Strides forward in lung cancer treatment

Mr Gerard Fitzmaurice, Consultant Cardiothoracic Surgeon, speaks to David Lynch about developments in lung cancer care at St James’s Hospital, Dublin, and nationally

Based on recent data published by the National Cancer Registry Ireland (NCRI), it was the leading cause of cancer death between 1994 and 2020. The survival rate of patients with lung cancer has more than doubled since the 1990s. While this trend is welcome, the disease is often caught too late to allow for surgical intervention.

As the surgical referral unit for four of the eight rapid access lung cancer clinics in Ireland, St James’s Hospital, Dublin, plays a pivotal role in the provision of this care. In March, this service was internationally recognised when the hospital’s department of cardiothoracic surgery was awarded institutional accreditation by the European Society of Thoracic Surgeons (ESTS) (See panel).

Quality

“I think the single biggest thing about the accreditation is that it is a quality marker,” Mr Gerard Fitzmaurice, Consultant Cardiothoracic Surgeon, Trinity St James’s Cancer Institute, told the Medical Independent (MI). Mr Fitzmaurice, who was also the hospital’s accreditation team lead, said that it “reassures” surgical patients who attend St James’s that they receive care that “is equivalent” to major cancer centres across Europe.

“For clinicians it is a similar quality marker,” he said, “so clinicians [across Ireland] who are referring patients to St James’s can be reassured that they are sending patients to the best hospital in Ireland for the treatment of lung cancer from a surgical point of view.”

Centralisation of cancer services, including surgical care, has been a priority within all the national cancer strategies over recent decades. The process has led to significant advances in specialised lung care in St James’s, according to
Mr Fitzmaurice. 

“Because we do such a significant volume of surgery for lung cancer we have developed a special expertise in the…perioperative [management] of complex lung cancer care,” he told MI.

Specialism

Lung cancer, like many types of cancer, benefits from being managed in centres that provide care to a high number of patients, according to Mr Fitzmaurice.

“In St James’s we look after more than half of the patients in Ireland who have surgery for lung cancer, so we have developed a unique specialism within complex lung cancer care.” This includes services for patients who have advanced disease – for example, cancer which has spread “into the major blood vessels around their heart and into their chest wall”. Another area of specialism is perioperative management of patients who may be receiving newer treatments, or on clinical trials.

Mr Fitzmaurice said that in a reasonably small country, it is preferable to centralise the management of more complex treatments in a main centre, or hub, which would provide support to other units. This approach facilitates the streamlined transfer of patients along a dedicated pathway, offering those with more complex lung cancer the chance to undergo surgical management in a specialised centre.

Comparing Ireland’s lung cancer care to that of the UK, Mr Fitzmaurice said patient outcomes in this country are “much better”. He attributed this, in part, to the centralisation of cancer care which commenced in 2007.

“One of the big things in Ireland from the cancer strategies… was the establishment of these eight rapid access lung cancer centres and four surgical centres.”

Mr Fitzmaurice said that “ideally” all lung cancer cases would be “centralised within that pathway”; however, he added there are still patients who are managed outside this process.

The important role of St James’s within this system has meant “from a surgical point of view, over the years, we have built up a wealth of experience of managing more complex lung cancer patients… and also in undertaking surgery and looking after them in their post-operative recovery”.  He said there “is a fantastic team and a wealth of experience” at the hospital.

“I suppose the whole overarching aim is to see can we continue to improve how we look after Irish people who have lung cancer.”

Screening

But significant challenges remain. Mr Fitzmaurice noted that “unfortunately” lung cancer is the number one cause of cancer mortality in the country and “it is only going to get more common”.

Highlighting predictions from the NCRI that there will be a “significant increase” in lung cancer in the coming two decades, Mr Fitzmaurice said Ireland “has to have some kind of plan or strategy to manage that”.

He also noted that, as with all cancer treatments, “the options and pathways for care are constantly evolving and getting more complicated.” This makes specialised centres of excellence essential.

“So if you try, particularly for the more complicated cases, to give people the opportunity to begin with the unit that has the most experience of managing those patients, it just kind of makes sense – that you would hopefully improve the opportunity for those patients to have surgery and also improve outcomes.”

Asked what the single biggest difficulty in lung cancer is from a clinician point of view, Mr Fitzmaurice replied: “Early diagnosis, without doubt.”

“The vast majority who have lung cancer, by the time they present, and have symptoms, it has already spread or metastasised or become too advanced to have an opportunity to have a treatment with a means of curing them. One of the biggest focuses for everyone who is looking after lung cancer patients is how we can try and find the patients who have lung cancer earlier.”

Mr Fitzmaurice cited cases where a patient might be scheduled for an unrelated operation and “for some reason, they have a chest x-ray and they are picked up [with lung cancer]”. However, he noted such instances are “pure luck”.

“We need to have some kind of mechanism where we [target] patients who are in a high-risk group and see if we can offer them a mechanism to identify lung cancer earlier.

“So, I suppose I’m talking about lung cancer screening, which is the ultimate aim, so that patients are detected earlier. The best way to do that is with screening.”

Currently, there is no national screening programme for lung cancer in Ireland, but work is underway in the area. Mr Fitzmaurice is currently one of the people involved in a screening pilot project that involves the RCSI and the ICS.

“There is a lot of work going on,” he said. He hopes that the pilot “can demonstrate in the Irish population that lung cancer screening would be beneficial”. And that this would mean the case “for more widespread use of lung cancer screening” in Ireland would be made stronger.