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  • Writer's pictureDoç. Dr. Hasan Ersöz

Understanding Cancer: Insights, Innovations, and Strategies for Lung Cancer Care

Updated: Jan 20


what-is-lung-cancer

What is Cancer?

Uncontrolled proliferation of cells. Deteriorated cells may fall into the blood or lymph circulation andreach a distant tissue via blood or lymph and adhere there. Therefore, in the advanced stage of thedisease, these damaged cells are not only limited to that region, but can also infect other distant organs.



Influential Factors Shaping Cancer Progression and Potential Patient-Centric Interventions

So, there are a few factors here that determine the course. The behavior of the cancer cell. Just as somedogs are docile while others, such as the pittbull, can be aggressive, just as the characters of not onlydogs but all animals and humans are different, these cancer cells can also vary. In my 15 years of practice, I have also seen a tumor that remained in place for more than 10 years without infecting any distant organ or growing much, and a tumor that had no metastasis anywhere 15 days ago, but 15 days later it spread to almost all tissues of the body. For this reason, we can list the behavior of the tumor first in terms of determining this course. That's why cancers are classified according to certain behavioral groups and the tissue types from which they originate. These groups are given separate names. Adeno cancer and squamous cell cancer are just two examples of these names.


what-is-lung-cancer

In addition, the organ where the disease first begins can determine the course. For example, although there are exceptions, thyroid gland cancers can generally be more benign, while pancreatic cancers generally have a worse course. Here, the characteristics of the relevant organ play a different role on the course of the disease. For example, a cancer originating from a tissue with high blood supply may spread more slowly when it occurs in an organ with less blood supply, even though it is of the same class. Or, there is a vital vessel adjacent to the organ, and the tumor may grow at a low stage before it has spread further, and may pose a life-threatening threat by putting pressure on that vessel from the

outside and disrupting the blood flow within the vessel. Therefore, the organ in which the tumor is located and its location are another factor that determines the course. For this reason, today we are talking about the type of cancer that we classify as lung cancer, which is the organ of interest of my branch.

What is Cancer

Apart from the type of cancer and the organ in which it is located, a third factor that determines the course of the disease is the stage of the disease, which we mentioned at the beginning when defining cancer. I will give a dramatic example, but we have seen all of these in real life. We took the patient, who had a serious injury to his lung due to a gunshot wound, into emergency surgery. Without having time to repair it due to excessive bleeding, I removed half of the lung with lobectomy surgery so that the patient could continue his life. Even though we performed trauma surgery, the general rule is that every tissue removed is sent to the pathology laboratory for pathological examination. Proving how true this rule is, in the pathological examination report of my patient, we saw that cancer at the cellular

level, which we call "carcinoma in situ", was detected in the lung, which was caught while it was still at the microscopic cell level. Perhaps those who shot him had saved him from an aggressive cancer that he would suffer in the future. I say they saved it because it was caught while the cells were still in the division stage, so it wasn't even stage 1.


If we give information about the stages, there are basically 4 stages in lung cancer. There are subtypes of these stages, but it is enough if we know them as 4 stages. Let me talk about the scientific studies conducted by recording the 5-year follow-up of thousands and even millions of patients diagnosed with lung cancer. The ratio of patients who have not died due to lung cancer within 5 years to all patients is made and this is called "5-year survival". Look, these data have been collected from reliable sources from all geographies of the world and are accepted all over the world, especially in developed countries such as the USA, which we follow in the literature data. It is not something you just say "it's for me, it's for you" and get out of it, but it is the accumulation of knowledge gained as a result of life experiences. That's what science is. It should not be disconnected from life, nor should it differ fromperson to person. The 5-year survival of these patients with lung cancer diagnosed at stage 1 was found to be 70%. So what I'm saying is that when stage 1 lung cancer is detected in a patient, science says that there is a 70% probability that that patient will not die due to this disease for 5 years, with the knowledge gained from the 5-year follow-up of millions of lung cancer patients. However, this rate drops to 40-55% for stage 2 disease, 5-25% for stage 3, and only 1% for stage 4. In other words, just as a stage 1 patient may not die due to this disease with a 70% probability for 5 years, this means that a stage 4 patient may die due to this disease with a 99% probability within 5 years.


