1. Current Issues in the Surgical Management of Lung Cancer Jonathan Ferguson

2. Areas for Discussion Access to VATS Lobectomy The N2 debate Surgical cover of MDTs Concentrating expertise Tracheal resection Pancoast tumours Spinal Resection Working with SBRT

3. VATS Lobectomy More centres starting Still a small proportion of all resections +++ interest nationally in expanding access Less post op pain Potentially shorter post op stay Already being successfully performed by Mr Stamenkovic at the Freeman

4. The N2 Debate Do we operate on patients with N0 N1 disease only? N0 N1 and non bulky N2? N0 N1 and single station N2? Adjuvant or Neo-adjuvant therapy for N2? The debate continues....... For discussion at another time

5. Surgical Cover of MDTs – No Easy Solution The problems – Largest volume cancer – Surgery for only 10 – 15% of patients – Ratio of patients to surgeons is very high – Individual surgeons covering many hospitals – Surgeons enjoy theatre more than the MDT room!!!!! In contrast – Breast Cancer – Large volume – Simple pathway – Vast majority of tumours are removed – Breast surgeons in every hospital – Ratio of patients to Surgeons is low

6. Concentrating Surgical Expertise? Tracheal / Carinal resection, Spinal resection & Pancoast tumours No UK surgeon sees large numbers of these. The more a surgical team does the better it gets! Some large US centres provide this low volume, technically difficult surgery to large areas of population. Should the UK identify 2 or 3 centres for each of these problems?

7. Working Along with SBRT Main part of presentation Some surgeons worry that radiotherapy will reduce the number of cancer resections Some surgeons worry that SBRT is not as good as surgery This presentation will try to explain how informed patient choice is more important than cure!

8. The Surgeons’ View of SBRT An insight into the surgical mind Not evidence based Aims – To provoke discussion – The history of surgical reaction to new technology – Clarify motivation – Comparisons from the past – The role of a SBRT v Surgery trial

9. New Treatments for Old Diseases The Surgeon has a new toy – e.g. Laparoscopy The Physician has a new toy – e.g. Vascular stents

10. The New Toy Laparoscopy – the last few decades  Distrust  Enthusiasm from a few  Enthusiasm from many  Patient benefit  New challenge  Inappropriate application  Finally we have appropriate and beneficial equipoise

11. The New Toy in the Playground Others own the toy – New method CLEARLY BETTER than surgery for many patients Cerebral aneurysms and renal stones Change in surgical practice Little to argue about

12. The New Toy in the Playground Others own the toy – New method slightly better, as good or nearly as good as surgery for many patients Coronary Stents Peripheral Vascular stents – Threat to surgical practice – Much to argue about...

13. Much to argue about... Factors that fuel arguments – The narrower the gap in efficacy the bigger the debate and the bigger the trials needed – Moving goalposts – “The new stent is better” – How much of surgical practice is under threat.

14. Surgical Evolution “What will WE do if the oncologists cure cancer?” – a UK thoracic surgeon

15. Surgical Evolution “What will WE do if the oncologists cure cancer?” – CELEBRATE – Facilitate – Retrain Patient focused approach This is obvious and without controversy This needs to be said!

16. Facilitation Surgeons should be willing to provide surgical staging [e.g. mediastinoscopy] for patients who have chosen SBRT

17. Patient Choice SBRT does not need to be as good as surgery to have a valid role – As long as the patient understands the risks and benefits of each treatment then it is up to the patient to choose – NOT THE DOCTOR OR SURGEON – Patient focused approach – This is obvious and without controversy – This needs to be said!

18. Lessons from the past - Mesothelioma Long debate over many years concerning the role of extrapleural pneumonectomy in mesothelioma Divided opinion Patient anxiety

19. SBRT vs Surgery Trials Should happen Now Timely fashion Embraced by surgeons Physicians, surgeons and patients need to know how good it is.

20. The Areas for Debate - Summary Further access to VATS Lobectomy The N2 debate Surgical cover of MDTs Concentrating of expertise Tracheal resection Pancoast tumours Spinal Resection Working with SBRT

21. Questions