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EDITORIAL |
South Korea
Current medical practice is a reflection of disease patterns and of recent advances in medical knowledge and technology. Gradual or abrupt changes in disease patterns have influenced our practices in the cardiothoracic surgical fields. These changes can also redistribute human and material resources according to the requirements of the medical field. For example, the decrease in birth rate in Korea is no longer a new topic; the number of newborns in 2005 was approximately 430,000, which was about two-thirds of the 630,000 newborns in 2000. The nationwide decrease in the number of newborns has influenced the practices of many medical departments in addition to obstetrics and pediatrics. In cardiothoracic surgery, the decrease in the number of newborns has affected congenital cardiac surgery, so decreases in the surgical volume and number of new positions in congenital cardiac surgery were inevitable. Advances in medical knowledge and technology have also influenced medical practice. The drug-eluting stent was introduced several years ago in Korea. Now, it is the most powerful alternative to coronary artery bypass surgery. The increase in the use of drug-eluting stents has slowed the rate of increase of bypass operations in Korea for the past 5 years, as bypass grafting is no longer the only option for treatment of multivessel coronary artery disease.
In the field of general thoracic surgery, abrupt changes have not occurred until recently. However, the changes that did occur have continued, and our practices have adapted accordingly. In an earlier period of thoracic surgery, inflammatory disease was the most common condition encountered by the thoracic surgeon: most frequently, empyema, bronchiectasis, and tuberculosis. Drainage, thoracoplasty, and resection of the infected pleural space and lung parenchyme were major surgical procedures in the late 1800s and early 1900s. However, the introduction of antibiotic therapy in the 1920s and 1930s gradually decreased the prevalence of complicated inflammatory disease. During the last 50 years, like many other surgical departments, thoracic surgery has changed from surgery for inflammatory disease to oncologic surgery. In our hospital, the number of general thoracic surgical cases was approximately 200 in the early 1980s. Only 10% of cases were resections for lung cancer, while inflammatory disease constituted 36%. In recent years, the surgical volume has increased to 1,000 cases annually, and the proportion of lung cancer resections has increased to 36%, whereas inflammatory disease has decreased to 8%.
Changes have also occurred in the profile of lung cancer. In the early 1980s, squamous cell carcinoma was the predominant cell type and constituted 65% of all lung cancers, while adenocarcinomas accounted for only 18% of the surgical cases in our hospital. Since the start of the new millennium, the proportion of adenocarcinomas vs squamous cell carcinomas has changed to 48% vs 35%. Together with the increase in the number of adenocarcinomas, early lung cancer has become the major indication in lung cancer surgery. The proportion of stage I lung cancers has risen from 29% in the early 1980s to 56% in the 2000s.
The increasing numbers of adenocarcinomas and early lung cancers have introduced two new trends into the field of lung cancer surgery. The first trend is the emphasis on systemic chemotherapy. Because of the early lymphatic and hematogenous metastatic nature of an adenocarcinoma, the role of chemotherapy has increased. The International Adjuvant Lung Cancer Trial, which reported improved survival in an adjuvant chemotherapy group, has made many medical oncologists and thoracic surgeons less resistant to adjuvant chemotherapy.1 The introduction of new chemotherapy agents, such as gefitinib which is generally known to be effective in oriental, nonsmoker, and female adenocarcinoma patients, has led to a new field of individualized targeted therapy for lung cancer.2 The second trend is an increase in minimally invasive surgery. Most early lung cancers present as small peripheral nodules with the opacity of ground glass. The decrease in the number of centrally located advanced tumors has made hilar dissection easier, and thoracoscopic resection more favorable. Therefore, video-assisted lobectomy is becoming an important option for early lung cancer surgery. A recent study reported comparable results for video-assisted lobectomy and open thoracotomy in the treatment of early lung cancer.3 This procedure also fulfills the desire of our patients to have less harmful and more comfortable surgery.
Changes have continued and will continue in general thoracic surgery. Fortunately, no abrupt change has occurred in our practice since the birth of thoracic surgery. Nevertheless, our current situation will become more and more susceptible to influence by changes in the milieu of medicine. Changes in disease patterns and rapid improvements in technology will lead to thoracic surgeons of the future being very unlike the thoracic surgeons of today. The question of whether or not thoracic surgeons will continue to occupy a significant position in the treatment of thoracic disease cannot be answered easily. The outcome depends on our society and on what happens within that society.
REFERENCES
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