Paul Roach:

Oh, all right. Hey, welcome everybody. Welcome back to so doc it's cancer. This is episode eight today, uh, in our podcast to understand cancer, how it happens, how it's treated, how we arrive at a diagnosis and at a prognosis. Cancer's impact upon a person's quality of life and how to move forward in life after a cancer diagnosis, the show airs monthly and we welcome your engagement and feedback. Today we are super excited and proud to present as our special guests, Keith Bowersox, and we have our ordinaries, Paul Roach, Peter Schlegel, and Michael Reardon. Welcome

Michael:

Hello,

Paul Roach:

to

Michael:

everyone.

Paul Roach:

the show guys.

Michael:

Thanks, Paul.

Paul Roach:

How you been? How you been? It's been a little more than a month this time. We all got busy.

Michael:

Oh good.

sox:

Spring.

Paul Roach:

Yeah. Yeah. Very good. Very good. All right. Well, let's introduce Keith today. Uh, Keith, uh, if you would, first of all, hello and thanks for being on the show. And,

sox:

Thanks

Paul Roach:

uh,

sox:

for having me.

Paul Roach:

and, uh, we're delighted. And if, you know, where are you from? Where'd you grow up?

sox:

Basically I was Navy brat, started on the East Coast around Rhode Island and then my parents moved cross country, Texas, California, back to Midwest for high school and college.

Paul Roach:

All right, all right. And then how did you end up getting this idea of going into medicine?

sox:

Wow, you know, I think I just enjoyed a combination of science and helping people. And there's really not many ways that you can keep it current. And medicine is a good way to do it.

Paul Roach:

Awesome. And then you got a PhD as well.

sox:

I do.

Paul Roach:

And, uh, I mean, first of all, isn't that a little excessive, just an MD

Michael:

Does

Paul Roach:

and

Michael:

that

Paul Roach:

a

Michael:

make

Paul Roach:

PhD?

Michael:

you Doctor

Paul Roach:

Yeah.

Michael:

Doctor?

sox:

Sadly, yes. No, no, I... I enjoyed chemistry quite a bit. And I think the biggest decision was not whether I want to be a doctor, but whether I wanted to be a surgeon or, you know, something else. So I really enjoyed chemistry. When I was going through it, my program director said... Do you want to keep doing this while you go to medical school or should we let your research sort of fizzle and I kept with it? Plus I got paid so you can't beat that.

Paul Roach:

Oh, not bad. Not bad at all. Then, and then how did you pick a thoracic surgery, CT surgery?

sox:

Well, I don't want to dump on you, Paul, but it's clean, it's beautiful, it's elegant, and it's got a lot of mystery. So I just love the heart and love the lungs and it's good.

Paul Roach:

Yeah,

Michael:

You said

Paul Roach:

no.

Michael:

CT, what's the C? I get

sox:

Cardiothoracic,

Michael:

thoracic on the T.

sox:

yeah.

Michael:

Cardio-thoracic. There we go.

Paul Roach:

All right. All right. Well, uh, so today's topic is going to be lung cancer. It's a big subject more than we can cover in 45 minutes or an hour, but, uh, well, maybe we'll hit the high points or the low points or whatever points we need to hit. So Keith, what do you think in terms of lung cancer overview and its impact across the world?

sox:

So we'll talk about some generalities, but I think the biggest thing to say is that lung cancer is bad, right? But 2023 is probably the best time in history to have it. And I think Peter can talk about it and other people can talk about it. I think lung cancer has lagged a little bit behind breast cancer, but it's sort of in parallel, but a little behind. They're just doing so much amazing things as far as uh... screening uh... genetic markers you know manipulation of things advanced stage treatments so it gets a bad diagnosis but today's one of the best times in history to have it

Paul Roach:

All right, Peter, what do you think?

sox:

it

Peter Schlegel:

Sorry about that, I was just fumbling with my microphone and unmuting. Yeah, lung cancer is a heavy diagnosis. It is bad, it results in considerable amount of illness and death. It is one of the most preventable types of cancer simply by not smoking. But there are different environmental risk factors and there's just bad luck. the stage of diagnosis makes the biggest difference so that if you wind up with an early detection of your lung cancer and see a surgeon, your outcomes are much, much better than letting it fester and spread and metastasize and then try to deal with it. Having said that, that we have good options along the way, but the earlier, the better.

sox:

So just to give you

Michael:

question already,

sox:

some

Michael:

Paul.

sox:

statistics, 238,000 people every year in the United States get diagnosed with lung cancer. That's one person every 2.2 minutes. And the kind of the bad thing is that 80% of those are diagnosed in an advanced stage, where it's already gone to the lymph nodes or even further. That's because it's such a painless process. I think that with the current push towards lung cancer screening, we're trying to change that so that as Peter mentioned, that we can get more people into the surgical arm because it's just the statistics of, for example, regular lung cancer, I guess, or non-small cell lung cancer for medical type people. much higher survival if you get a diagnosis while it's still in the early stages.

