Sandra L. Starnes1, Jin Ye Yeo2
1Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; 2CCTS Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. CCTS Editorial Office, AME Publishing Company. Email: ccts@amegroups.com
Editor’s Note
Current Challenges in Thoracic Surgery (CCTS) has published a number of special series in recent years, receiving overwhelming responses from academic readers around the world. Our success cannot be achieved without the contribution of our distinguished guest editors. This year CCTS launched a new column, “Interviews with Guest Editors”, to better present our guest editors and to further promote the special series. We also hope to express our heartfelt gratitude for their tremendous effort and to further uncover the stories behind the special series.
The special series “Lung Cancer Screening”(1) led by Prof. Sandra L. Starnes (Figure 1) from the University of Cincinnati College of Medicine has attracted many readers since its publication. This special series, with the input of many renowned experts in the field of lung cancer screening, aimed to provide some valuable information and insight into the past, present, and future of lung cancer screening. At this moment, we are honored to have an interview with Prof. Starnes to share her scientific career experience and insights on this special series.
Figure 1 Prof. Sandra L. Starnes
Expert Introduction
Sandra Starnes is a Professor of Surgery and the John B. Flege Chair in Cardiothoracic Surgery at the University of Cincinnati. She is the Director of the University of Cincinnati Cancer Center’s Comprehensive Lung Cancer Center and Medical Director of the Lung Cancer Screening Program. She has expertise in the diagnosis and surgical treatment of thoracic malignancies, including lung cancer, esophageal cancer, and mediastinal tumors, with a focus on minimally invasive treatments. Her research interests include outcomes research for lung cancer surgery, lung cancer screening, and education in thoracic surgery.
Interview
CCTS: What drove you into the field of lung cancer research?
Prof. Starnes: Lung cancer remains the number one cause of cancer mortality in the United States and the world. While there have been significant advances in the last decade, overall survival remains poor, access to care is not equally accessible, and lung cancer research has lagged way behind other malignancies. The introduction of effective lung cancer screening with low-dose computed tomography (LDCT) has changed the landscape of lung cancer and if maximized could allow most lung cancers to be detected early. However, it remains disappointingly underutilized and those most in need often do not have access to quality lung cancer screening programs. In addition, many of those diagnosed with lung cancer do not meet current screening criteria. Early lung cancer detection requires maximizing the effectiveness of lung cancer screening as well as incidental nodule management.
CCTS: Have there been any exciting new advances in minimally invasive approaches in the past two years? How have these advances impacted the field of thoracic surgery??
Prof. Starnes: With the advent of lung cancer screening, we are detecting lung cancer at an earlier stage with smaller tumors. The Lung Cancer Study Group trial, published in 1995, revealed an increase in local recurrence after sublobar resection compared to lobectomy. While this trial has been criticized, it set the standard for lung cancer resection for the next several decades. Recently, two landmark trials were published, JCOG 0802 in Japan and CALGB 140503 in the United States, Canada, and Australia, which revealed equivalent outcomes for sublobar resection compared with lobectomy in peripheral tumors <2cm in size. We are currently trying to figure out the nuances of how to apply this data, but certainly, we will see more sublobar resections in the future. While the CALGB study included both wedge resection and segmentectomy, I expect segmentectomy will be increasingly used for the treatment of early lung cancer. With the increasing use of minimally invasive approaches, including thoracoscopy and robotic lung resection, anatomic segmentectomy is more accessible. There is exciting research on the horizon with the use of a combined diagnostic/localization approach using robotic navigational bronchoscopy followed immediately with sublobar resection. I think this will be an important advance to increase the efficiency, safety, and oncologic outcome of lung cancer resection.
CCTS: What are some significant challenges of lung cancer screening?
Prof. Starnes: As stated previously, lung cancer screening remains underutilized, with <10% of those eligible in the United States undergoing screening. If we are to increase the overall survival rate of lung cancer, currently <20%, we must increase these low rates of screening as well as refine eligibility. Potential reasons for this low utilization include lack of awareness by patients and providers, lack of access to screening programs, and concerns regarding the risks of lung cancer screening. Lung cancer screening is more complex than other screening tests, as LDCT images the entire thoracic area, not just one organ. Therefore, there is the opportunity to detect other incidental findings that also need to be managed. It is critical to minimize procedures for benign nodules and make lung cancer screening as safe and cost-effective as possible. In addition, a significant portion of patients diagnosed with lung cancer do not meet current eligibility. The first decade of lung cancer screening focused on implementation and program development, insurance coverage, and development of a reporting structure, Lung-RADS. The next decade will focus on program expansion and increased utilization, improving access and decreasing disparities, refining eligibility criteria, and the addition of biomarkers in lung cancer screening. An additional challenge to consider as we expand screening is the workload for reading radiologists. In the United States, there is a shortage of chest radiologists, and the workload of reading screening LDCT is high. We will need to optimize the efficiency of the interpretation of lung cancer screens, with the use of radiomics and possible artificial intelligence.
CCTS: Could you share more about your current research works?
Prof. Starnes: My recent focus has been on the outcomes of lung cancer screening. With a large lung cancer screening program in operation for over a decade, we have been able to study the outcomes in our population. We have shown that by using a multidisciplinary approach, we can minimize unnecessary procedures for those with benign pulmonary nodules. We have also shown excellent surgical outcomes for screen-detected lung cancers. We have confirmed that less than 50% of incidentally detected lung cancers meet current screening criteria. Our future focus will include decreasing disparities in lung cancer and improving utilization.
CCTS: What are some of your aspirations for the future of lung cancer screening? How has the direction of your past/current research works changed to reach your research goals?
Prof. Starnes: My goal is to increase the utilization of lung cancer screening and also increase access to lung cancer screening for those most in need. Incorporating biomarkers and refining eligibility are important future needs. My aspiration would be to have lung cancer screening utilization reach that of breast cancer screening and ultimately have most lung cancers diagnosed at an early stage.
CCTS: If given the opportunity to update this special series, what would you like to moderate, add, or emphasize to provide a more comprehensive series?
Prof. Starnes: We have made some progress in lung cancer screening over the last several years, but certainly much more progress is needed. I think it is important to note all of the past successes, current challenges, and future opportunities for lung cancer screening.
Reference
- Lung Cancer Screening. Available online: https://ccts.amegroups.org/post/view/lung-cancer-screening