State of the Union: Lung and Chest Care Today

An interview with Joshua R. Sonett, MD, Chief of Thoracic Surgery and Director of The Price Family Center for Comprehensive Chest Care, Lung and Esophageal Center.

Thoracic surgery has changed dramatically in the past decade. Operations that once meant large incisions and long hospital stays are now often done minimally invasively, with many patients going home the next day or even the same day. At the same time, advances in molecular medicine, robotics, and truly multidisciplinary care are reshaping how doctors diagnose and treat conditions ranging from lung cancer to complex diaphragm disorders.

We spoke with Dr. Sonett about what’s changed, what’s coming next, and why conditions like lung and esophageal cancer should not be feared the way they once were.

Smaller Incisions, Quicker Recovery

How have surgical recovery times evolved in thoracic surgery over the past few years?

I think all the procedures that were already minimally invasive are becoming even less invasive, with shorter hospital stays. Virtually 70-90 percent of patients coming in for major lung cancer resections leave the next day.

For some patients it’s even possible to leave the same day. Most of the people who want to stay longer are doing it because they don’t want to deal with driving home or things like that.

What’s allowing for that advancement—tools? Technique?

It’s better anesthesia, better tools, fast tracking, and understanding everything, including patient expectations.

Procedures like lung cancer resections or thymectomies used to routinely require one or two days in the hospital. Now, most of the thymectomies we perform, for myasthenia gravis [a chronic condition where weakened muscles can affect breathing] or other conditions, I offer patients the option to go home the same day. It’s rare that I don’t, and they don’t.

Precision Medicine and Lung Cancer

Looking at the way a true multidisciplinary approach now often includes genetics, how is molecular profiling influencing the way you treat lung cancer today?

Every tumor we treat undergoes genotyping.

That information can sometimes be assessed directly from the tumor or sometimes directly from the blood. We’re now in the era where we’re starting to offer patients with early-stage disease options based on the genetic makeup of the tumor.

It allows us to tailor treatment to the specifics of the tumor and the specifics of the patient.

Wow. What are early-stage options?

It’s similar to the way breast cancer is treated now, where women tend to take a medicine for years afterward to decrease the chances of recurrence. The same thing is beginning to evolve in lung, depending on the genetic makeup of the tumor.

Two patients may have tumors that are the same size and appear very similar clinically, but the genetic makeup of those tumors may make how we approach them completely different. One patient may go straight to surgery, and another might receive molecularly targeted therapy first. Another might receive therapy afterward.

It’s very specific to each patient scenario and it’s just now widely becoming acceptable and sort of proven.

Also, we’re one of the few centers that offer direct ablation of tumors with microwaves or cryo, and we can basically diagnose almost anything with a robotic bronchoscopy.

Will you expand on the role that robotic bronchoscopy is playing in earlier diagnosis and treatment?

Our interventional pulmonologists are part of the surgical team, and we’re proud to be one of the busiest robotic bronchoscopy centers in the country.

As I mentioned, we can diagnose almost anything using robotic bronchoscopy, and with direct ablation of tumors through the bronchoscope, for the right patients, we have the ability to diagnose and treat at the same time.

And to be fair, the “at the same time” approach can be complicated. I actually did one yesterday, diagnosing and treating a tumor in the same setting. It sounds simple, but it has a lot of moving parts, so really it’s only for the right patients.

The key is that we, as a team, discuss every aspect of treatment for each patient we see and can make those determinations together.

How does understanding the genetics of a tumor change the decisions you make in real time?

Understanding the genetic makeup and the immunologic makeup of a tumor helps us decide whether to treat patients with therapy before surgery to make the operation easier, smaller, and safer. It also helps us decide whether to use targeted therapy afterward.

We’re tailoring the specifics of the tumor, the specifics of the technique, and the specifics of the patient’s situation to give the best approach for each individual case.

And sometimes we’re not just thinking about the tumor in front of us. For example, we’re seeing more nonsmoking women in their 40s and 50s presenting with lung cancer. And those patients almost certainly will develop more lung cancers over time. If you think about it, it makes sense—they developed one without smoking.

So when we treat them, we’re not just thinking about the tumor they have today, but what we might have to treat in the future. It's the genetic driver of the cancer and the propensity or possibility of future cancers, too, that helps drive those decisions, timelines, everything.

Any theories on why we’re seeing such a rise in lung cancer in this population of women?

It’s really not clear yet. There are some theories about air pollutants and micro materials, and hormones for women, but it’s not defined yet.

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Expanding Lung Transplant Possibilities

How have innovations like ECMO and improved organ preservation changed lung transplant eligibility?