Paul Roach:

Michael, what was your question?

Michael:

of that large statistic, what's the... To me and I think to a lot of people, this is a smokers disease, which is probably not true, but what's the percentage of, I think you said 238,000? What's the percentage that it's due to smoking?

sox:

Well, 65% of cancers are diagnosed in non-smokers. That doesn't mean they never smoked. So people who smoke college, whatever, and then stopped. But 12%, 12 to 20, depending on your study, were diagnosed with never smokers. Asian women have adenos, things like that. So it's not uncommon for people who... don't have cancer or no smoking to have it. But as Peter said, the best thing you can do for risk prevention is not to smoke.

Michael:

Well, you said Asian women, is that a high prevalence among Asian women?

sox:

It's not really a high prevalence, but that's just kind of the one where you think about it.

Michael:

Okay, because I lived in Japan for a little while and I know, well, that's 25 years ago now, 30 years ago now, but at that time, it was a pretty heavy smoking country. So even if you didn't smoke, I would think that your exposure to it, I guess that's where I'm going. How much of it, even to the people who didn't smoke, is secondhand? You know, if you had a spouse that smoked, or is that also factored into that? Or you just say, I never smoked, so

sox:

I think that

Michael:

your statistic

sox:

secondhand

Michael:

changes.

sox:

smoking would enter into it, and perhaps Peter can talk about statistic. It's probably, I'll just thumbnail it, 20% versus a regular smoker. And we could talk about some lung cancer screening rules for all those people out there who may have had a little bit of a history of smoking. We could talk about what the government's currently allowing and providing for.

Michael:

What is the screening push that you're talking about? I haven't heard anything about

Peter Schlegel:

Yeah,

Michael:

that.

Peter Schlegel:

I'd be happy to address that. The US Preventive Task Force basically is trying to follow suit with the breast cancer and mammography, cervical cancer, and pap smear to promote early detection and more successful treatment when it could be detected early, successfully cut out without having to worry about death and advanced disease. So the US Preventive Task Force suggests that people who've had greater than 20 pack year history. That means that they've smoked one pack per day for 20 years or they've smoked two packs per day for 10 years. In any case, the term that doctors use is pack year smoking history. The more smoking exposure one has, the higher the risk for having lung cancer. You had spoke in about second here. exposure to smoke when they worked in a tavern and didn't smoke or they were married to a spouse who smoked. There's still some increased incidence compared to the general population that has never smoked, but there's usually there's a pretty clear relationship between the amount of smoking that one has had and the chance of having lung cancer. The the US Preventive Task Force suggests that people from the age of 50 to 80 Some of the other groups are a little bit more inclusive and don't, and exclude some of the older patients are eligible for this screening. And if they haven't quit within 15 years, i.e. they're still smoking, they quit five years ago, 10 years ago. But after about 10 years of quitting smoking, then their risk of lung cancer pretty much comes back to what the baseline risk in this country is, which is fairly low and not worthwhile to go through all the pain and suffering. of getting a yearly CT of the chest and everything secondary to that.

Michael:

What is the early detection test?

Peter Schlegel:

The early detection test is a CT scan. Pretty simple. I think people go into a CT scanner, takes less than two minutes, and they get a pretty good picture of what's going on in the lung. There's no contrast, nothing really fancy. Really the key is that you have trained radiologists that are monitoring for any sort of changes that may have existed from year to year.

sox:

sort of a low dose cat's gate, low dose radiation. It's, it's pretty good. The.

Peter Schlegel:

One of the disadvantages for every one lung cancer that we detect, we may detect as many as eight or nine, what we call false positives, where we see a ditzel and that takes us into the pattern where we're saying, hmm, this could be lung cancer, but ultimately just turns out to be a scar or a benign tumor or something that's not important. Yet we don't know that when we have the CT scan.

