The Comprehensive Lung Cancer Program at Stony Brook University Cancer Center Brings Individualized, Multidisciplinary Care to Every Case

By Thomas Crocker
Wednesday, July 21, 2021

After decades of providing leading-edge lung cancer care to Long Islanders, the comprehensive Lung Cancer Program at Stony Brook University Cancer Center continues to grow and innovate in line with one of its guiding principles — a multidisciplinary approach to every patient’s care.

Lung cancer accounts for nearly 25% of all cancer deaths, claiming more lives than any other form of cancer, according to the American Cancer Society. Cases and deaths are declining, but lung cancer’s continued prevalence, virulence and complexity practically mandate multidisciplinary care. That is an approach at which the comprehensive Lung Cancer Program excels, in large part because of its centerpiece, the Lung Cancer Evaluation Center. This multispecialty center provides patients with a single destination for diagnostic testing and treatment planning by a diverse team of experts that meets weekly to review complex cases.

“The Lung Cancer Program features experts in all of the facets of care that comprise the total package of lung cancer services,” says Allison McLarty, MD, Director of the Lung Cancer Program and Associate Professor of Surgery at the Renaissance School of Medicine at Stony Brook University. “This includes an interventional pulmonologist, surgeons, nurse practitioners, medical oncologists, radiation oncologists and radiologists. Several of our team’s interventional radiologists are experts at diagnosing lung cancer and treating it with a novel form of therapy, cryotherapy, when appropriate. Our team also includes dedicated lung cancer pathologists who help us analyze tissues we remove via biopsy or resection. Ours is a sizable multidisciplinary group, and each subgroup of experts in its own sphere has a high-volume practice in lung cancer.”

The multidisciplinary team diagnoses and treats many types of lung cancer, including non-small-cell and small-cell lung cancers, as well as pulmonary neuroendocrine and pulmonary carcinoid tumors.

Allison McLarty, MD, Director of the Lung Cancer Program and Associate Professor of Surgery at the Renaissance School of Medicine at Stony Brook University, and Stony Brook Cancer Center hematologist/oncologist Roger Keresztes, MD, who specializes in lung cancer, confer with a patient.

A Culture of Collaboration

A lung cancer surgeon who completed a research fellowship and a cardiothoracic surgery fellowship at Mayo Clinic in Minnesota, Dr. McLarty has performed lung resections at Stony Brook for most of the past two decades. Surgery, she says, is the most effective method of curing lung cancer, but only a fraction of individuals diagnosed with the disease, which rarely causes symptoms in its early stages, are surgical candidates. A recent revision to national lung cancer screening guidelines may increase the number of patients who are diagnosed early and, in turn, increase the number of individuals for whom surgery is appropriate (see “Casting a Wider Screening Net”). No treatment for lung cancer, including surgery, takes place in a vacuum.

Patient Access Representative Daniel Braun registers a patient for an appointment at the Cancer Center.

“It’s important when caring for these patients to not see their disease in isolation but as part of their body as a whole, and to be appreciative of the multiple ways that may be available to treat the problem,” Dr. McLarty says. “If I were to see a 60-year-old individual who smokes and is found by screening to have a 2-centimeter lung nodule, in the absence of a multidisciplinary ethos, I might resect the nodule. That’s my job as a surgeon. However, cancers like this can be insidious and spread in subtle ways. By resecting it, I might miss cancer that has spread to another organ or lymph nodes. That would be a tragedy for the patient because there are better ways to treat this kind of cancer than surgery alone.”

In this scenario, Dr. McLarty says she would confer with her colleagues about how best to stage the cancer, perhaps send the patient for a PET scan, and ask the multidisciplinary tumor board group to evaluate the results and identify sites of concern for metastasis. The interventional pulmonologist might do a procedure to evaluate the lymph nodes for cancer. If disease is present, the patient might be enrolled in a clinical trial.

“If the patient responded appropriately to treatment in the trial, then he might be referred back to me for surgery, but this time, with the full, metastatic disease addressed,” Dr. McLarty says. “This type of treatment algorithm offers a better chance of cure and a longer life.”

