Told surgery is not an option for your lung cancer?
The reasons people are given, and which of them can change

The sentence comes from one of four findings. The stage: cancer in the lymph nodes in the middle of the chest, a tumour growing into a structure that cannot be removed, or cancer found outside the chest. Fitness: a judgement that your lungs or your heart would not withstand the operation. A previous treatment: radiotherapy to the area, or an operation that was started and stopped. Or the diagnosis itself: a tumour that has not been sampled, or lymph nodes staged on a scan alone. Each has a different chance of changing.

A decision made on the stage can change with treatment. Chemotherapy and immunotherapy given before surgery shrink the tumour and clear involved lymph nodes in a proportion of patients, and an operation that was not possible at diagnosis becomes possible after three or four cycles. A decision made on fitness can change with a more detailed assessment, or with a smaller operation. A decision made on a scan finding can change when the finding is sampled.

Some decisions do not change. A tumour growing into the heart itself, the aorta or the point where the windpipe divides is usually still not removable. Cancer confirmed in several organs is treated with drugs. The second opinion does not alter these. What it does is establish which of the four findings produced your decision, whether that finding has been confirmed, and what would alter it. The tests and staging page explains the three questions the staging tests answer.

No. Cancer in the lymph nodes inside the chest is stage 3, and stage 3 lung cancer is treated with the intention of cure. For many patients the treatment includes an operation, given after chemotherapy and immunotherapy. Whether surgery is part of the plan depends on which nodes are involved, how many, whether they are bulky, and whether the tumour can be removed with clear margins. Where it is not, chemotherapy with radiotherapy followed by immunotherapy is also given with the intention of cure.

Cancer in the lymph nodes within the lung itself is usually stage 2. Nodes in the middle of the chest on the same side as the tumour usually make it stage 3a. Nodes on the opposite side, or above the collarbone, make it stage 3b or 3c. The difference between 3a and 3b is one of the things that decides whether an operation is offered, and a single involved node station is treated differently from several.

A lymph node above the collarbone counts as stage 3, not stage 4. For a tumour at the top of the lung, called a superior sulcus or Pancoast tumour, a node on the same side above the collarbone is often treated as part of the local disease and included in treatment given with the intention of cure. This is decided at the multidisciplinary meeting.

What stage 3 treatment involves, including the operation after chemotherapy and immunotherapy, is set out on the stage 3 lung cancer page. The treatment journey from the first scan to recovery is on surgery after chemotherapy and immunotherapy.

A tumour in the middle of the chest, near the heart and the main airways, is called a central, hilar or mediastinal tumour. It sits close to the main bronchus, the pulmonary artery and the covering of the heart. Some of these tumours can be removed. A sleeve resection takes the lobe with a section of the airway or the artery and joins the ends, so that the rest of the lung is kept. Part of the covering of the heart, the pericardium, can be removed with the tumour. Where no smaller operation will clear the tumour, the whole lung is removed.

Chemotherapy and immunotherapy given before surgery change the picture for central tumours. In a proportion of patients the tumour shrinks away from the structures it was pressed against, and an operation planned as removal of the whole lung becomes a sleeve resection or a lobectomy. The operation planned at diagnosis is reassessed on the scan after treatment.

Some central tumours cannot be removed. A tumour growing into the heart muscle, the aorta, the oesophagus or the point where the windpipe divides is usually treated with chemotherapy and radiotherapy. The scan shows which structure is involved, and the second opinion is a reading of the scan by a surgeon who performs the operations described above.

The operations are described on the sleeve resection and pneumonectomy pages. A tumour growing into the ribs is a separate situation, covered on the chest wall invasion page.

Fitness for lung surgery is judged against a specific operation. The question is how much lung function you would have left after the operation, and whether your heart would withstand it. A patient who is not fit for removal of a whole lung may be fit for a lobectomy, and a patient who is not fit for a lobectomy may be fit for a segmentectomy or a wedge resection. The tests that show this are lung function tests, a cardiopulmonary exercise test, and a scan that measures how much work each part of the lung is doing.

A decision made on the resting breathing tests alone can understate what is possible. Where the part of the lung to be removed is contributing little, removing it costs little, and the functional scan shows this. Where the operation planned at diagnosis is a large one, chemotherapy and immunotherapy can shrink the tumour so that a smaller operation is needed, and the fitness question changes with it. Age by itself is not a reason; a geriatrician-led assessment is available to private patients at London Bridge Hospital and The Lister.

The assessment is set out on the fitness for lung surgery page, the borderline case on borderline lung function, and the older patient on lung cancer surgery in the elderly. Who should make the fitness judgement, and against which operation, is the subject of a commentary in the Journal.

Stage 4 means the cancer has been found outside the chest, in the other lung, or in the lining of the lung. Most stage 4 lung cancer is treated with chemotherapy, immunotherapy or targeted tablets, because the disease is in several places. When there is a single site of spread, and it has been treated or can be treated, the lung tumour may still be removed or irradiated as part of a plan intended to cure. This is offered to selected patients and decided at the multidisciplinary meeting.

