The 18th World Conference on Lung Cancer (WCLC) organized by the International Association for the Study of Lung Cancer (IASLC) was held in Yokohama, Japan from 14–18 October, 2017. As the world’s largest multidisciplinary oncology conference on lung cancer, it gathered more than 7,000 key opinion leaders, professionals and researchers from over 100 countries, who came together to unfold a series of in-depth academic exchanges and collaborations. In the meantime, AME seized the opportunity to conduct interviews with a number of experts.
Dr. Jhingook Kim is a professor and thoracic surgeon at the Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. He has worked as a clinical and translational cancer researcher who aims at defining and expanding the role of surgery in the locally-advanced lung cancer (T4, N2) in collaboration with systemic treatment (chemotherapy and/or immunotherapy). He has tried to identify the high-risk group of recurrence among the curatively-resected early stage lung cancer by clinicopathological and molecular parameters. Besides, he has worked to identify the carcinogenesis and progression mechanism of lung cancer in never-smoker adenocarcinoma.
At the 18th WCLC, he chaired the subject “Mediastinal and Esophageal Tumor: Insight and New Treatment” and gave an astonishing speech on “What is Resectable N2 Disease, and What is Unresectable N2 Disease: A Surgeon’s Viewpoint”.
During the interview, Dr. Kim shared with us his experience and analyses of IIIA (N2) non-small cell lung cancer treatment at his center. Statistics have shown quite favorable outcome after induction therapy followed by surgery. It was found in recent decade that the overall survival rate reached 57%, which included cases with bulky and multi-station nodal metastases. Most of the surviving patients could maintain acceptable living quality. Despite the ineffectiveness in reducing the rate of recurrence, which was still as high as 70%, the number of patients surviving after the recurrence has been escalating.
To Dr. Kim, this heartening result is due to the improvements in both systemic treatment and supportive care after recurrence. For example, patients with brain metastasis detected before any symptoms can now receive short-course radiotherapy like gamma-knife surgery, and maintain their usual happy life without affecting their living quality significantly.
In spite of the essential role of systemic treatment in N2 disease, Dr. Kim believes that the importance of surgery can never be overlooked. He said, “Due to complete local control and close follow-up, most of the recurrences were radiologically-detected systemic recurrence without any symptom. Even with recurrence, patients maintained their usual life and could undergo further treatment if needed. Therefore, we can speculate that complete local control and close follow-up may play certain role in patients’ survivals after recurrence.” He then emphasized, “Therefore, safe surgery without complication and maintenance of performance might be the most important points to be considered in locally-advanced lung cancer. With combined chemoradiotherapy we can offer a lot less risk with more than 40% chance of survival in this patient group. Inadvertent application of surgery with high risk should be avoided.” Based on his experience, the data for trimodality treatment was very good—only 3% of mortality. Nevertheless, he strives to bring it further down to less than 1% mortality and 15% morbidity.
Unfolding a new series of case studies is thus imperative. More and more individual studies in surgery and other modalities, especially immunotherapy, should be carried out. Dr. Kim insisted that there should be more studies in combined local control (surgery) and systemic control (chemo and/or immunotherapy), either as adjuvant, neoadjuvant or salvage purpose, and either with or without radiotherapy. By year 2025, Dr. Kim anticipates to see a giant leap to 70% of overall survival rate in stage IIIA (N2) lung cancer.
When asked to advise younger doctors on how to become successful surgeons, Dr. Kim said, “Surgeons are not merely a technician, but scientists. A competent surgeon must be equipped with a wealth of scientific knowledge about the disease, the patients and the techniques.”
Dr. Kim followed, “Always bear in mind that lung cancer is a systemic disease. Surgeons must first understand well the lung cancer biology and other treatment alternatives such as proton therapy, targeted therapy and immunotherapy, together with their risks and benefits. They then can decide whether surgery should be performed, when to perform, and how to perform. Never should surgical oncologists neglect the genomics, genetics and immunology of cancer. Secondly, of course, safety is always the key element that surgeons should give priority to. Hence, to become a successful surgeon, the prerequisite is to comprehend the patients’ performance and function in general, both before and after the surgery. Thirdly, advancement of surgical techniques as well as other local modalities should be equipped as well. The goal of surgeries is not to resect the cancer mass itself, but to survive the patient. Any strategy with better survival and least risk should be recommended to the patients.”
What Dr. Kim suggested are as what the old Chinese saying goes, “Know thyself and thy adversary to win a hundred battles.”
Conflicts of Interest: The author has no conflicts of interest to declare.
(Science Editor: Brad Li, TLCR, firstname.lastname@example.org)