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News — When he was young, Daniel Boffa MD, watched a lot of television and that, at least in part, contributed to him becoming a surgeon.

“I was really drawn to the show M*A*S*H, more for the medical aspects and the dynamics,” Dr. Boffa recalls, of the show about life in a mobile army hospital close during the Korean War. “That really drew me to surgery.”

It wasn’t until well into his career that Dr. Boffa learned that the character he was most drawn to—Hawkeye Pierce, the lead of the show—played a thoracic surgeon. “But that wasn’t what drew me to the specialty.

“As a surgery resident, I had a mentor who really got me interested in thoracic surgery and the anatomy,” said Dr. Boffa, who is Division Chief, Thoracic Surgery and Clinical Director, Center for Thoracic Cancers. “It’s one of the few specialties where we go into multiple different parts of the body and treat literally hundreds of different types of diseases. And so, it allows you to be a physician as much as it does a surgeon, and I really like that.”

In a wide-ranging conversation with Dr. Eric P. Winer, the director of Yale Cancer Center, Dr. Boffa, who is Chief of Thoracic Surgery at Smilow Cancer Hospital, discussed the dramatic changes in cancer care, specifically surgery and targeted cancer therapies. Following are excerpts:

Beyond lung cancer, what other types of cancers fall under thoracic surgery?

Esophageal cancer is probably the second most common, but really any tumor that arises in the chest. We can help the teams that manage colorectal cancer, for instance, by treating some of the sites of disease that spread to the lungs. And in the abdomen, there are various cancers that we get involved with, sometimes, gastric cancers that are close to the esophagus. But, really, anything that happens in the chest that doesn't need a heart surgeon, we're the people to call.

How has the recent evolution of medical therapies—like immunotherapy and targeted therapies—changed what is done in lung cancer surgery?

Whenever we think about cancer, we think about what we see and what we can’t see. Surgery is very effective for cancer that we can see, but the disease we can’t see—microscopic cancer—is often what gets patients into trouble. What’s really exciting about the current era in cancer, is we now have answers for that microscopic disease that we’ve never had before. We’re turning more patients into curable cases than ever before. People who in the past wouldn’t have been curable, now we can eradicate their micro-metastatic disease.

Thoracic surgery used to mean some very large incisions. How has that changed for lung cancer?

We used to make a 5- to 10-inch incision to remove early-stage lung cancers, maybe 20-25 years ago. Now 90 to 95 percent of lung cancers are removed using minimally invasive techniques, mostly using the robot. Your biggest incision is maybe a 1.5- to 2 inches, which really speeds up recovery and allows people who maybe weren’t as healthy to get through an operation more easily and get back to their life faster.

I don’t sure I’ve ever asked anyone this before, but I’m sure when you are doing a bigger surgery you are in the operating room for quite a number of hours. What’s that like?

It’s amazingly compelling when you are in charge of a patient’s life. When someone trusts you to take them to the operating room, they are trusting you to fight the battle for them. You are looking for any site of disease, you are so focused on getting every part of that tumor out as cleanly as possible. It really commands your attention so much that the time really flies by. I consider myself to have a pretty short attention span outside the operating room, but not inside the operating room.

Let’s shift gears to esophageal cancer. It’s a frightening diagnosis for many. Why is esophageal cancer so concerning?

Esophageal cancer is a dangerous cancer that we don’t have a great way to screen for yet. A lot of times we don’t find it until people develop symptoms—like difficulty swallowing or food getting stuck—and by then it’s often at a more advanced stage. People are risk generally have heartburn, are over the age of 50, being overweight, and being a white male are also risk factors. If you have those symptoms talk to your primary about testing. Barrett’s esophagus can lead to changes that can become cancer, but most Barrett’s does not. Smoking and alcohol both raise the risk, and if you combine them, the risk is higher than one plus one.

How has treatment for esophageal cancer changed?

For the earliest-stage esophageal cancers, we can often treat them endoscopically—either by heating, freezing, or scraping—so you come and go the same day. That used to be an esophagectomy. Now, when we do need to remove the esophagus, 90 percent of the esophagectomies I do are with a minimally invasive approach. The biggest incision, which used to be a pair of 8-inch incisions, is now a single 2-inch incision. With that plus immunotherapy and improved chemotherapy approaches, we’re helping address the microscopic cancer we can’t see on scans. It’s showing great promise in esophageal cancer.

What are some of the unique challenges patients face after esophageal surgery?

If you have your esophagus removed and reconstructed there’s no valve separating the stomach from the esophagus. Everyone walks around with about a Coke can’s worth of fluid in the stomach, which is now in the chest as opposed to the belly. Because of that, you can’t lie completely flat—you have to sleep with the head of the bed at about 30 degrees to prevent fluid from going into your mouth. It can be an adjustment, but I have patients who are competitive triathletes, swimmers, cyclists. People can get back to a fairly normal quality of life.

I’d like to talk about lung cancer screening, which you’ve mentioned can have a big impact. Why is it so important?

In my lifetime, lung cancer screening will probably be the single most impactful medical discovery for the cancers I treat. Lung cancer screening reduces a person’s chances of dying of lung cancer by more than 20 percent. It’s just a CT scan once a year for people 50 or older with a history of smoking. For reasons we don’t understanding, only about 10 percent of eligible people are screened. Some don’t have a primary care physician. If you know someone over 50 who has smoked, please reach out to a primary care clinician or call us. It’s so powerful and such an important thing to do.

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