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Lung Cancer Screening – Process and Potential Benefits

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GCVL_LU-A05_Lung_Cancer_Screening_Process_Potential_Benefits

 

Dr. Jed Gorden, Swedish Cancer Institute, reviews the lung cancer screening process, including low-dose CT scanning, smoking cessation, follow-up testing and counseling, and describes the potential benefits.

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Lung cancer screening is a very exciting advance in the field of lung cancer which has come about in the last several years. This is where low-dose CT scans, or “CAT” scans, very high resolution images of the lungs, are used to identify nodules and identify early cancers. The critical thing to know is that this is an advancement that has come about in the last several years due to a tremendous amount of government-funded research looking at the safety and the efficacy of using low-dose CT scans to identify high-risk patients who have lung cancer.

Let’s talk about that for a second: high-risk patients. Patients that qualify for lung cancer screening need to understand certain things, and you’re going to have to participate in a shared decision-making conversation with your team and caregivers. So who qualifies, who is high-risk? The high-risk criteria for lung cancer screening and people who should undergo low-dose CT imaging are patients who are 55 to 80 years old, who smoked for at least 30 pack-years which is one pack of cigarettes a day for 30 years, and are actively smoking or quit within the last 15 years. This is the minimum population who is at risk for lung cancer and meets the criteria to undergo low-dose CT screening.

It’s really important to understand that embarking on lung cancer screening and low-dose CT is a journey and a partnership with your team of professionals in the lung cancer screening center. The reason that I say this is because, number one: no single scan will prove that any individual doesn’t have lung cancer. It is through a partnership and continued surveillance based on specific criteria, and discussions with your team over time that will help minimize any risk of lung cancer.

Why would anyone want to embark on this journey? The data that we have and the reason we’re so excited about lung cancer screening now is that the data suggests that through low-dose CT screening of high-risk individuals that the mortality associated with lung cancer is decreased by 20% and the overall all-cause mortality is decreased by almost 7%. But it’s important to understand that this is done in the confines of a multidisciplinary team with counseling and active participation of patients who continue throughout the program and follow the guidelines that are established through screening.

So let’s talk about each one of these components. We’ve talked about the high-risk, which is the patient that’s involved — let’s talk a little bit more about high-risk. So we know that even within this risk profile are those that are at minimal risk for lung cancer, there are those that are at increased risk. We have an identified population of high-risk patients for lung cancer that we described: 55 to 80 years old, actively smoking or quit within the last 15 years, and smoked for at least 30 pack-years. We know that’s the minimum risk and it’s important for people to understand that at the minimum risk level for lung cancer, it takes almost 5,300 people screened to identify one single cancer. As the risk goes up, age goes up, increasing pack years of smoking goes up, we know that the number of people to screen goes down to about 160 to 170 people in the highest risk groups. Therefore it’s important that we adhere to these rigorous guidelines of only those patients who are at the highest risk, who meet the criteria that was described, to undergo lung cancer screening.

Number two: partnership. No single scan allows people to move forward without being continued in the program. It is a continuum that people need to engage in and a partnership with your professional team.

Number three: smoking cessation. Smoking cessation for those that are still smoking is critical to minimizing the risk for lung cancer. This is a teachable moment. This is an opportunity to partner with your team to identify the ability to quit, potential medications for helping you quit, triggers and counseling. I urge people to take advantage of this and to inquire with their team on how best to approach this process as you engage and move forward in the lung cancer screening arena.

The final thing is counseling. It is important to understand that many people who embark on the journey of lung cancer screening, both those that are in the highest risk group and those that are in the minimum risk group to qualify for lung cancer screening will oftentimes be found with an abnormality or what’s called a pulmonary nodule. A pulmonary nodule is a small abnormality seen on a CT scan. It can be described as a dot or a nodule or an abnormality, all descriptors of the same thing, but the critical thing to understand is that the overwhelming majority of the time, these are not cancer. They are benign, but we only know that through continued surveillance and strict adherence to guidelines on when to follow patients up, when to move to additional testing, and when to move on to invasive testing.

The confidence that you build with your professional team will allow you to move forward through this process with education and without fear, and allow you to move forward and minimize the risk of lung cancer in those patients who are high-risk.