To summarize, so far I have talked about the importance of 3 issues that determine the course of the disease for any cancer, not just lung-specific. The first was the behavior and class of the tumor, the second was the organ where it was seen and its location in this organ, and the third was the stage of the disease, that is, the amount of progression since its beginning. We may not be able to change the first two of these issues in today's conditions, in fact they can be changed, but first let's focus on the change in today's conditions and touch on the idealistic change part in a moment. In today's world order, we

can only contribute to patients by changing the stage at which the disease is detected. If you ask how we can do this, the priority should be education, as in everything else. This information and the importance of early diagnosis should be emphasized. Self-examinations at home can help detect early-stage breast cancer, for example. Educational services such as these and similar public information activities, meetings, use of written and visual media, and involvement of municipalities and other community organizations can be provided. Simple information can be lifesaving. Again, thanks to this information they receive, it can be very important for people to feel the change in themselves early and consult a doctor. For example, a cough that does not go away for several months should raise suspicion for lung cancer.


Let's talk about the other two of the three issues. What can be done about the behavior of the tumor and the organ in which it is seen. This may be possible in the future, but I think it would be too idealistic right now if I talked about gene therapies. Cancer is basically a genetic disease. It does not have to be inherited in families, as a result, there is something we call mutation. A mutation is a change that occurs in a person's genes, such as due to exposure to a beam of radiation. In other words, when we say genetic disease, we do not necessarily mean genetic transmission from the family, this can also happen with changes that occur later, and since it is genetic as its name suggests, it can also be transferred to children born after the mutation occurs. We can improve the behavior of the disease

and eliminate the disease by treating the genes that carry this disease in the patient, whether it is inherited from the family or by mutation. You don't need to be a professional to see this happening in the future, the trend is that way. In the past, people will say that they had to remove half of the lung or one of the two lungs because they had lung cancer. But the real treatment will be on these genes. Let's see when the capital centers will decide this and move the treatment in this direction. After all, the current order works for them.


I would like to reiterate that today we do not have the chance to change the type of tumor and the organ in which it is seen, but there is a chance of early diagnosis based on the stage factor. What I am trying to say is that, in the example of the shooting of the patient I just mentioned, it is not an example of the person who wants to take his life, with a divine blessing, ensuring that the patient's early stage cancer is detected. Screening examinations, the emergence of new tumor markers with advances in medicine, advanced diagnostic methods such as tomography, MRI devices, PET tomography. Until they reach this level that I just mentioned, it is important for patients to be educated, to be able to notice the changes in themselves and to consult their doctors without delay.


Early Detection Benefits in Cancer: Impact on Treatment Options and Stage-Based Interventions


Early Detection Benefits in Cancer

What is the advantage in the early stages? Of course, the fact that the tumor has remained local without reaching the lymph and blood vessels and spilling there, that is, being stage 1 for 4-stage lung cancer, provides the patient with a chance of recovery if this tumor is removed cleanly in today's conditions. That's why it has a 70% survival rate. And without the patient having to take anysupportive medication (chemotherapy) or radiation therapy (radiotherapy). Because the disease is still regional.


But as the disease spreads to the lymph and blood vessels, the chance of cure decreases. Although there are still cases where there is a chance of surgery for lung cancer in early lymph infection and the surgery is performed in the same way, once the lymph fluid is infected and there is a possibility of spreading to other tissues. According to data from the same center where surgeries were performed in the same way, the 5-year survival rate for stage 1 disease is 70%, while this rate drops to 55% even in the best case of Stage 2, which still has a surgical chance. In case of more advanced lymph spread or distant organ spread through any blood, the patient has almost no chance of surgery, and chemotherapy or radiotherapy procedures are applied directly.


