Episode #29: Thoracic Surgeons on the Lung Cancer Team with Dr. David Tom Cooke

Dr. Albert Rizzo:
Welcome back to Lungcast, the monthly respiratory health podcast series from the American Lung Association and medical news site HCP Live. I'm your host, Dr. Albert Rizzo, chief medical officer of the American Lung Association.

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Today we're speaking with Dr. David Cook, professor and founding chief for the Division of General Thoracic Surgery at UC Davis Health's Department of Surgery, on a litany of topics throughout thoracic surgery, namely the role he and his peers play in fulfilling current standards for lung cancer care.

Thank you, Dr. Cook, for speaking with me today and for being an active volunteer and a national spokesperson for the American Lung Association.

Dr. David Cook:
Thank you.

Dr. Albert Rizzo:
You're welcome. To begin, will you please briefly tell our listeners how you were drawn to thoracic surgery and what your current role at the UC Davis School of Medicine involves?

Dr. David Cook:
Great, thank you, Al, for the nice invite. I'm happy to be here and talk with you. I’m the chief of thoracic surgery at UC Davis in Sacramento, California, and I’ve been at UC Davis for 15 years.

In this role, I lead our surgical direction for the treatment of lung cancer. I helped found and develop our comprehensive lung cancer screening program. I'm also the director of robotic thoracic surgery, which provides minimally invasive diagnostic and therapeutic care for patients with lung cancer using robotic platforms and also educates the next generation of thoracic surgeons in robotic technology.

I’m also the program director for our cardiothoracic surgical fellowship, which trains the next generation on how to best care for patients with lung cancer. I’ve been a volunteer for the American Lung Association for over a decade, initially with the California Lung Association, and I’m happy to serve as a national spokesperson.

Dr. Albert Rizzo:
You certainly have the best perspective to talk about some of the questions I have today. So, let's begin our discussion with lung cancer screening. We all know the uptake of this potentially life-saving procedure in the high-risk group identified by the USPSTF remains low—recently quoted at about five to six percent nationally. I know you're involved in trying to raise awareness and move the needle on getting more individuals screened.

Best practices for implementing lung cancer screening include input from a multidisciplinary team. Can you describe the role of the thoracic surgeon on this team? And as a follow-up, do you feel this is a role that many of your colleagues embrace?

Dr. David Cook:
Yes, most thoracic surgeons embrace lung cancer screening. The American Lung Association’s State of Lung Cancer Report showed that less than six percent of eligible individuals are actually screened. Compare that to mammography for breast cancer, where over 70 percent of women who qualify get screened.

Lung cancer kills more people than breast, colon, and prostate cancer combined, so we have to do better. Screening must be a multidisciplinary effort—thoracic surgeons, primary care physicians, medical oncologists, and radiologists all working together.

At UC Davis, we conducted research to increase screening. Using targeted patient projects, including a pre-visit planner for upcoming primary care appointments, we reached out to eligible patients and increased screening by over 200 percent.

Dr. Albert Rizzo:
Do you use your electronic records to identify potential patients ahead of time?

Dr. David Cook:
Yes. Initially, we evaluated patients based on upcoming visits. With grant funding, we’re exploring ways to use the patient portal to reach qualified patients and make it easier for them to enter the screening process.

Dr. Albert Rizzo:
The less hurdles, the better. Speaking of hurdles, aside from the multidisciplinary team, shared decision-making has long been part of lung cancer screening. Surgeons guide patients through weighing the potential benefits and harms of surgery, as well as alternative treatments. What are your thoughts on the surgeon’s role here?

Dr. David Cook:
Shared decision-making is a partnership between clinicians, patients, and families. We review the benefits and risks of tests and interventions, including best-case and worst-case scenarios. Lung cancer screening is crucial for stage shift: most patients are diagnosed at stage 3 or 4, but screened patients are usually stage 1 or 2—the best chance for cure.