Patients typically enter the Lung Cancer Program’s care through an intake center operated by the Lung Cancer Evaluation Center. Most patients are scheduled for evaluation within one week of their initial contact with the center. For their initial appointment, patients see a surgeon or a pulmonologist, depending on the nature of the problem. Either way, obtaining additional clinical perspective is never difficult.

“If I see a patient and feel he would benefit from a pulmonologist’s input, I can arrange for a colleague to see the patient right away,” Dr. McLarty says. “That’s also the case if a medical oncologist’s opinion is needed. Once our team has developed an initial plan, we schedule the patient’s appointments. Next, we discuss preliminary results at the tumor board meeting and arrive at a consensus plan of action, which may include surgery, radiation therapy and/or chemotherapy. We follow post-treatment patients closely for at least five years to catch recurrent disease and ensure patients reach our five-year outcome benchmark.”

Dr. McLarty with Dr. Keresztes

Surgical Options: Lobectomy and More

Determining candidacy for surgery necessitates evaluating a tumor’s resectability and a patient’s operability.

“We look at where the surgical margins would be to ensure we wouldn’t be removing a critical structure, such as part of the heart or a key blood vessel,” Dr. McLarty says. “If we believe we could cleanly remove the tumor, it’s resectable. We also need to ensure the patient is a good operative candidate. The individual would undergo cardiac testing to make sure his heart is strong, and pulmonary function testing to confirm he has adequate pulmonary reserves so that if we were to remove part of his lung, he would still be able to breathe sufficiently.”

The Lung Cancer Program’s surgeons perform several procedures to treat lung cancer by removing all or part of the lung, including lobectomy, segmentectomy, wedge resection and pneumonectomy. Lobectomy — resection of a lobe of a lung — is the gold-standard treatment for lung cancer, according to Dr. McLarty, due to its ability to remove the tumor and surrounding microscopic disease that could lead to cancer recurrence if it were to remain in the lung and enter the bloodstream or spread to the lymph nodes. For some patients, lobectomy can be performed using video-assisted thoracoscopic surgery (VATS), a minimally invasive approach. She points to the development of better staplers — used to divide lung parenchyma and blood vessels — and other specialized surgical instruments as one reason for increased use of minimally invasive techniques.

“Previously, we made 12- or 15-centimeter incisions and fractured or removed ribs to resect lung tumors, but now, we reserve that sort of large incision for sizable tumors that might be invading large structures,” Dr. McLarty says. “For routine patients, we use thoracoscopy with smaller incisions and small instruments. This translates to enhanced recovery.”

The Lung Cancer Program benefits from being part of Stony Brook Medicine, which allows the program’s clinicians to easily consult and collaborate with other specialists within the network. An example is collaboration between a lung cancer surgeon and a plastic surgeon to treat a patient with a large, resectable tumor that has grown into surrounding structures, such as the ribs and chest wall. Resecting the tumor may necessitate removal of part of the chest wall, leaving a defect. If that seems likely, the plastic surgeon plans a chest reconstruction prior to tumor resection, and then joins the lung cancer surgeon during the operation to perform the reconstruction.

The Lung Cancer Program features dedicated cardiothoracic anesthesiologists who assist with surgical cases and provide postoperative pain control. A diverse team of nurse practitioners, physician assistants, respiratory therapists, physical therapists and others helps patients recover and ambulate after surgery.

Radiation oncologist Mark Ashamalla, MD, who specializes in lung cancer, and Co-Director of the Center for Lung Cancer Screening and Prevention April Plant, DNP, meet with a patient.

Medical Oncology’s Crucial Role in Care

The Lung Cancer Program’s medical oncologists typically meet with patients following a biopsy and diagnosis of lung cancer. These clinicians coordinate chemotherapy, radiation therapy and surgery for individuals with advanced disease, and they conduct long-term follow-up care to monitor patients for recurrences and complications of treatment.

