SBRT vs surgery for operable adenocarcinoma in elderly pt: need your advice pls.

[Alina]

Asking advice please. Need to make a decision what would make better sense for under 2 cm peripheral (easy to reach location) spot with adenocarcinoma (lymph nodes negative) for an old patient who is in good shape and is "operable" with curative intent.  studies I read point to SBRT but surgery is still a treatment standard. You, guys, went through so much already and someone must have experience with dilemma like this, except mommy is older than any of you. Please, help with advice. Thank you

[TJM]

First off..what do her doctors think?

I have not received precision radiation so no first hand knowledge to share. I did have the lobectomy. It was not nearly as rough as I feared but it's still major surgery.

From what I gather from others posts is SBRT (or equivalent) is fast, effective and has few side effects. Talk with her doctors, they should be able to tell you the risks. If you don't agree with them get a second opinion. I got one.

It would be a tough choice to be honest.

Peace

Tom

[BridgetO]

Hi Alina, Surgery is considered the gold standard for early stage lung cancer, when someone can tolerate surgery. It matters more what kind os shape tha patient is in than what their chronological age is.  Since the doc said it's operable, I assume your mom has had the battery of lung function tests.  Would the plan for her be to have VATS (video assisted thoracic surgery) or robotic surgery, rather than thoracotomy (open surgery)? VATs and robotic are fairly easy as surgeries go, although of course any surgery requiring general anesthesia is a serious procedure. SBRT is generally used when a person can't tolerate surgery.

What does your mom think about this? If she feels like she can deal with the surgery and the risks(and the surgeon agrees), I'd be inclined to encourage her to go for it.  If you and she are undecided, I agree with Tom that a second opinion might be advisable.

BTW, I had a VATS lobctomy almost 5 years ago and I'm doing well with no lingering side effects.

 

[Alina]

Thank you very much for your responses, Tom and Bridget,

you are awesome. I appreciate your time and sharing thoughts. Surgeon is advising to go for VATs (probably segmentectomy or wedge) and RO is advocating SBRT based on studies that point to its benefits in survival and cancer free time compare to surgery. Lobectomy is gold standard but mommy is in late eighties and smaller recession (which is less effective ) will be offered. Which doctor makes this type of decision as to which path to take. We saw a surgeon and a Radiation Oncologist and each advocates for their discipline. We dont have an oncologist-we just found out about cancer and dont know yet who to see. Is it oncologist who makes a decision on these types of dilemmas. Mommy doesn't know what to do.I  read every research on SBRT and it points out benefits in survival and cancer free survival over surgery but by some reason ppll prefer going to surgery (may be because they are younger or may be because they dont know about SBRT being more effective or may be I am missing something). She did thansthorasic lung biopsy with no complications and was miserable till the morning, I dont know how VATs recovery might be compare to biopsy recovery. Thanks a lot for your input. 

[Tom Galli]

Alina,

Unfortunately, speciality doctors tend to advocate for using their specialty. This is natural and expected. Who might help with your discipline. I'd consult with either (or perhaps both) a medical oncologist or a pulmonologist. They might offer a more nonpartial view. In any event, after surgery your mom will need scheduled diagnostics to early identify a recurrence. This is what makes lung cancer so very dangerous. 

My experience is a surgical biopsy recovery is a piece of cake. I've not had VATS and offer no opinion. A complete thoracotomy recovery is not a piece of cake.

Stay the course.

Tom

[BridgetO]

I had a VATS lobectomy at age 71.  I was in pretty good shape before the surgery. I was up and around in the hospital unit the same day and  discharged from the hospital the following day with a chest tube and drain bag in place because I had an air leak. It's  unusual for people to be discharged so soon. Usually it's two or three days and the drain is out before that. My drain was in for about 10 days at home, until the leak stopped. I was up and around, though I did rest a lot.  I went for walks in the neighborhood with my tube and bag hidden under a big raincoat. Ineeded some help changing dressings, especially the one around the drain tube, and I wasn't supposed to  drive or to lift anything over about 8 pounds (if I recall correctly). Otherwise I could take care of myself. I did have some pain, mainly from the drain tube, and especially when I moved in certain ways-- I learned pretty fast not to move in those ways. I needed some opiod pain meds but pretty quickly got off them after the tube was out. 

So the surgery wasn't too bad. Others will probably offer their opinions on it too.  

 I think getting an opinion from a medical oncologist who has lung cancer experience is a good idea. Probably no-one will make the decision other than your mom with your input. The surgeon has said he/she can do surgery and the radiation oncologist has said he/she can do SBRT, so your mom is lucky to have choices. 