There are risks, like false positives and complications from biopsies or treatment, but these risks are decreasing with technology. Shared decision-making should inform, not hinder, access to population health.

Dr. Albert Rizzo:
During my pulmonary training, case conferences with thoracic surgeons often involved decisions about lobectomy versus sublobar resection. Can you speak to changes in philosophy regarding lobectomy versus wedge or segmentectomy, as well as the role of minimally invasive and robotic techniques and bronchoscopic advancements?

Dr. David Cook:
Each lung lobe has segments; removing a segment is called a segmentectomy, and removing part of a segment is a wedge, both sublobar resections.

Recent trials from Japan and the U.S. show that for tumors under 2 cm, segmentectomy or wedge resection has similar survival outcomes to lobectomy, often with better physiological outcomes. This mirrors what happened in breast cancer surgery, moving from radical mastectomy to lumpectomy.

We can perform these minimally invasively via video-assisted or robotic surgery. Navigational bronchoscopy allows marking small tumors for precise removal in partnership with interventional pulmonology colleagues.

Dr. Albert Rizzo:
Are PET scans still part of staging alongside CT?

Dr. David Cook:
Yes. PET/CT scans use radioactive glucose to detect metabolically active cancer cells. Advances in CT and PET imaging have minimized false positives and invasive procedures, improving pre-test probability for true malignancy.

Dr. Albert Rizzo:
Regarding stage 4 metastatic disease, TNM staging now divides it into M1a, M1b, and M1c. Does this change surgical approaches?

Dr. David Cook:
Yes. Patients with oligometastatic disease (few metastases) can sometimes have isolated metastases treated with focused radiation or surgery, while their primary lung cancer is treated surgically. These decisions must be made within a multidisciplinary tumor board.

Dr. Albert Rizzo:
With longer survival due to screening and therapies, what is your role in follow-up, and how might surgical intervention occur with recurrence?

Dr. David Cook:
Thoracic surgeons monitor patients after surgery for five years, with follow-ups every six months for two years and annually for three more years. We collaborate with a multidisciplinary team to manage recurrence and guide ongoing screening and shared decision-making.

We also need to understand tissue analysis for targeted therapy and immunotherapy, coordinating with medical oncologists for optimal treatment plans.

Dr. Albert Rizzo:
Do patients ever resist waiting for neoadjuvant therapy before surgery?

Dr. David Cook:
Some do, preferring immediate surgery. However, data show benefits of neoadjuvant therapy for certain tumor sizes or stages. Shared decision-making helps patients choose between standard care or clinical trials.

Dr. Albert Rizzo:
How can thoracic surgeons help with palliation in advanced disease, such as malignant pleural effusions?

Dr. David Cook:
Malignant pleural effusions occur when cancer obstructs lymphatic drainage. Thoracic surgeons can perform pleurodesis using medical-grade talc or insert tunneled pleural catheters, allowing patients to manage fluid at home comfortably and safely.

Dr. Albert Rizzo:
With all these changes, what’s on the horizon for thoracic surgery and lung cancer care?

Dr. David Cook:
Robotic surgery will expand, making segmentectomy and wedge resections easier. Navigational bronchoscopy allows precise tumor marking, potentially enhanced by bioluminescence. Artificial intelligence could augment robotic platforms, helping surgeons operate more safely and accurately.

Dr. Albert Rizzo:
You've provided a great perspective on lung cancer and surgery. Thanks again, Dr. Cook, for your time and insights.

We’ve discussed lung cancer diagnosis and intervention extensively. For more, check past interviews with Dr. Carla Lamb, Dr. James Malstein, and Dr. Mizoki in the show notes. Be sure to subscribe and rate Lungcast on your preferred platform, and visit lung.org and HCP Live for more resources.

Until next time, I’m Dr. Albert Rizzo, reminding you: if you can’t breathe, nothing else matters. Take it one breath at a time.