In summary, the requirement for a cancer to be considered to be at a treatable stage today is that it be at an early stage, that is, at a stage where surgery can be performed. Although there are alternatives to this, none of them are definitive rivals to the surgery that has proven itself in the guidelines. For example, the application called "virtual knife" or "space knife" applied by radiation oncologists called stereotactic radiotherapy. Although successful, it is not the gold standard, that is, a practice accepted by everyone. The first option is surgery, it is just an alternative to try if surgery cannot be performed. Surgery may not be possible in some patients. For example, the patient's heart disease may not allow him to receive anesthesia, or he may have other medical reasons, or his social situation may not allow

him to undergo surgery. For example, some patients may worry that they will not have anyone to care for them after surgery. In such cases, this option is also available.


Again, in recent years, targeted drug treatments have become available, which I call the ancestors of "genetic therapy". This is very promising as it is the forerunner of future treatments. Classic chemotherapy is poison as you know. While it poisons the tumor, it also poisons the person, but since the tumor cells multiply too much, it wears them out more, and if the patient is strong enough to withstand this process, it is beneficial for the disease. However, in targeted therapy, a specific feature of the tumor is targeted. The attack only targets that feature without damaging other tissues of the body. Thus, an advantage is gained against the tumor without causing a change in the general condition of the patient. Moreover, it is not applied to every tumor. The tumor must have certain characteristics. In order to understand whether this can be applied, some features of the tumor need to be examined by biopsy. Unfortunately, this treatment can only be applied to tumors with this feature.


But let me repeat, none of these replace surgery. Virtual knife or targeted treatment is not offered as the first option in stage 1 tumors in any accepted guideline in the world; the first option is always surgery if it can be done. Others are auxiliary treatments for today. No one knows what will happen in the future.


Comprehensive Lung Cancer Diagnosis and Surgical Practices


Comprehensive Lung Cancer Diagnosis and Surgical Practices

Let's come to the subject that is required by my branch... What kind of surgical practices do we use in lung cancer? First of all, we have some applications at the diagnosis stage.


In case of suspicion of lung cancer, one of the most important diagnostic methods is bronchoscopy. Bronchoscopy means the use of an optical instrument called a bronchoscope, which can be inserted into the bronchi and their branches from the trachea and allows those areas to be viewed and examined. With these, it is even possible to penetrate bronchial branches with a diameter of a few millimeters. Patients are given a sedative medication and the mucus membranes of the nose, throat, larynx and large bronchi are locally anesthetized using a spray. Bronchoscopy does not require an incision and is performed through the mouth or nose. In rare cases, it may be necessary to take a sample with a thicker tube, which we call rigid bronchoscopy, and therefore the need for general

anesthesia may arise.


Sometimes bronchoscopy, called ebus, which has an ultrasound probe at the tip of the bronchoscope, can also be performed and samples can be taken from deeper tumor tissues or lymph nodes. Tissue sample collection from the lung tissue is performed through a needle insertedthrough the bronchial wall. Suspicious tissue samples taken are subjected to pathological examination. If the location of the tumor is in the part that the bronchoscope can reach, it is possible to reach a diagnosis based on the tissue and cell samples taken in more than 70 percent of these patients. Sometimes tumor tissues may be located on the side, close to the ribs, rather than in the area close to the windpipe. In these cases, sampling can be done with a needle inserted between the ribs with the help of ultrasound or tomography, just like in bronchoscopy. This is called transthoracic needle biopsy.


Comparative Analysis: Recent Advances vs. Classical Surgical Treatments in Cancer Care


Comparative Analysis: Recent Advances vs. Classical Surgical Treatments in Cancer Care

Again, in order to sample a tumor or lymph node in the area close to the esophagus, EUS can be performed, which is a method of taking samples by entering the esophagus with endoscopy and inserting a needle into the relevant tissue with the help of the ultrasound probe built on this endoscope.