Medical oncologists oversee patients’ chemotherapy and immunotherapy treatments — a list of options that seems to grow by the year. Stony Brook Cancer Center hematologist/oncologist Roger Keresztes, MD, who has been practicing in the field for more than two decades, marvels at the ongoing rise in FDA-approved medications to treat lung cancer. Dr. Keresztes gives an annual lecture to medical residents about new developments in oncology, and the pace of change in the field is such that he updates the slide about FDA-approved medications for lung cancer with new additions each year.

“When I started in oncology in the 1990s, there was only one FDA-approved medication for lung cancer. Now, there are dozens,” he says. “We’ve begun testing every tumor for specific mutations, many of which we can treat with an oral medication with few side effects and very good response rates. We now have the capability of enhancing the immune response to tumors, and many of our patients will have good, long-lasting responses with immunotherapy drugs. There have been a number of advances in immunology that allow us to link certain medications to antibodies that can carry the medication directly to the tumor and reduce side effects.”

Patients who need chemotherapy infusions receive them in the Outpatient Cancer Center — the same building where the medical oncologists’ offices are located. That streamlines the evaluation and treatment processes and allows the medical oncologists to check on patients during treatment, if necessary. Dr. Keresztes praises the oncology nurses who serve as sources of knowledge and support for patients during treatment.

“Our oncology nurses develop special relationships with patients,” Dr. Keresztes says. “These nurses administer treatments and advise patients on how to cope with side effects. They also direct patients to community resources. Many of our nurses are involved with our support groups and community outreach programs.”

Director of Outpatient Imaging Charles Mazzarese, MPS, RT, performs a low-dose CT scan.

Radiation Options: Targeted Treatment for Lung Cancer

The Department of Radiation Oncology offers patients with lung cancer several options to receive radiotherapy. Highly focused radiation therapy, called stereotactic body radiation therapy (SBRT), has become an important type of treatment for early stage lung cancer and for isolated metastatic lung nodules. Intensity-modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT) and intrabronchial brachytherapy are additional procedures that also deliver extremely targeted radiation to the cancer. These treatments can be given as a primary modality, or combined with chemotherapy, immunotherapy or surgery, as determined by the multidisciplinary team.

Stony Brook’s cutting-edge SBRT program achieves high local control rates (over 90% success rate), and consists of no more than five sessions of outpatient treatments. SBRT is given by visualizing the target tumor under respiratory gating along the breathing cycle with the current gold standard four-dimensional imaging, which monitors tumor motion during treatment. These advanced noninvasive procedures are well tolerated without causing an increase in side effects.

“Often, we see patients who are not surgical candidates for various reasons,” Dr. McLarty says. “Many have smoked for a long time and have advanced emphysema or associated heart disease or other comorbidities that make them poor candidates for surgery. SBRT is a good treatment option that can control the disease in patients who might otherwise go on to have cancers grow and spread and be fatal sooner rather than later.”

Cardiothoracic and lung cancer surgeons Dr. McLarty and Henry J. Tannous, MD

Interventional Pulmonology: A Key Differentiator

One of the important factors that distinguishes the Lung Cancer Program at Stony Brook Cancer Center from similar programs in Suffolk County is the presence of board-certified interventional pulmonologist Stephen Kuperberg, MD, Clinical Assistant Professor of Medicine, Pulmonary Critical Care Medicine, at the Renaissance School of Medicine at Stony Brook University, who is on the program’s multidisciplinary team of clinicians. Dr. Kuperberg’s extensive training in pulmonology went beyond pulmonary and critical care fellowships to include two years of interventional training, including one year of advanced diagnostic bronchoscopy followed by a year in diagnostic and therapeutic interventional pulmonary procedures. This medical training exceeds that of most fellowship-trained pulmonologists. He performs a variety of advanced diagnostic and therapeutic procedures, including several types of bronchoscopy.

“I use a multimodal approach to diagnose lung cancer with ultrasound, electromagnetic tools and advanced imaging,” Dr. Kuperberg says. “We have tools in the bronchoscopy suite that may not be available in other areas of Long Island, namely ultrasound bronchoscopy and electromagnetic bronchoscopy. I think that separates our program in a big way.”

