and genetic components.

The Future of Lung Cancer Care: Same-Day Diagnosis and Ablation

In our last interview, you mentioned the vision of diagnosing and treating lung cancer on the same day. Are there new techniques helping with that? Ablative techniques?

Yes. We’re leading the country in some of these. For patients who can’t have surgery, we can now use bronchoscope-based ablation—no chest wall access is needed. One technique is called pulse electric field—it may enhance the immune response while killing the tumor. It’s like an auto-vaccine: it kills the tumor and vaccinates the patient at the same time.

We also use radiofrequency ablation through the bronchoscope, which wasn’t possible before. We combine that with cryobiopsy, which enables us to diagnose benign and malignant disease at much higher rates. We have a much better chance of proving something is 100% not cancer, and knowing what it is, rather than just proving cancer.

That's really incredible.

The arc of lung cancer surgery has changed from having a hard chance at cure to now, if we catch it early, it’s basically curative. The biggest risk becomes future cancers, not recurrence.

Any updates on immunotherapy?

We just had to close a personalized vaccine trial due to budget constraints, which was brutal. But personalized vaccines are on their way. Immunotherapy and targeted therapy have dramatically changed how we treat more locally advanced tumors. We can now convert patients from incurable to livable diseases or even cure.

Do those therapies require cancer to be caught earlier to use?

No, they’re actually used for more advanced tumors. Research for very early-stage vaccine therapy is coming, but right now, it’s for more advanced cases.

Every tissue biopsy at Columbia gets worked up molecularly, genetically, and immunologically—no matter how small the tumor. That’s our standard routine here, and it’s not everywhere. It lets us harness all the benefits of immunotherapy and targeted therapy.

As Surgery Evolves, Less Is More

Moving to lung transplant, I know you've been pushing boundaries with ECMO. Anything new to know?

Like everything else, ECMO has evolved. We now use less anticoagulation and smaller catheters, which pushes the boundaries of who we can put on ECMO. It’s also made lung transplant even safer.

We also have tools now to keep lungs in storage longer, so we’re no longer limited by time constraints. We can keep lungs healthy for over 12 hours, which essentially makes the surgery semi-elective.

That’s amazing. Is that through perfusion?

Actually, no. It’s a special cold storage at 10 degrees that keeps the organs metabolically viable. You don’t need to perfuse them to get the same benefits. We’re moving toward never storing anything on ice. Everything goes into special refrigerators or climate-controlled devices that keep the lungs—and even hearts—in optimal condition.

Is ex vivo becoming more routine, impacting the donor pool, or matching?

Bioengineering lungs to make them better or more compliant is still evolving. It’s not quite there yet.

Any progress toward personalized lung transplants?

There is some. Dr. D’Ovidio leads research on personalizing immunosuppression based on patients’ genetics. He studies different types of surfactants in the lungs to see which responds better to which immunotherapies. There’s also the impact of esophageal disease on the lungs—it’s an important nexus. The esophagus and lungs affect each other and can either lead to transplant or damage a new lung if not managed correctly.

How about managing chronic conditions like COPD or pulmonary fibrosis?

For COPD, we’re doing more minimally invasive volume reduction using endobronchial valves. For patients who aren't candidates for bronchoscopic valve placement, we now have surgical techniques to make them candidates. We can recreate their anatomy minimally invasively and then place the valves during the same operation. And if they’re still not candidates, we can offer standard minimally invasive volume reduction surgery.

Any advances in medical therapies?

For emphysema, not dramatically. Some medications have improved, especially for patients with allergic or immune components to their lung disease, but for standard COPD, nothing major.

Let’s pivot to esophageal and paraesophageal surgery. You previously said esophagectomy has become less toxic and more routine. Has that held up?

It’s remarkable. I was reviewing our data for a talk in Chicago. Over the last three years, complications like esophageal leaks, chyle leaks, or delayed hernias have almost disappeared. We've really fine-tuned the procedure. It should no longer be feared—it should only be avoided if not needed or if there are better options, not because it’s too much to go through.

There are basically no age limits anymore because we’re so good at doing this minimally invasive.

That’s life-changing, especially given how these diseases affect people’s ability to eat and live normally.

Exactly. No one should be denied the ability to eat as they get older, whether it's esophageal dysmotility or something like a Zenker’s diverticulum. It's an outpouching in the neck that causes aspiration or prevents eating. We treat that with outpatient surgery and a small incision in the neck. They go back to eating fine.

Is that the same as a paraesophageal hernia?

No, this is in the neck. But paraesophageal hernias—same thing. We’ve done patients well into their 90s. That operation has dramatically changed. It used to be feared like a heart operation. Now it’s basically outpatient.

I think it’s starting to percolate through the community that we’ve gotten so good at fixing it that it shouldn’t be delayed. It’s at least 30% of my practice now. I do two to four a week.

Have there been any changes to the treatment of pectus or other conditions we haven’t covered?

We continue to refine techniques and make them available to more people. For non-malignant surgery—like the Nuss procedure for pectus or surgery for hyperhidrosis—we’re expanding to offer those at multiple sites.

It used to be that late-presenting pectus required open surgery. Now we know we can apply the minimally invasive Nuss technique at any age. The techniques we’ve learned from Nuss have even enabled our cardiac surgeons to operate on people with both heart disease and chest wall abnormalities—doing the heart surgery and then placing the bar afterward.

Looking Ahead

What’s on the horizon that you’re most excited about?

The next generation of truly single-access thoracic surgery. One small hole to do everything. Right now, I am deciding between uniport and multi-port robotic. Robotic uniport isn’t prime time in the U.S. yet, but it will be. Even robotic surgery is getting smaller.

Are there any conditions where cure is possible without surgery?

Esophageal therapy has gotten much better. We’re starting to consider not operating on some esophageal cancer patients. For lung, we’re not there yet, but we’re getting closer. Some patients get a complete response, but it’s not as common as with esophageal cancer.

I have a new favorite question I would like to ask: If you had no budget or bureaucratic restraints, what would you do first?

Honestly, I don’t treat patients based on bureaucratic restraints. But if I could do anything, I’d get our teams closer to where patients live so they don’t have to come to us—we come to them.

Any final thoughts?

Our motto is: there isn’t anything we can’t tackle. Whether patients have been deemed unresectable or untouchable at other places, I don’t think there are barriers for us here. If we can’t offer something, we’ll go out of our way to find someone in the world who can. We’ll see it through.

It's time for our last question—what’s your favorite part of your job?

Talking to patients in the office. Getting to know them long-term. In a matter of seconds, we get the privilege to talk one-on-one in a very personal way. You can’t get that at dinner parties. All the barriers break down. It doesn’t matter what someone’s status is—it’s just two people talking. That’s what I value most: long-term friendships with patients.