GRACE Video

Bronchoscopy and EBUS

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Dr. Jed Gorden, Swedish Cancer Institute, describes the differences between bronchoscopy and endobronchial ultrasound, highlighting the advantages of EBUS in diagnosis and staging.

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Today I’m going to talk to you about bronchoscopy with endobronchial ultrasound. It’s an interesting technology — bronchoscopy in its form that we know it now, flexible bronchoscopy, has been around since about the late 1960s. This allowed us to move bronchoscopy from an operating room into outpatient settings and allow us to navigate through the airways. For those of you that have heard of colonoscopies or upper endoscopies, these are all cameras that allow us to snake through the airway or other orifices and get a much clearer picture of what’s going on inside. The challenge though with traditional bronchoscopy is it allows you to only see what’s directly in front of you — what is in the airway, and the overwhelming majority of the time the airways are normal.

A tremendous advantage to us in the field of lung cancer, lung cancer diagnosis, and lung cancer staging has been bronchoscopy coupled with ultrasound, creating what’s called endobronchial ultrasound or EBUS. This is a very small ultrasound probe coupled at the end of a bronchoscope. It enters into the airway in the exact same fashion that bronchoscopy does for traditional procedures, but what it allows us to do is look through the airway wall. This is critical because looking through the airway wall now allows us to identify lymph nodes, abnormalities that are around the trachea, the bronchi which are the divisions of the airway that go to the left lung and the right lung, and this is critically important because we know that with staging where we’re not only diagnosing those that have cancer, but where the cancer is and whether it has spread to the lymph nodes is crucial to an understanding and developing a treatment plan.

Some we now have a tool in our armamentarium to, in a very minimally invasive way, go into the airways, see what’s in the airways, and see through the airways into the lymph nodes that live in and around those airways. Once we’ve identified these very specific structures, we can sample them with small needles allowing us to puncture through the airway wall directly into a lymph node, collect a sample, have a pathologist look at it under a microscope, and tell us whether that lymph node is involved in cancer or that lymph node is not involved with cancer. Critical are the decisions that will be made for creating a treatment algorithm.

The advantage of this is that it’s minimally invasive; it’s done in the outpatient setting. It allows us to sample most of the lymph nodes that are present and are critical to decision making around lung cancer and lung cancer staging. Complications of it are very rare — sometimes after bronchoscopy and bronchoscopy with ultrasound, people can experience a fever, or maybe a sore throat, but larger complications like bleeding and infection are very rare.

The most important thing though to understand is that this is a partnership with your physician and that they explain to you what procedure you’re going to have, and how this procedure is going to benefit you, whether it’s bronchoscopy or bronchoscopy with ultrasound.

The final thing that I’m going to talk about with bronchoscopy and bronchoscopy with ultrasound is how you’ll be during the procedure. Most patients ask, “am I going to be awake; am I going to know what’s going on?” There are two ways to do bronchoscopy and bronchoscopy with ultrasound. One is what’s called conscious sedation — this is sort of a twilight phase where people are sleeping, they’re breathing on their own, responsible for their own vital signs, but a bronchoscopist is allowed to do procedures without it causing too much disturbance to the patient. This is good for procedures that last about 25 to 30 minutes and allows people to sample in the airways in a very safe fashion. Another way that bronchoscopy with ultrasound is performed is with anesthesia — this is where an anesthesiologist takes over the safety of the patient and the control of their airway. A breathing tube or a small cap over the back on the airway is placed allowing air to pass in and out and control the breathing and ensure safety during the procedure.

So when you talk with your physician about this, it’s important to understand how you will feel during the procedure, what is going to be going on in terms of your safety, sedation, and your comfort. It’s also important to know that there’s data for this; the data for this suggests that the procedures are equal. Bronchoscopy and bronchoscopy with ultrasound can be done safely in the setting of conscious sedation and in the setting of general anesthesia, and you should feel confident that you can have a safe and effective procedure.

So in summary the most important thing is that you partner with your physician in order to get the most information possible from any procedure. In this case the procedure will be bronchoscopy. Bronchoscopy is an inspection of the airway. We couple that with ultrasound which is not only inspection of the airway, but visualization through the airway wall, identifying the lymph nodes and structures. Biopsying those gets tissue which is staging and telling us how much cancer there is, and this can be done safely and effectively with you sleeping in either a conscious or twilight phase, or with general anesthesia.