Michael:

So you're saying that smoking is by and large the biggest reason. What are some other reasons that might lead someone to be diagnosed with lung cancer?

sox:

Well, there's

Peter Schlegel:

One of the common threads is...

sox:

go ahead.

Peter Schlegel:

Go ahead, Socks.

sox:

No, I mean, I think if you're asking like what other environmental factors can contribute to lung cancer, the number one that I am aware of is radon. And it's sort of an untalked about thing. And, you know, where people who have like a basement apartment or in some parts of the country, that's a fairly significant risk factor. And it's important to

Michael:

Oh

sox:

remember

Michael:

wow.

sox:

radon. As far as the... just to talk about screening really quick, there's a couple of caveats to the screen.

Michael:

Oh, we lost you.

Paul Roach:

Oh, Keith? Hey Keith?

Michael:

Elastic Keith.

sox:

Oh, did

Michael:

Now

sox:

that,

Michael:

we can hear you.

sox:

is that better? Um, is that better?

Peter Schlegel:

You may want to start back with the radon. We kind of lost you when

sox:

Uh,

Peter Schlegel:

you were discussing

sox:

so basically

Peter Schlegel:

radon.

sox:

radon is an undiagnosed, it's a painless, it's an odorless gas that happens in certain parts of the country, particularly in people with basements or live in basements. As far as, um, the, the, what I was talking about with screening, the couple of caveats that you got to remember are it's not a get out of jail free card. And part of the program, because we follow so many of these, as Peter mentioned, is that we have to have smoking cessation protocols in place. So that means people that come in and are smokers, we gotta try and stop them because the survival benefit is only if you kind of stop smoking and try and change your ways. If you keep smoking, then all you're doing is finding the problem after it started. What was also gonna say about screening.

Michael:

It sounds like my doctor isn't going to bring it up to me because I'm not a smoker. So I'm at less of a risk. So is this something when I go to see my GP, they're just basically, if you have a history of smoking, they might say, Hey, we need to screen you. Yeah. Okay.

Paul Roach:

Yeah, exactly.

Peter Schlegel:

Yeah, it's

Paul Roach:

You know,

Peter Schlegel:

the job

Paul Roach:

I mean.

Peter Schlegel:

of the primary care doctor to go through your history and say, hmm, you're a smoker. And if you're honest with them, that they'll be able to give you accurate information and say, gee, if you're smoking, maybe we should think about quitting and you're maybe at higher risk for lung cancer. So let's do this CT screening program with a yearly CT scan, et cetera. One thing I just wanted to add regarding risk factors, we talked about radon, agent orange, some of our Vietnam

sox:

Oh, that's

Peter Schlegel:

veterans

sox:

a good point.

Peter Schlegel:

do have a higher risk of lung cancer. Some things that are just very unclear is the vaping and whether you're vaping nicotine or THC, I don't think we've seen quite as much risk of lung cancer with the typical marijuana smoker. There is some increase, but it's not nearly as high or as risky as tobacco smoking is for lung cancer.

sox:

So when you're asking, so you were asking about, I kind of answered the radon and smoking, but the scariest thing is the guy walking down the street, how do you know if you might be at risk for a lung cancer, particularly if you smoked or didn't smoke,

Peter Schlegel:

and

sox:

cough, an unexplained cough that you're, you know, that's a change in your normal behavior, you know, unexplained weight loss, those sorts of things would, you know, you should. you know, bring it up with your doctor and they would then get a chest x-ray or whatever studies appropriate without a screening reason.

Michael:

Okay. Peter, you said something that sort of amused me, which is, if you're honest with your doctor,

sox:

Haha

Michael:

so

Peter Schlegel:

I'm

Michael:

you

Peter Schlegel:

sorry.

Michael:

guys

Paul Roach:

Yeah

Michael:

are doctors. And I just find it, I mean, I can tell when someone's a smoker. Do people really lie to you? And you must

Paul Roach:

Oh,

Michael:

know, like, you're not a smoker.

Peter Schlegel:

Oh,

Paul Roach:

constantly,

Michael:

You're a smoker.

Peter Schlegel:

absolutely.

Paul Roach:

constantly.

Peter Schlegel:

They want to hear the lecture for the 80th time about their smoking. They're just like, come on, doc, I love smoking. And those are actually the hardest people to have quit, but it is just, yeah, there's a lot of misinformation in communication with patients. I mean, it's really critical that our audience is truthful with their primary care. It makes your care so much better than if you're hiding some little details about. what some of your personal habits are, albeit suboptimal.

