Individuals with chronic obstructive pulmonary disease (COPD) are already compromised, so the prospect of removing all or part of a lung is especially daunting for these patients if they are also facing lung cancer, said Joseph S. Friedberg, MD, in a presentation at the GOLD International COPD Conference.

When appropriate, surgery remains the most effective treatment option for non-small cell lung cancer (NSCLC), including for patients with COPD, said Friedberg, professor in the Department of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University, Philadelphia.

Less invasive options are available for NSCLC. These include radiofrequency ablation, microwave ablation, photodynamic therapy, and cryotherapy, Friedberg said. However, the standard noninvasive option for early-stage NSCLC, especially for inoperable patients, is stereotactic body radiation therapy (SBRT), he said. SBRT delivers precise, high-dose radiation to the tumor that spares healthy surrounding tissue. SBRT usually involves three to five treatments.

However, patients with COPD are caught between the proverbial rock and hard place, said Friedberg. The reduced pulmonary reserve in these patients, especially patients with certain types of COPD, may be more vulnerable to radiation-induced injury, he said. Chronic inflammation, emphysema, and microvascular changes are among the factors that amplify radiation toxicity, he noted. Potential complications from lung radiation in patients with COPD include accelerated lung function decline and COPD exacerbations, increased risk for radiation pneumonitis and pulmonary fibrosis, and a slight increase in risk for death, especially in patients who undergo SBRT or chemotherapy, Friedberg added.

Ultimately, a team approach is the secret to success in managing patients with COPD with lung cancer, Friedberg said in his presentation. He emphasized a multidisciplinary approach, including a full cardiopulmonary evaluation for risk stratification and prediction of the impact of a lung resection on the patient’s quality of life.

Optimize outcomes as much as possible prior to surgery through smoking cessation, pulmonary rehab, nutrition, and anything else recommended by the pulmonologist, Friedberg said. However, “the real battle begins after the operation,” he said. Optimal postoperative pain control, such as patient-controlled thoracic epidural anesthesia, is key to preventing splinting and to promoting coughing and walking after surgery, he said.

Selecting a Strategy

Once a patient is set to proceed, approaches include minimally invasive surgery, such as video-assisted thoracoscopic surgery (VATS) and robotic approaches, and partial resections such as sleeve resection and wedge resection, Friedberg said.

Several recent studies, including a meta-analysis, support the use of sleeve resection vs larger resections, with lower operative morbidity and mortality than pneumonectomy, he noted. Additionally, segmentectomy appears equivalent to lobectomy for stage I tumors < 2 cm, based on recent studies, he added.

Wedge resections, by contrast, are the best or only option in some cases, but patient selection is critical, said Friedberg. A 2023 study showed no significant difference in 5-year disease-free survival for patients with NSCLC who underwent wedge resection vs segmentectomy for very early-stage NSCLC, although the study population was not strictly patients with COPD.

As for lung transplantation, data do not support it outside of investigational settings, given the high rate of recurrence and demonstrated poor long-term outcomes, Friedberg said.

Overall, careful patient selection, optimizing pre-op factors, attention to pulmonary rehab, and meticulous postoperative care will allow for safe lung cancer surgery in individuals with lung cancer and COPD, Friedberg concluded.

Finding the Risk-Benefit Balance

The key considerations for managing patients with COPD with lung cancer are no different than for patients without lung cancer, said Douglas Arenberg, MD, professor of medicine in the Division of Pulmonary & Critical Care Medicine at the University of Michigan, Ann Arbor, Michigan.

“People with COPD have a high rate of cardiovascular disease, so even if the COPD itself is not limiting, we always ask about cardiovascular risk, and our surgeons are equally concerned about this,” Arenberg said. Assuming cardiovascular status is not the rate-limiting factor, the main difference in clinical perspective over the last 25-30 years is the recognition that pulmonary function tests, which used to be the main determinant of surgical pulmonary risk, are no longer the determining factor in driving treatment, he said. “Many patients with severe emphysema but well-preserved exercise capacity can tolerate surgical resection, particularly in the current era with minimally invasive and less painful operations that facilitate more rapid recovery,” said Arenberg. “I always tell my patients that the best predictor of how they will feel the day after surgery is how physically fit they are the day before surgery,” he added.

In addition, clinicians and researchers have recognized that many lung cancers arise in an area of lung that is more diseased with emphysema and effectively nonfunctional, Arenberg explained. “Removing this nonfunctional lung has less impact on postoperative pulmonary function than one might anticipate from removing a similar volume of ‘normal’ lung,’” he said. Although surgeons will sometimes try to predict postoperative functional status using preoperative ventilation and perfusion mapping, this is generally used only in extreme circumstances, he said.

To determine a patient’s fitness for surgery, the surgeon will assess not only pulmonary function but also the location of the tumor, whether it is located in an area of healthy lung or nonfunctional lung, Arenberg said. Surgeons also take into account whether the tumor is located in an area of healthy lung or nonfunctional lung. “Removing nonfunctional lung often improves breathlessness, and if you can get the patient through the postoperative recovery, then their functional status is minimally affected,” he said. Also, “a patient’s presurgery exercise tolerance is probably as good a predictor of postoperative success as their pulmonary function test are,” he noted.

Contraindications for surgery are assessed by the surgeon, Arenberg told Medscape Medical News. However, “as a pulmonologist, what I encounter when speaking with my surgical colleagues is the question of whether the surgeon can gain access in a minimally invasive (VATS or robotic) approach to the hilar vessels and bronchial structures,” he said. “What might prevent or restrict this would be excessive scarring and/or adhesions from prior surgery, thoracic radiation, or infection, or other pleural complications that limit access to the hilum,” he said. “Perhaps very large tumors might be more difficult to remove through a small incision, but I’m always surprised at the size of tumors my colleagues are able to remove through a minimally invasive approach,” he said.

What Lies Ahead

As for additional research, the debate as to whether or not stereotactic body radiotherapy, as the primary alternative to surgery, is as good as surgery remains ongoing, Arenberg said. “SBRT can be extremely effective, but my personal experience is that it can create difficulties when performing follow-up surveillance for cancer recurrence, as it leaves behind scar tissue that can be very difficult to distinguish from recurrent and or persistent tumor,” he explained.

Lung cancer treatment options and the success of lung cancer treatment are moving targets because many different advancements occur in systemic therapy, radiation therapy, and surgical techniques, Arenberg told Medscape Medical News. Sorting through new options to provide the best advice for patients will be challenging, but current evidence supports surgery as the best option for early-stage lung cancer, he said. “Fortunately, advances in minimally invasive access to the lung or lungs and the skill of our surgical colleagues, more patients are eligible for surgery that would not have been safe two or three decades ago,” he added.

Friedberg and Arenberg reported having no financial conflicts to disclose.