GRACE Video

Multiplex Testing for Rare Mutations: What Are the Potential Benefits?

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Dr. Ross Camidge, University of Colorado, discusses the potential benefits as well as the disadvantages of multiplex mutation testing.

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More and more, when people are doing molecular testing on their tumor, they’re not just getting one test and if it’s negative doing another test — that’s called sequential testing, they’re doing lots of tests at the same time — that’s called multiplex testing. There are certain good things about that and certain things which are less than good.

In terms of good things, if you do a whole bunch of tests at the same time, you don’t have as long a delay. If you test sequentially it may take you a while before you get to the positive and if you want to make a decision on your treatment as soon as possible, it’s good to get all the information upfront. Also because when you do the sequential testing, each individual way of preparing the tissue wastes some; multiplex testing is a more efficient use of the tissue, so it reduces the chance that you’re going to need another repeat biopsy.

There’s a certain health economic advantage when you utilize multiplex testing, it is what’s called a noncumulative increase in cost. So to look for ten mutations doesn’t cost as much as ten times looking for one mutation. Maybe it costs two or three times as much, and you can add on extra tests.

Perhaps one of the reasons why we’re most enthused by this idea of multiplex testing is you’re going to find some of these rarer abnormalities. Not just the ALK and the EGFR, but increasingly, there’s a collection of abnormalities which are actionable, sometimes through licensed drugs which are not yet licensed in lung cancer but licensed in other diseases, sometimes because they’re an entry into a specific clinical trial. Examples that spring to mind in lung cancer include RET rearrangements, ROS1 rearrangements, and BRAF mutations.

I said there were a few things which were not good. Perhaps the biggest thing is there are some companies commercially doing this who perhaps are adding too many unnecessary tests, and by that I mean tests that really haven’t got any proven value and they’re using up your tissue, they’re increasing the expense to your insurance firm. Perhaps the other downside is that sometimes you get such a wealth of data, like a data dump, you don’t quite know which one to take to the bank. You get all of this information, there are multiple different mutations, and many of them are not driving the cancer, they’re what are sometimes called passenger mutations, and sometimes that ability to sift through it is pushed back onto you or your doctor. Sometimes there’s an algorithm that will print out, “oh, you’re eligible for this trial, or that trial” and there the issue is, what is their metric for saying there’s good enough data to say, “yes, you should go travel to go on this clinical trial.” Sometimes they have a pretty low bar to get over.

For me the best thing to do is — yes, multiplex testing is a good idea, there are certain companies which are better at this than others, and when you get that information you can’t just assume that everything in it is a meaningful result and you really have to sit down, hopefully with an oncologist who understands this, to go through it.


GRACE Video

Video-Assisted Thorascopic Surgery vs. Open Thoracotomy

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GCVL_LU-D07_Video-Assisted_Thorascopic_Surgery_Open_Thoracotomy

 

Dr. David Harpole, Duke University Medical Center, compares traditional open thoracotomy with video-assisted thorascopic surgery, highlighting the advantages of the newer approach.

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Historically, lung cancer has been treated with a large incision between the ribs, and in the early-mid ‘90s we began to investigate uses of the laparoscope, which was used to do gallbladders and so forth, in the chest. So we began using the devices to do more limited resections with this and ultimately we were able to have instrumentation which has allowed us to do more anatomic resections, in other words a lobectomy and segments and so forth, with the video instruments — so-called video thoracoscopy.

Probably at this point two-thirds to three-quarters of my patients undergo a video-assisted approach and in the most recent Society of Thoracic Surgeons Database, which enters all of the information on lung cancer surgery for 500 centers in the U.S., it’s around two-thirds of all of the resections are done this way now. We’ve watched that evolve from centers such as my own where we were islands that did this 12 to 15 years ago, now to the majority of centers have surgeons that are facile with the scope.

