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We have to change our practice if we want better results

Prof Marcello Migliore, Section of General Thoracic Surgery, University of Catania, Policlinic University Hospital, Catania, Italy

Interviewed by James Coker Reporter, EMG-Health

During last year’s European Respiratory Society (ERS)’s International Congress, held in Madrid, Spain, we took time out to speak to a well-renowned expert in thoracic surgery, Prof Marcello Migliore, Section of General Thoracic Surgery, University of Catania, Policlinic University Hospital, Catania, Italy. Topics included in this discussion were the future of surgery in respiratory health, Prof Migliore’s ambitions for his newly elected position of Chairman for Thoracic Surgery at the ERS, and much more.

Q: What do you believe have been the most impactful advances in thoracic surgery over the course of your career?

A: The most important are the advances in minimally invasive thoracic surgery; these have changed the lives of patients because their hospital stay is reduced, their pain is lower, and they have a very quick return to normal life, so there is no question that these changes in the clinic are changing the lives of our patients.

Within minimally invasive thoracic surgery, there are several different approaches and there is much discussion about these. But what we need to tell people is that the most important thing is not the approach; it is to maintain safety for our patients. The surgeons must choose a technique according to what is best for the individual patient, without pressure to do one particular technique or another. In terms of the future of minimally invasive thoracic surgery, there is no question that large thoracotomies are disappearing.1

Q: To what extent are the patient’s wishes taken into account when deciding whether or not to undergo surgery?

A: We must realise that patients have the power to decide many things today. There are often different techniques for the same operation; for example, to remove a piece of the lung. All these techniques have the same results so how do we know which one should be chosen? Sometimes I let the patient decide the approach for the operation: do they want a single but larger skin incision or 2–3 small skin incisions for example? Patients should have the power to decide as long as it is proven that the techniques produce similar results.

There is no question that in the era of technology, medicine and surgery are changing.2 The surgeon of 50 years ago was viewed as the person who decides the life of patients, and his decision was often incontrovertible. Things are now viewed in a different way because patients want to know all the information necessary and they also take evidence from the web, and then decide what happens themselves after seeing their doctor/surgeon.

Q: To what extent do you believe advanced technologies such as robotics are enhancing thoracic surgery and how do you expect these to be used into the future?

A: Everybody wants robots at the moment. I wrote a paper a few years ago about robots; the main issue is that they are very expensive.3 Not all hospitals can buy them and the other big issue is that they have not yet shown any survival advantages with regard to long-term results in patients, including those with lung cancer.4 So the question at the moment is that if the robot is so expensive and doesn’t show any advantages over other techniques other than being less invasive, why should we use it? That is a big question that is unresolved at the moment. I think all university hospitals need a robot because the residents need to expose themselves to different techniques and then decide which one is the best for them. If the price of the thoracic robot is reduced it will be used a lot in the future. Only large hospitals and universities can have a robot at the moment because their price is very high. We are not able to justify the price if the results are not superior, so we need to think carefully about this issue.

Q: Which topics would you like to see discussed at ERS and other respiratory congresses in the coming years?

A: I think we should be discussing the future of robots in medicine and surgery. It is also important to invest in the future, to find the therapies for those patients who cannot currently be operated on. Currently, 70% of patients with lung cancer do not have an operation because they are already at an advanced stage. My belief is that we should be giving more attention to this 70% of patients: if we prolong survival in this group of patients, we will significantly increase overall survival. In most of the 30% of patients in whom we operate, they survive, because we know the Stage 1 cancer survival rate is 90% over 5 years. We cannot do much better than this, so instead we should now concentrate on the 70% of patients in whom surgery is not contemplated and only chemotherapy and palliative treatment is available.

When a patient with lung cancer is told that they cannot have an operation, it is terrible for them because every patient wants an operation to have their cancer removed. Therefore, if we find a space for some of these patients to have an operation and prolong survival, we can give them real hope. Hope is very important in our lives; people always need to be able to see a light at the end of the tunnel. We have proven in a systematic analysis of advanced-stage lung cancer patients with pleural effusion and malignant pleural effusion that some of these patients can be operated on because the disease is concentrated only in the chest; there is no spread outside the chest in the liver, in the brain, on the contralateral nodes. These patients can be operated on and survive longer.5

Although our systematic analysis was only with a few patients, we showed that survival can be triplicated through surgery and that is very important because patients need this hope. Everybody wants to stay in this world even if it is not a perfect life, but if they can live longer with good quality of life, it is one of the best achievements we can accomplish. Certainly more robust science is necessary, and therefore prospective randomised trials are necessary.

Q: Do you think there are any other conditions for which surgery could be used more often than is currently the case?

A: Yes: in advanced lung cancer. Mesothelioma is another tumour that is devastating for our patients. There is a relatively new treatment now being used in many patients, which is hyperthermic intrathoracic chemotherapy together with surgery. This means that we perform the operation and at the end deliver hyperthermic chemotherapy drugs directly to the chest cavity. This kills all cells that are left inside the chest after the operation, which is a new way of thinking. It’s not going to be used everywhere but I believe in it because it’s a different way of doing things: we have to change our practice if we want better results, and therefore we need to create a strong basic science upon which we build our practice for the benefit of patients. Other authors and our team have done lots of very good work on this.6,7

Q: Are there any topics you think deserve greater attention at major respiratory conferences like the ERS in future years?