[Alina]

thank you very much for your input. I really appreciate it, Tom and Bridget

[TJM]

FWIW....in the end I think the decision will be your mothers and family. I would recommend seeing a pulmonologist over a oncologist at first. No dog in the hunt. An oncologist may be most comfortable with Chemo than either of the other two choices.

Just an opinion. If I was in that position I would go with SBRT. Less invasive. Seems effective. Easy and fairly rapid feed back. My mass was too big to even consider SBRT over surgery. That's just one man's opinion.

Wishing you the best with this difficult decision 

Peace

Tom

Edit: Tom G. You did SBRT didnt you? I was surprised you didnt mention it in your response.

[Curt]

Hi Alina.  I had an upper right lobe lobectomy at 42.  The recovery was much better than I expected but I was young, in pretty good shape and worked at the recovery.  

Tom is right. Surgeons want to treat cancer with surgery.  Clinicians want to do it with their particular focus.

Surgery is the gold standard but age does have to be considered. My grandmother had a lung nodule in her eighties.  The doctors opted for surveillance to monitor its growth. They felt that her tumor was slow growing and that she would probably pass away naturally prior to needing any treatment.  She passed away at 92 of natural causes with no ill affects of the lung cancer.   

If they are going to go in anyway to do a biopsy before SBRT then just doing the wedge reception might not be that much more difficult a recovery.  

At your moms age I’d consider quality over quantity.  Which procedure is going to give her the best quality of life for the years she has left. Most major cancer treatment centers have a tumor review board that reviews the case as a group to determine the best approach with both quality and quantity of life in mind. If your mom is being treated somewhere doesn’t have that you might want to look into if there is larger cancer center close enough for you to get a second (or third) opinion.    
 

Having had cancer and a parent who had cancer I know that cancer is rough.  I also know that helping a parent navigate cancer is rough. You are asking the right questions.  Keep asking them until you get answers that feel right to you and your mom.  

[LUNGevityKristin]

You have received some great input. Just wanted to share this resource where you can compare the different options available to your mom: https://lungevity.org/for-patients-caregivers/lung-cancer-101/treatment-options-for-lung-cancer Please keep us updated on what decision she makes.

[Alina]

Curt and Kristin, thanks a lot for your input. I did tons of reading of research and all points to SBRT over wedge resection (which will be offered most likely). mom did have biopsy 2 weeks ago , she recovered well although first 30 min after the procedure were rough then had AF once. You think recovery from wedge (3 cuts)  is comparable to recovery from biopsy (1 tiny hole) ? I wish, not sure.  mom will do what doctors say and so far she was seen by a thoracic surgeon so he will be making that decision . I feel so unsure if I can and should talk mom out of surgery and into SBTR against surgeon's offer of wedge resection. we are going tomorrow morning, major cancer center. you are here very wonderful people, I am lucky I found this site.

[LUNGevityKristin]

Please keep us updated on what your mom decides. With either treatment plan, she is lucky to have you advocating for her!

[TJM]

Please do keep us informed. In the end sounds like your mother will decide (as she should).

I still advocate for an opinion from a pulmonologist. But that would add time.

Unique situation your in. All of the choices have a great chance for sucess...so that's positive 

Peace

Tom

[Alina]

On 7/2/2021 at 2:26 AM, TJM said:

Please do keep us informed. In the end sounds like your mother will decide (as she should).

I still advocate for an opinion from a pulmonologist. But that would add time.

Unique situation your in. All of the choices have a great chance for sucess...so that's positive 

Peace

Tom

 

[Alina]

Thanks a gain for all your responses. The surgeon feels surgery is better option than SBRT. RO and oncologist said both options are similar but surgery is better in terms of follow up afterwards. All three MD's said that VATS is an easy surgery to tolerate. If pass presurgical testing, going ahead with surgery, scheduled for 7/20. We are very nervous how mommy will tolerate it. Oncologist gave good advice to make sure molecular testing is done on pathology in case further treatment is necessary ever. Not sure if this is routine but thought to share with everyone. Stay strong. 

[Curt]

I imagine they are referring to genetic testing when they refer to molecular testing. That is very important for forming a follow up treatment if one is necessary after surgery. Genetic testing can be the cancer Itself and the person (somatic).  You’ll want to make sure sure they are planning a full genetic work up.  
 

Surgery is the most affective treatment.   VATS is a very manageable recovery. I and others have written quite a bit about the surgery, what to expect and some tips post op. You should be able to find it on this forum with a quick search.  Your mom will do great.  
 

.  

[Alina]

Thanks a lot, Curt

[LUNGevityKristin]

It sounds like you received some really great advice.  Biomarker testing can be very valuable so it's great they have a plan to get that done.