The advantage to the patients is obvious. If you don’t have an incision on your side, you have two or three small holes of about three-quarters to half an inch, your recovery time is faster, less drainage from the tubes, home faster. I have people playing golf and tennis in two weeks, certainly everyone is driving in two weeks. What we found in a lot of the investigations we’ve done, not only that, if a patient has a larger tumor that requires adjuvant chemotherapy which is chemotherapy after surgery, sometimes there is a delay in the recovery of the patient because of the large incision, so that it delays their chemotherapy, and we’ve found with the video-assisted approach there is no delay and so patients are able to get their therapies on time and are able to tolerate them better because they haven’t had such a large insult.

Now not all cancers are able to be resected with a video-assisted approach, but I will say that in 2015 the vast majority are. We can do pneumonectomies or take out the whole lung with a scope, we can do surgery after chemotherapy and radiation — I just did one of those last week with a large tumor but we were able to do it with a scope. You can take out two lobes with a scope and you can do chest wall resections with a scope, so that’s much less invasive.

So we’ve really reserved now, the large incisions for really large operations that require you frankly from a safety standpoint to have your hands in there. Our instrumentation is so good with the video-assisted technique that we’re able to do it on lots of people.

The next question people ask is, “what’s the difference between using the video thoracoscopy and the robot?” The robot has come along over the last five to six years as another potential instrumentation in a minimally invasive fashion you can use for patients. The robot does require several small holes but they’re all holes about 1/4 centimeter each and the robot allows the surgeon at the console to really see things well. The video system that I use magnifies things about 3 times, and I’m at the table with my hands using instruments through small holes. With the robot it magnifies things 6 to 10 times and you have a virtual reality headset that you wear that really shows you things in 3 dimensions. What’s nice about the robot hand, whereas my sticks, I can only do this, the robot has a little wrist on it so it’ll move in all directions inside the chest and some surgeons like that for its mobility.

In my center we have two surgeons that use the robot, there are three of us that use the video-assisted technique. We have the same results and I think the two methods are equivalent and I think that they are allowing us to do more things in smaller areas in patients, because frankly our goal is to remove a cancer and not hurt the patient. “First do no harm” is what we’re all taught and these minimally invasive techniques have allowed us to do that. The other nice thing about it is that we have videos that the patients can watch and see the surgeries, see the incisions and see what’s going to happen to them, and I think they’re more informed when they make the decision of whether or not they would like to have a video-assisted approach for their operation.


GRACE Video

What Is the Significance of Mediastinal Node Sterilization After Neoadjuvant Therapy?

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GCVL_LU-D11_Significance_Mediastinal_Node_Sterilization_After_Neoadjuvant_Therapy

 

Dr. David Harpole, Duke University Medical Center, defines the concept of mediastinal node sterilization and its use after neoadjuvant therapy.

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When we have patients who have a mediastinoscopy that’s positive, in other words we’ve found mediastinal lymph nodes that are involved with cancer, the decision comes down to what’s the best approach. Usually, when patients have what we call locally advanced lung cancer, which is lung cancer that has significantly involved those lymph nodes, that’s reserved for a concurrent chemotherapy plus radiation approach, and surgery is usually not indicated. But we do have patients whose lymph nodes were slightly involved, either with microscopic deposits or only a couple of lymph node areas that were involved, and in those patients we will give them upfront chemotherapy or chemotherapy plus radiation therapy at a moderate dose, and then reassess them after they’ve had their therapy. If their tumor has responded to the therapy, in other words on the PET scan and CT it’s smaller and the lymph nodes are less active, then we may consider a resection in those people.

The very best scenario is for patients that we do that, but then we go in and operate, that they’ve actually had their tumor completely sterilized by the therapy. I tell my patients that we use the lung mass as a measure of their response to the chemotherapy in their body, and the reason is that people don’t die from lung cancer in their chest after we operate on them, they die of lung cancer that’s out in their body and if there’s microscopic cancer out in their body, I’m not helping them by taking the lung mass out. I usually say the horses are out of the barn, and it really doesn’t care what I do to the barn, the horses are gone. If the tumor in the chest has been sterilized, there’s a very good chance that denotes that all of the tumor in their body is sterilized.

So when we resect patients who’ve had upfront treatment, if their tumor is completely dead or almost all dead from the therapy, that denotes very good outcome for the patients and they’re the ones that we have that are long-term survivors, and we do have patients that are long-term survivors after they’ve had chemotherapy plus or minus radiation and surgery.


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