What surgery can and cannot offer in stage 4 with one site of spread, and how the decision is made, is on the stage 4 lung cancer with a single site of spread page. A cancer that started elsewhere and has spread to the lungs is a different situation, covered on cancer spread to the lungs.

Radiotherapy to the same area usually cannot be repeated. If the cancer persists or returns in the treated area, radiotherapy is unlikely to be the next step, and the choice is between drug treatment and surgery. Surgery after radiotherapy, called salvage surgery, is possible in selected patients where the disease is confined to the treated area and restaging scans show nothing elsewhere. The operation is harder than a first operation because the tissues are scarred, and it is assessed with a new PET-CT, a brain scan, a biopsy of the area and a fresh fitness assessment.

Previous radiotherapy also changes how a new area on a scan is read. Scar tissue after radiotherapy can look like cancer, and cancer can hide in scar. A sample of the area is needed before any decision, and where the area is small or deep in the lung, robotic navigational bronchoscopy can reach it through the airways.

The operation and its assessment are on the surgery after radiotherapy page. Cancer returning after a previous operation is covered on when lung cancer comes back after surgery.

An operation that is started and stopped means the surgeon found the tumour involved a structure that could not be removed with the operation planned, or found disease that the scans had not shown. The findings are recorded in the operation note and the case goes back to the multidisciplinary meeting. The usual next step is chemotherapy with immunotherapy, or chemotherapy with radiotherapy, given with the intention of cure.

A second surgical opinion in this situation reads the operation note alongside the scans. The question is which structure stopped the operation. Involvement of the chest wall, the pericardium, the pulmonary artery or the airway can sometimes be dealt with by an extended operation, a sleeve resection or removal of the whole lung, at a centre that performs them. Involvement of the heart, the aorta or the oesophagus usually cannot. After chemotherapy and immunotherapy the tumour may have shrunk away from the structure, and the operation is reconsidered on the new scan.

The extended operations are on the chest wall invasion and sleeve resection pages. The treatment given before a second attempt is on the stage 3 lung cancer page.

Dr Okiror requests your CT and PET-CT scans from the hospital that performed them and reviews the images himself before the consultation, so the appointment is spent on the decision. The consultation is by video within 24 hours, or in person within 2–3 days at London Bridge Hospital, The Lister Hospital Chelsea, Canary Wharf or the City of London. A written report follows within 48–72 hours, which you can take back to your NHS team. The consultation fee is £250–£350. Self-referrals welcome.

The consultation settles two things: what type of surgery would be needed, if any, and what recovery would look like. Where the case has not been considered surgically, or where a different operation is being proposed, it is presented to the London Bridge Hospital chest multidisciplinary team before any surgical decision is made. Where the opinion changes the plan, surgery is usually within a week of completing investigations; patients who already have their tests can be booked within days of the consultation.

Out-of-area patients are seen by video first. Several people can join the same consultation from different places, so a parent in one city and an adult child in another, or in another country, can be in the consultation together. Patients travelling from outside the UK can read how the international pathway works.

Most insurers, including AXA Health, Bupa, Aviva, Vitality, WPA and Cigna, fund a second opinion consultation and usually settle it in full, less any excess written into the policy. If an operation follows, guide prices are published on the fees page; hospital charges are the largest part of every total, the hospital issues a written fixed quote before treatment, and insurers usually settle the hospital, surgeon and anaesthetist fees in full, less any policy excess. A second opinion does not commit you to private treatment.

A proportion of second opinions confirm the original decision. In that case you receive the reason in writing, which of the four findings produced it, and the tests or treatment that would change it: restaging after chemotherapy and immunotherapy, a biopsy of the lymph node or of the single suspected site of spread, or a functional assessment of the lungs. A decision confirmed on tested evidence is a different thing from one made on a scan reading, and the report says which you have.

Where surgery is not the right treatment, chemotherapy with radiotherapy followed by immunotherapy is given with the intention of cure in stage 3, and radiotherapy alone can treat a single area with the same intention. These are treatments in their own right, chosen because they fit the disease, and the report says so where that is the case.

The decision can also be revisited. A patient judged unfit during a hard period of treatment may be a different person a year later, and a tumour that did not respond to one treatment may respond to another. The report sets out the point at which the question should be asked again.

Many enquiries come from an adult son or daughter, or a partner, rather than the patient. That is welcome. The patient’s consent is needed to request the records and scans, and the practice will tell you what is needed. Send what you have: the staging letter, the scan reports, the letter with the multidisciplinary team’s decision and the biopsy result, and tell us which hospital performed the scans so the images can be transferred. If you do not know the details because the patient does not like talking about them, send what you can and say so.

The questions families bring are the same ones: what this means, what to expect, what type of surgery would be needed, what the recovery would be like, and whether anything has been missed. These are answered in the consultation, with the scans on screen. Several family members can join a video consultation from different cities or countries, so nobody has to travel to be part of the conversation.

Survival figures found online for stage 3 lung cancer mostly predate the trials of chemotherapy and immunotherapy before surgery, and do not describe the treatment now given. What the figures mean for an individual patient is a conversation for the consultation, with the stage, the biopsy results and the fitness assessment in front of the surgeon.