We continue to push the boundaries of who qualifies for lung transplant. There’s basically no age limit anymore; it’s based on physiologic status. There are very few people who are too sick for transplant now. We can rehab them or place them on artificial support like ECMO [a machine that works like a temporary, artificial lung].

For the right patients, we now have the ability to do more minimally invasive lung transplants through little incisions, routinely.

With all of these factors, like more personalized testing and immunosuppression, how close are we to truly individualized transplant care for lungs?

Well, we’re getting closer. We’re actively working toward more personalized transplant care. One of our investigators, Dr. D’Ovidio, in our department, has a lab working on that. He developed biomarker testing from lung fluid and gastric fluid that may help determine the best immunosuppressive medication for a particular patient.

What exactly is assessed in these fluids?

You have some bile, and the bronchial lavage, as we call it. We’re figuring out how to tailor immunosuppressives to the patient and also tailor adjunct surgical procedures to help with reflux, help them have better transplants, and maybe avoid transplant altogether.

But the number one mission when someone comes in for transplant evaluation is actually to ask: can we get them better without a transplant? We look under every leaf to try to figure that out before we transplant them. And it’s a fair number of patients we can treat without transplant.

Rethinking Esophageal Surgery

You said in our last State of the Union interview that esophagectomy (removal of part or all the esophagus) isn’t what it used to be. Why is that?

Esophagectomy shouldn’t be feared. It was often something patients wanted to delay because of how big an operation it is. I would never call it a routine procedure, but it feels routine in the sense that we routinely do it minimally invasively, we have our own data on it, patients go home quickly, start eating, no feeding tubes, and can resume a full normal life. It’s a big operation, but it’s not at all what it used to be.

Does that mean people are being referred earlier for esophagectomy?

Yes, they are being referred earlier, but most important is that the earlier the referral, the greater the chance of not having an esophagectomy at all; they could have it resected by our GI colleagues.

It’s the same thing with other conditions like paraoesophageal hernia. Even large paraoesophageal hernias are routine outpatient surgery. Now I do these routinely in 90-year-olds and ask them to go home the same day. It’s routine, well tolerated, and has a very low failure rate.

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The Diaphragm and Specialized Expertise

How about diaphragm dysfunction? Has more awareness grown around diaphragm disorders and treatment?

It’s certainly underrecognized. We have one of the few diaphragm centers in the world.

And it's also underrecognized that we can repair the diaphragms directly or by reinnervating them with our neurosurgeons, together. We do combined hours every week. We’re actually presenting a case soon where we preserved a nerve up in the brachial plexus, and we have two more cases booked of the same sort of thing.

We're able to add the nerves in the chest and save important nerves. And we’re one of the few centers in the country that does this routinely.

What is that collaborative process like with neurosurgery?

We use imaging and sometimes neurologic testing to try to figure out which nerve is the nerve in question. And then, if it's a dysfunctional nerve, can we repair it? If it's a tumor, can we take the tumor out and keep the nerve or repair the nerve? With proper testing, we can know these things before surgery.

Are there other specialized programs or conditions where Columbia’s thoracic team has unique expertise?

We’re definitely world leaders in thymectomy [removal of the thymus gland] for myasthenia gravis and thymic tumors. We led the studies that proved thymectomy is beneficial and helped develop many of the surgical techniques used today.

We also have new options to treat airways that are malacic, or excessively weak or collapsing—both with robotic surgery procedures and customized stents that are made specifically to your anatomy.

The Bright Future Ahead

Are there diseases today that may not require surgery in the future?

The best example is cystic fibrosis. Cystic fibrosis used to be the number one indication for lung transplant. In the future, we may never transplant lungs for cystic fibrosis again because there are now medications that can control the disease. It’s really amazing.

And if people think that kind of progress won’t happen for other diseases, they’re wrong.

We’re not there yet for lung cancer, but we’re moving toward combinations of molecular therapies and smaller surgical procedures that may dramatically change how we treat it.

When it comes to awareness, what do you wish patients understood sooner?

The biggest message I give patients with lung or esophageal cancer is not to go on the internet. If they go online, especially with esophageal cancer but even with lung cancer, they’re going to get scared very quickly. But the reality today is very different.

There’s basically no stage of those cancers that we can’t treat, and most of the time, the expectation is cure. And if we can’t cure them, we now know how to manage them so people can live with the disease. There are very few patients today who don’t have options. We have targeted therapies that keep the tumors at bay, and then sometimes different minimally invasive procedures to ward off what’s coming up on the horizon. So really, there’s no patient without options.

What remains the most rewarding part of your work?

My favorite part of the job is long-term follow-up with my patients and getting to know them over a long period of time. You can break down barriers very quickly in a doctor-patient relationship and start to know people in a way you never would otherwise.

That’s what I like the most.