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Lung cancer represents the most common cause of cancer-related death in the world. It was considered a rare disease until the early part of the 20th century. In 1879, lung cancer represented only 1% of cancers identified at autopsy compared to 14% in 1927.1 The famous surgeon, Alton Oschner reported that as a medical student in 1910, he was called to the autopsy suite to see a case of lung cancer, since it was so rare he was likely to never see another case. Seventeen years passed before he saw another case of lung cancer and then he saw 8 cases in 6 months.2 The link between tobacco use and lung cancer has been common knowledge since the surgeon general's report in 1964, and despite that knowledge, the death rate continued to rise in men until 1991 and in women until 2003. The treatment of lung cancer has evolved from a single modality, surgery, to a multimodality approach that calls upon the skills of numerous specialists. Physicians, who diagnose and treat lung cancer, must work together to define the role that surgery plays in the modern management of lung cancer. Surgery, when appropriate remains the cornerstone of therapy, and surgeons play an integral role in the diagnosis and treatment of patients with lung cancer.
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The diagnosis and staging of lung cancer is covered elsewhere in the text. It is illustrative to consider the route taken by most patients before being referred to a surgeon and the qualifications that the surgeon should ideally possess to contribute optimally to the management of the patient with lung cancer. Patients with lung cancer may present with obvious symptoms such as hemoptysis or chest wall pain. The most common presenting complaints are respiratory symptoms that prompt a chest radiograph. From the surgeon's viewpoint, the evaluation of patients with abnormal imaging studies depends on the likelihood of malignant disease. In patients with a history of smoking the level of suspicion is higher. Lung cancer is seen in nonsmokers, but the suspicion for cancer is significantly lower in this group than in smokers, in whom an abnormal chest radiograph is lung cancer until proved otherwise. If previous chest imaging is available those studies should be compared with the current imaging. A lesion that appears unchanged from older films, particularly those obtained more than 2 years previously, markedly diminishes, but does not eliminate, the probability that the current finding represents a lung cancer.
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When a surgical referral is indicated, the surgical specialist should offer a complete armamentarium of surgical options and techniques as well as an understanding of the principles of lung cancer treatment. The technical ability to perform lung resection is the minimum requirement but by itself is not sufficient. There is an increasing trend toward thoracoscopic techniques such as video-assisted thoracic surgery (VATS) or robot-assisted surgery. At least 30% of lobectomies are performed ...