In addition to diagnostic procedures, we can sometimes perform procedures to ensure accurate staging of diagnosed patients. If suspicious findings are detected in another organ or lymph nodes as a result of tests such as tomography or PET, the only explanation for this may not be that lung cancer has spread to those areas. Some conditions unrelated to cancer, such as various infections and rheumatic diseases, can also cause these suspicious findings. To distinguish these conditions, a biopsy can be performed for staging purposes on these suspicious tissues.


For this purpose, mediastinoscopy surgery can be performed with a 3 cm incision similar to the thyroid surgery incision in the neck, and mediastinotomy, which is a biopsy procedure taken from the anterior chest wall, over the breast, between two ribs.


Despite all these options, if the tumor or lymph node is inaccessible, samples can be taken from the lung or the relevant lymph node by entering the chest cavity through 2-3 cm incisions with VATS, which we call closed chest surgery. If this is not successful, open surgery may be required as a last resort.


In the last two options I have mentioned, that is, closed or open surgeries, both diagnosis, staging and, if the stage is appropriate, a chance for surgical treatment can be provided in the same session. With rapid pathology, which we call Frozen, the sampled tissues are sent to the pathology unit of the hospital during the surgery, and after a maximum of half an hour, the pathology team reports the rapid pathology result via phone, giving a 90% reliability rate. Accordingly, if the patient's stage i appropriate, this time the surgery is taken into the treatment dimension.


Another importance of the permanent pathology report after surgery or biopsy, as I mentioned in targeted therapies, is to determine whether the target of that targeted therapy is present in the patient's tumor. If the features are present, the patient can be started on smart drugs instead of classical chemotherapy, and this is of great importance.


Post-Diagnosis Lung Cancer Treatment Approaches and Strategies


Post-Diagnosis Lung Cancer Treatment Approaches and Strategies

In terms of surgical treatment, it is possible to say that the most desired ideal treatment for lung cancer is lobectomy surgery, with some exceptions. In other words, it is to remove not only the tumor or the surrounding 1-2 cm tissue, but also the lung lobe where the tumor is located (the right lung has 3 lobes, the left lung has two lobes), by tying and cutting its arteries, veins and bronchi. This corresponds to the removal of half of the left lung. In the right lung, lobe sizes can be very different.


Sometimes, if the location of the tumor is at the point where the other lobes meet, it may be necessary to remove the entire lung, whether the tumor is in the right or left lung. This is what we call pneumonectomy, and it is a surgery we do not like very much. However, it is taken only if the oncological principle requires it to be taken.


Some patients do not have the respiratory capacity to tolerate the removal of a lobe. In such cases, we can remove a portion of the lung smaller than the lobe by segmentectomy or wedge resection. Again,sometimes we can perform surgeries that involve more technical details, which we call sleeve resections, in order to protect the lung.


In the treatment, removal of the relevant lung is not enough; the lymph nodes in the mediastinal region between the two lungs are also removed completely or partially and sent to pathology. At the end of this pathology, the actual stage of the patient is determined and it is decided with this pathology result whether chemotherapy or radiotherapy is required following surgical treatment.


Sometimes it can be the opposite. In other words, the patient's stage may be determined as advanced and the patient may not be operated on at that stage. Instead, the patient can receive chemotherapy or radiotherapy. With these treatments, the tumor can shrink, the swelling in the lymph nodes can recede, and the disease can be reduced to an operable stage again. In this case, we can perform “lung resection after neoadjuvant treatment”, that is, therapeutic surgery.


Another detail is extended resections. Sometimes, even if the tumor does not spread to distant lymph nodes or organs, it can grow and progress to neighboring organs. We distinguish this from the tumor that mixes with the blood and travels away, because science says that if we can remove the tumor with completely clean margins, it will cure the patient. In these cases, we can simultaneously remove the lung and the relevant organ, such as the ribs, diaphragm or the membrane of the heart. We call these extended resections.