Any patient with an abnormal CT result, such as a lung nodule with or without lymph node enlargement, or abnormal fluid accumulation in the pleural cavity, is a candidate for referral to an interventional pulmonologist for evaluation and potential biopsy, according to Dr. Kuperberg. He estimates he has performed approximately 400 diagnostic procedures during the past two-plus years, including flexible bronchoscopy, rigid bronchoscopy, electromagnetic navigation bronchoscopy and endobronchial ultrasound-guided transbronchial needle aspiration, in addition to multiple procedure types for the pleural cavity.

“We can perform advanced diagnosis of peripheral lung nodules, which requires multimodal techniques, including multiple imaging techniques, to reach these nodules and sample them appropriately,” Dr. Kuperberg says. “We can use endobronchial ultrasound, electromagnetic navigation and traditional fluoroscopy in a combined approach to reach those nodules and diagnose lung cancer. For cancers that lie in the pleural cavity or along the chest wall, we work with surgeons to diagnose them using thoracentesis and, sometimes, VATS.”

Treating lung cancer, including cancer that has not responded to other forms of therapy, is also an important part of Dr. Kuperberg’s role. For patients with a tumor in their airway that is causing breathing problems, Dr. Kuperberg can use bronchoscopy, cryotherapy and balloon dilation to remove the tumor and open the airway.

“When fluid accumulates during end-stage lung cancer, which is known as pleural effusion, we specialize in the management of this condition using thoracentesis and placement of an indwelling catheter,” Dr. Kuperberg says. “This allows patients to have a better quality of life and avoid hospitalization by giving them the ability to drain fluid at home with the aid of a nurse.”

Members of the Lung Cancer Program, top to bottom: Dr. McLarty, Dr. Keresztes, and Plank

Looking Ahead

The members of the Lung Cancer Program’s multidisciplinary team of specialists anticipate continued growth for the program, which is why they are preparing to welcome a new medical oncologist and a new surgeon later this year. The team plans to add new diagnostic and treatment modalities and expand enrollment in clinical trials, which may add to the increasing number of new therapies available to patients. The program participates in national and international clinical trials, and its members can initiate their own investigations. A key tool for such investigator-initiated studies is an internal database of thousands of patients with lung cancer stretching back years that clinicians can use to evaluate outcomes for a variety of patient groups.

“Stony Brook offers unbeatable care for patients with lung cancer,” Dr. McLarty says. “We provide leading-edge, efficient and effective treatment, and we follow our patients for years to ensure they have the best possible outcome.”

Casting a Wider Screening Net

In March 2021, the U.S. Preventive Services Task Force (USPSTF) revised its recommendation for low-dose CT screening for lung cancer to include individuals 50–80 years old with a 20-pack-year smoking history who currently smoke or quit during the past 15 years. That is welcome news to Allison McLarty, MD, Director of the Lung Cancer Program and Associate Professor of Surgery at the Renaissance School of Medicine at Stony Brook University, who believes it will allow the Lung Cancer Screening Program to find more malignant nodules. That could produce more candidates for curative lung surgery.

“Only about 10% of patients who are diagnosed with lung cancer are surgical candidates at the time of diagnosis, and surgery is still the best means of curing patients,” Dr. McLarty says. “Ninety percent of patients have disease that is advanced enough at the time of diagnosis that they’re not surgical candidates. Once a patient has advanced lung cancer, the clock is ticking in terms of survival. If we can increase the number of patients who are diagnosed early, we can increase patient survival.”

In addition to increasing candidacy for surgery, such as lobectomy — the preferred form of lung cancer surgery — diagnosing lung cancer early may allow a surgeon to perform a smaller form of resection known as segmentectomy. This involves the removal of part of a lobe rather than an entire lobe, as in lobectomy. Segmentectomy preserves more lung tissue.

Radiologists review the results of low-dose CT screenings performed as part of the Lung Cancer Screening Program. Patients who are found to have concerning findings are presented at the weekly thoracic tumor board meetings and receive expedited workup as needed.

“Our program wholeheartedly embraces the new USPSTF guidelines,” Dr. McLarty says. “We strongly believe this will translate to saved lives.”

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