July 14, 2017 | Lindsay Morgan
UC San Diego's Division of Cardiovascular and Thoracic Surgery, part of the Department of Surgery, is internationally recognized as a leader in the field of cardiothoracic surgery, especially in the surgical treatment of chronic pulmonary emboli through a procedure called pulmonary thromboendarterectomy.
And now things are getting even better, with the expansion of the Division's general thoracic surgery enterprise, which includes expanding access to highly specialized, multidisciplinary care for lung cancer patients; preventative screenings; and increasing use of minimally invasive and robotic techniques.
Clinical Advances in Thoracic Oncology
Lung cancer is the second most common cancer and the leading cause of cancer death among both men and women. Lung cancer is a complex condition—one that requires input and evaluation from multiple physicians and experts. For example, patients who benefit from chemotherapy after successful surgical resection can benefit from being seen by both a medical oncologist and thoracic surgeon during the same visit. Patients who lack the lung function to tolerate a surgery can benefit from input from both a thoracic surgeon and radiation oncologist to determine the optimal treatment regimen. And some patients with locally-advanced cancer may benefit from chemotherapy, radiation therapy, and surgery—with the multidisciplinary care that implies.
Until recently, there was a dearth of multidisciplinary clinics in San Diego County wherein a patient could be seen by a thoracic surgeon and other disciplines in the same clinic at the same time. Even at UCSD, where specialists in lung surgery and thoracic medical and radiation oncology have been working together for a number of years, robust and systematic multidisciplinary interactions were not well developed.
But that is changing. With the recruitment of surgical and medical specialists from Duke University and MD Anderson Cancer Center, a formal multidisciplinary lung cancer clinic was established in the Moores Cancer Center in October 2016 to ensure that care is given through a multidisciplinary team of lung cancer specialists who offer the most advanced services to patients—from screening and diagnosis to treatment—with comprehensive support and education services for patients and survivors.
Minimally Invasive Approaches and Robotics
The Division is also dedicated to expanding the use of minimally invasive and robotic approaches to thoracic surgery. Data clearly shows the benefits to patients of such approaches including shorter postoperative hospitalization; earlier resumption of full activity, including work; less acute and chronic postoperative pain; fewer respiratory complications; and earlier ability to tolerate postoperative chemotherapy in VATS patients in comparison to open thoracotomy patients.
Drs. Patricia Thistlethwaite and Anthony Perricone, both of the Cardiothoracic Surgery Division, have performed VATS lung resections over the past several years, and recently, the Division introduced use of robototics in surgery, and have begun to perform minimally-invasive segmentectomies, in which less lung is removed with equivalent oncologic results.
Spearheading the Division's newest advances in thoracic surgery is Mark Onaitis, who joined UCSD in August 2016, from Duke University. Dr. Onaitis is a board-certified thoracic surgeon who specializes in malignant and benign conditions of the chest, including lung and esophageal cancer, and specializes in minimally invasive approaches—minimally invasive video-assisted thoracoscopic surgery (VATS), thorascopy and robotics—to treat these conditions.
According to Dr. Bryan Clary, Chair of the Department of Surgery, "through the efforts of Drs. Perricone and Thistlethwaite, UCSD has been a regional leader in minimally invasive lung surgery for a number of years, performing these procedures both at UCSD as well as as the Kaiser Permanente Zion Medical Center. Dr. Onaitis and his partners at Duke University have been the leading group in the country in developing and studying minimally invasive approaches to lung cancer. The addition of Dr. Onaitis to UC San Diego brings even further sophistication to our lung and esophageal clinical programs as well as an incredible translational science portfolio aimed at developing better treatment options in lung cancer."
Despite the relatively short time since his arrival, Dr. Onaitis, in partnership with surgical and multidisciplinary partners at Moores Cancer Center, has had a remarkable impact. For example, in the time since Onaitis joined the Department, the Division has tripled the volume of minimally-invasive surgeries of the lungs. This is in part a result of the expansion of Jacobs Medical Center, as well as the expansion of UCSD's surgical presence to affiliate partners such as Tri-City Medical Center.
Expanding Screening—And Patient Access to Services
Detecting lung cancer at its earliest stages is critical, and annual screening with low-dose computed tomography (CT) can find lung cancers in their earliest stage, when the cancer is most easily treated. A large national study showed that annual CT screenings can reduce the risk of lung cancer death by 20 percent in current and former heavy smokers, compared to those who were screened using a chest X-ray.
UCSD's Department of Surgery, together with the Moores Cancer Center, launched at CT screening program in July 2017, which provides access to low-dose CT screening for individuals at high risk for developing lung cancer; smoking cessation counseling; and, if needed, follow-up treatment.
This is the first smoking cessation program in San Diego County that combines screening and smoking cessation counseling, and is sponsored by a cancer center.
"This is a really important program because lung cancer is asymptomatic until it spreads," says Onaitis. "The recent National Lung Screening Trial clearly demonstrated that low-dose CT screening of current and former smokers gives us the ability to find lung cancers while they are still curable. This will significantly benefit smokers in Southern California."
Not only is the aim to improve services, it is also to increase the number of people who can access them. San Diego County is massive, with a population of over 3 million spread out across nearly 5,000 square miles.
To better serve patients who cannot easily access La Jolla facilities, the Department is employing a "spoke and wheel" approach—offering screening and some surgical services at partner hospitals in El Centro, Temecula, Oceanside, and Hillcrest.
New Research Initiatives
In addition to clinical advances, new strides are being made in lung cancer research. In his lab, Dr. Onaitis studies the cell origins of KRAS mutant lung cancer in transgenic mice, to better understand how to individualize therapies and better understand the molecular drivers of cancer. Although the lung cancer research community has developed targeted therapies for molecular drivers of lung adenocarcinoma such as EGFR and ALK/ROS, no specific therapies for KRAS mutant tumors exist.
Onaitis is also collaborating with basic scientists such as David Cheresh, Tannishtha Reya, Silvio Gutkind, and Judy Varner, to attempt to translate discoveries made in the lab into therapies that can benefit patients.
Much progress has been made in the Division of Cardiothoracic Surgery, and there is much more to come. Now and in the future, minimally-invasive surgical approaches will help patients to recover more quickly from lung resection. Collaboration with medical oncology, radiation oncology, pulmonology and radiology is allowing identification and implementation of individualized treatment plans for patients that maximize benefit and minimize risk. And collaboration with basic scientists may allow even better targeted genetic therapies in the future.