In summary, the aim should be to diagnose the disease, operate when it is at the right stage, and not leave any tumor cells behind as a result of the surgery, in accordance with oncological principles. In this way, when surgery can be performed closed, our first choice is always closed surgery. However, if there is even the slightest doubt due to closed surgery, the surgery can be made open or can be started directly with open surgery in order not to compromise oncological principles. What I am trying to say is that the long-term results of closed or open surgery do not matter as long as oncological principles are followed. What is more important is not to compromise on those principles. Closed surgery is only

effective on early postoperative results such as postoperative hospitalization, pain, and patient comfort. I would like this to be known.


The Role of Robotic Surgery in Modern Lung Cancer Surgical Practices



There is also a robot-assisted thoracic surgery that has emerged in recent years, namely RATS. Although this is basically the same as closed surgery, the surgeon does not perform these procedures by holding hands or the same instruments, but sits at a console and robotic arms hold those instruments, and the surgeon controls these arms from the console. There are advantages and disadvantages. The most important disadvantage is the cost. Its advantage is that it provides the ability to manipulate at more angles than the human hand, increasing the possibility of completing the surgery in a closed manner. Other than that, in my opinion, it is no different from closed surgery.


Prioritizing Prevention: Strategies to Minimize Cancer Risk and Understanding the Impact of Tobacco Use, Specifically on Lung Cancer


the Impact of Tobacco Use, Specifically on Lung Cancer

We touched on all of these, but I think the most important part is preventive medicine. Here is the secret of a cheap and healthy life for the society, which aims not to cure cancer but to prevent lung cancer at all, which is not very beneficial for the capital owners.


In this sense, the first thing that comes to our mind is cigarettes. Not only cigarettes, but actually all tobacco products are included in this group. Pipes, cigars, hookahs, drugs, electronic cigarettes and many more that I can't think of... They are all included. No one should deceive anyone, by saying that electronic cigarettes are harmless, there is a risk of smoke inhalation. If a person who smokes a lot gives up this habit, the risk of getting sick decreases from 15 times to 5 times within 10 years compared to a non-smoker. 15 years after quitting smoking, this risk decreases to only twice that of a non-smoker. This risk decreases even faster in women.


Not only tobacco products, but even stoves and barbecues are included in this. It does not necessarily have to contain nicotine, some of the thousands of chemicals found in cigarettes are also present in them. These chemicals can also trigger cancer. Unfortunately, nowadays we are exposed to chemicalsnot only through smoke inhalation, but everywhere. In our food, drinks, cleaning materials, detergents, air pollution and many more... Our radiation exposure is increasing due to factors such as existing base stations. Inevitable technological products such as phones etc. cause us to be exposed to magnetic

fields. We are all fed with genetically modified organisms, that is, GMO products. It should not be surprising that cancers, whose frequency is increasing today, progress in parallel with our exposure to them. I don't know how much of all these can be avoided, but it is an indisputable fact that we should stay away from them as much as possible to protect ourselves from cancer.


Asbestos, arsenic, chromium, nickel, radon and aromatic hydrocarbon are some of these substances and they play an important role in occupational health and protection measures for employees in relevant sectors. If the air outside contains very high levels of harmful substances, it can increase the risk of lung cancer by approximately 50%. It is among the important factors in this regard.


Soot and other fine dust created by diesel fueled engines can be counted. Nutrition is important, especially eating enough fruit obviously protects against lung cancer. But taking vitamin tablets or other food supplements instead of fruit does not replace this protective effect. Smokers, in particular, should be especially careful with these types of substances: In fact, in studies conducted to demonstrate the protective effect of some vitamins, an increase in risk was even detected in smokers if vitamin tablets were taken.


Are there any differences of lung cancer from other cancers?


Are there any differences of lung cancer from other cancers?

The most important feature that distinguishes lung cancer from other cancers is that it is preventable. In approximately 90 percent of lung cancer cases, the disease is related to known causes. Approximately 85 percent of these are linked to smoking. In professional life, people can take precautions against lung cancer by adjusting their behavior accordingly and taking preliminary measures. The lack of a screening test for early diagnosis brings prevention measures to the fore.

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Dec 22, 2023
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Amazing...

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