Thanks for joining us this morning. So um in thinking about uh this topic, I thought it'd be uh worthwhile to take you through a day in the life of a thoracic surgeon. And um the bye, there are essentially three groups of patients that a thoracic surgeon sees in clinic. Uh There are the operable ones, the inoperable ones and then the gray area, the borderline operable and these uh what distinguishes these three groups are patient factors and then tumor related factors. So I won't uh um won't go through too much about the tumor factors, but essentially to decide about resect. Uh depends of course on the stage, the histology, um the tumor size and the location these determinants um figure in uh helping the surgeon decide whether surgery is feasible, can it be safely done? And what type of resection will be required in order to achieve a complete resection. So while there are um while the um great outcomes that systemic neoadjuvant treatment uh offers has now broadened, perhaps um what surgeons might have previously considered borderline and pushed these patients into a more operable uh category. Um It's important to realize that the surgeon has to decide, ideally ought to decide at the outset of treatment in co ordination with the multidisciplinary team, whether the patient is resectable or not. And we ought to try to avoid. Uh let's see what happens kind of approach um with uh even even in spite of the advances and the successes of the neoadjuvant treatment in treatment response. So, patient factors, how do we decide um who is operable? And uh this um there are multiple factors that are considered when we first see a patient uh in consultation in the clinic, uh age comorbidities, um pulmonary function, their cardiac reserve, their overall functional status. We're trying to gain insight into their physiologic and their physical reserve, their ability to tolerate surgery. Um And there are indices that can help with that frailty index um which is highly associated with the risk for post op complications. And then of course, there's patient um autonomy. So in assessing the physiologic reserve, there are certain sort of non negotiables, certain tangible um end points that we seek an optimal surgical candidate ought to have a predicted post op fev one greater than 40% dlco greater than 40%. Uh their cardiac reserve should be robust. Uh They should have uh ideally a normal ef not have pulmonary hypertension, et cetera. Um I added this um to the, the cardiac catheterization discussion just to remind me to say that, you know, it's really important to have this multidisciplinary engagement with those who might be outside of the immediate oncology team. For example, if you send a patient to, uh, for a stress test, if the stress test is positive, what does that mean? Is the cardiologist is going to feel then obliged to do a cardiac catheterization. And if they see a lesion, what ought to be done, what they do has great impact on what may then be, um, able to be done for the, for the, um for the lung cancer. For example, if they were to put a drug looting, stent, then basically takes surgery off the table. Um The patient would then be referred for SB RT because we're unable to uh operate safely without a dual antiplatelet therapy which highly heightens the risk for um per bleeding. Um So at the end of the day, it's just important to have a discussion with all of the stakeholders at the outset. So, um in order to gain greater insight into the patient's physical reserve, there are less tangible, more subjective um measures. Um Do they pass the eyeball test if the patient comes in, in a wheelchair on oxygen? Obviously, it's not a good operable candidate. Um Do they exercise? Are they able to handle their Ad LS? Um, what's their level of nutrition? What's their cognition? And um then there are other provider. Um, the provider ought to have a more nuanced sort of discussion and engagement with the patient. And if the patient is not really committed to what it takes to undergo surgery, get through the post op recovery and get back to the onco the oncologist. Then, uh perhaps that patient is best, best served with a more, a less invasive approach such as SB RT. So, um, you know, the expected timeline, ideally when we see the patient, uh initially, there ought to be a 23 week, you know, we, we would like to book the patient uh for surgery. Uh within that time period, they have their surgery, they might stay in the hospital for a couple to a few days depending on what type of surgery is required. Um then they go home and they ST and the patients still have to work on physical therapy, optimize their nutrition in order to get back to the oncologist and, and potentially be considered for optimal um systemic treatments. So, uh it's a marathon, not a sprint. I say this every moment uh to every patient. Um and so as the surgeon, what opportunities are there to optimize to, to uh anticipate barriers to uh overcome uh potential problem spots with patients. Well, if patients are, you know, pre hab is a hot topic, um and while we may not have the opportunity to really intervene in time for patients who are having surgery, um as their first step in treatment, if they were to undergo neoadjuvant treatment, we have a few months by which that option should be considered um physical therapy rehab. Uh It's an opportunity for continued, you know, tobacco cessation enforcement engagement with pulmonary um then other multidisciplinary consultants and then uh just addressing their whole sort of social um context because there are uh you know, in terms of who is a surgical candidate who ultimately gets surgery, there are social determinants um that take that take part in that equation. Um older patients, those who may be non Caucasian um uninsured Medicaid patients, low income, all of that may provide um certain barriers to access that ultimately um have impact on who gets considered uh for surgery and who undergoes it. Um So it's found that these, these um demographics lead to uh patients who have lower rates of being offered surgery, um greater rates of having radiation, greater um delays to surgery and um less likelihood of undergoing minimally invasive approaches. So I just wanted to put a plug in while we've been talking about uh candidacy uh for surgical resection in the limited early stage setting. Um I was struck by a comment of a colleague um at a high volume of sender who said that half of his surgical practice um was um was managing patients after um chemo immunotherapy and also those um with oligo metastatic disease. And so just wanted to say that there is still, there ought to still be a role for surgery considered as a local consolidative treatment in the studying of oligo metastatic disease and a study that came out earlier this year, uh from MD Anderson, they had a retrospective review of 50 patients um who had uh oligo metastatic disease, um and who ultimately underwent lung resection for their primary tumor um with durable survival um rates. And um here's most of them had lobectomy. Um but this is just to say that surgery is not with the improved outcomes and great results uh using um immunotherapy surgery ought not be cast out the window at the outset just based on stage. So in summary, patient operability and tumor resect ability should be assessed by the thoracic surgeon. Ideally upon initial work up and diagnosis staging, there are objective physi physiological criteria but also more subjective functional um criteria that inform this assessment. And there are also social um biases that may play into this equation. Um And surgical outcomes ultimately rely on surgeon expertise, judgment and great selection. Thank you.
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