A: We certainly need to look at new ideas. We have to incorporate into our practice what has proven to be best for our patients. From my point of view, treatment of pleural effusion can be another point of discussion because we can work together and better with our chest physician colleagues. Co-operation is my main message for the future.

Another point of discussion relates to individualised therapy because this is going to change our practice. For example, it will allow two patients with the same disease at the same stage to undergo different treatments. The consequences of this individualised therapy concept should be discussed in depth as I think in the future, guidelines will move in a different direction to try and avoid putting all people in a single basket, and also to avoid medico-legal problems.

Amongst Stage 1A lung cancer patients, for example, are thousands of individuals with lots of differences: different genes, behaviour, family support, etc. Consequently, the same treatment will probably have different results in different individuals. The future is going to be very interesting because I believe humans will survive longer because we are going to think of patients more as individuals and not just as patients.

Q: This year you were elected as Chairman for Thoracic Surgery at the ERS from 2019–2022. Can you tell us about how you are finding the role so far and what your aims and ambitions are over the course of your tenure?

A: If I had to describe in two words what my main aims are, they would be co-operation and innovation. First of all, let me thank all previous chairmen of this active working group of the ERS as a tremendous amount work has already been done, and I just represent the continuation of the initial driving idea of the founder of the group Prof Keyvan Moghissi from UK, and therefore I’d like to thank all colleagues who voted for me. This is a very important duty for the next 3 years and I will try to do my best to help the society to grow in the right way. Co-operation is important with other societies and colleagues, and my main message in the programme is to help those people in less fortunate regions and countries. There are many people who could give a lot to our specialism and can’t, simply because they were born in the wrong place. So our goal is to organise meetings in poorer regions, for example Africa, to try and allow the young junior doctors to express themselves and to follow their dreams. Everyone needs dreams, and we want to ensure that these young people do not lose their ambition to change the world. What we would like to do is to convince colleagues to join us as an ERS family where we can build something great for our patients. Without sincerity, it is not possible to build anything. We need genuine people to join us to exchange ideas and from a selfish point of view, what I want is to learn a lot more from the young doctors because we always need their fresh minds and ideas to become better doctors, and pragmatically they are the future.

Q: Which people would you say have had the greatest influence on your career?

A: Since childhood, the man that helped me a lot was the historical scientist, Archimedes, who was born 200 years BC in Syracuse, Sicily.8 I was also born in Syracuse, and during childhood my parents always told me about this scientist, so I grew up under Archimedes’ influence. Moreover, my mother influenced me a lot because she gave me the freedom to choose to do everything I wanted in life and was always very supportive. I think family is important in our life, and we should never forget this. In modern life the other person who influenced my career and vision was Dr David Bernt Skinner and his school of thoracic surgery in the USA and Europe.9-11 He really supported me and I will not forget him because he was a surgical maestro, teacher, and mentor for many people worldwide.

REFERENCES

  1. Migliore M. Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease. J Thorac Cardiovasc Surg. 2003;126(5):1618-23.
  2. Migliore M. How surgical care is changing in the technological era. Future Sci OA. 2016;2(2):FSO104.
  3. Migliore M. Robotic assisted lung resection needs further evidence. J Thorac Dis.2016;8(10):E1274-8.
  4. U.S. Food and Drug Administration. Caution When Using Robotically-Assisted Surgical Devices in Women’s Health Including Mastectomy and Other Cancer-Related Surgeries: FDA Safety Communication. 2019. Available at: https://www.fda.gov/medical-devices/safety-communications/caution-when-using-robotically-assisted-surgical-devices-womens-health-including-mastectomy-and. Last accessed: 22 January 2020.
  5. Migliore M, Nardini M. Does cytoreduction surgery and hyperthermic intrathoracic chemotherapy prolong survival in patients with N0-N1 nonsmall cell lung cancer and malignant pleural effusion? Eur Respir Rev. 2019;28(153):pii:190018.
  6. Ried M et al. Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion for malignant pleural tumours: perioperative management and clinical experience. Eur J Cardiothorac Surg. 2013;43(4):801-7.
  7. Migliore M et al. Cytoreductive surgery and hyperthermic intrapleural chemotherapy for malignant pleural diseases: preliminary experience. Future Oncol. 2015;11(2 Suppl):47-52.
  8. Heath TL. The Works of Archimedes. Br J Philos Sci. 1955;5(20):355-6.
  9. Zarins CK. A tribute to David B. Skinner, M.D. Ann Surg. 2003;238(1):157-9.
  10. Skinner DB. Shaping the revolution: thoracic surgeons and something more. Presidential address. J Thorac Cardiovasc Surg. 1997;114(5):699-706.
  11. Southerland KW, D’Amico TA; The American Association for Thoracic Surgery Centennial Committee. Historical perspectives of The American Association for Thoracic Surgery: Dr David B. Skinner (1935-2003)—a surgeon and something more. J Thorac Cardiovasc Surg. 2016;151(1):1-3.