Michael:

That's come up a couple of times.

Paul Roach:

I was talking with my med students about that exact point today. Cause one of my patients this week was saying he smokes three to four cigarettes a week and we walk into the room and he's puffing out vaping. So it wasn't cigarettes, but, and I, and I was like telling the students, don't believe that for a second, you know, he smokes three to four packs a week, not cigarettes, you could tell. Um.

Michael:

Yeah, that that's come up a couple of times where we either through embarrassment or, you know, they just don't want to hear from you guys, like what good health is. But yeah, it's come back

sox:

or

Michael:

time

sox:

their

Michael:

and

sox:

wife

Michael:

time again.

sox:

is in

Michael:

Oh,

sox:

the room.

Michael:

but you really have to be honest, right? Because if if if you hold anything back that potentially like that's that first line of defense when you go see your primary care physician. And if you're not being honest with them, even about stuff that might be potentially embarrassing or or gets you in trouble with the Mrs. You're really setting yourself really far back. OK.

Paul Roach:

Totally. The system relies on that. That's like the entry point into the system. My, my grandmother who was born in 1900, uh, God rest her soul. She, we brought her to the doctor when she was around 90 and she didn't say a single thing to him. And my mom was saying to grandma, mom, why didn't you tell him anything? And she looked at her and she said, honey, he's the doctor. Like he's supposed to somehow know, you know, no.

Michael:

That's fantastic. I like that story, Paul.

Paul Roach:

Well, anyway, all right. So let's say a person has cancer. Uh, you know, they're, they're in your office, either, uh, Peter or Keith's office and you know, there's a spot that's been seen on a, let's say they developed a new cough or shortness of breath, uh, and then someone got an X-ray and the X-ray shows a spot. So it's really hard to, to know exactly what it is. What do you tell your patients at that point? in terms of, all right, this is what we've got to do to work up this spot on your X-ray, and these are the potential things it could be.

sox:

Well, I think the most important thing is we're becoming more data driven and it's all about stage. And as Peter mentioned before, we're getting a lot of nodules now that are diagnosed incidentally is the big word, which means you just find them. You know, if you live in like the south, like southern Arizona, California. you know, the kind of the Cryptococcus, histoplasmosis belt, these are fungal infections.

Michael:

All right, I got

sox:

That's

Michael:

to stop

sox:

all right.

Michael:

you right there. Crypt what now?

Paul Roach:

Yeah.

Peter Schlegel:

Hehehehe

sox:

It's a fancy

Paul Roach:

Yeah. It's a

sox:

word

Paul Roach:

clean

sox:

for

Paul Roach:

show.

sox:

fungus.

Paul Roach:

It's a clean show.

sox:

Yeah.

Paul Roach:

Yeah.

Michael:

Oh, okay.

sox:

So you.

Paul Roach:

But also Keith, we have a lot of listeners from around the world, it turns out. Uh, when I analyze who's listening. And so it's not just the USA. We've got people in Africa and in Southeast Asia

sox:

I don't know whether

Paul Roach:

and

sox:

Ebola

Paul Roach:

in

sox:

could

Paul Roach:

Western

sox:

cause it.

Paul Roach:

and Eastern Europe. Yeah.

Peter Schlegel:

Ha ha!

Paul Roach:

Yeah. But, uh, Anyway, yeah, Mike, you was talking about different fungi, fungi that can, you know, you inhale and they cause spots in your lung that, that maybe don't even bother you. But when you, someone shoots an X-ray, they can see something and they're like, Hey,

Michael:

And it looks like cancer. Can

Paul Roach:

it

Michael:

it

Paul Roach:

can

Michael:

become

Paul Roach:

look like

Michael:

cancer?

Paul Roach:

it can not. Yeah. It looks like cancer, but does it actually ever become cancer?

sox:

Well, there's

Paul Roach:

I don't

sox:

things

Paul Roach:

think so.

sox:

called scar cancers, but the bigger picture is

Paul Roach:

Uh.

sox:

that you can, for every person that gets a nodule, they should not immediately go to the worst case scenario. They should just, you know, let their doctor give them their recommendations and advice, and there's a lot of ways to look. Ironically, in my work, maybe not so much in Peter's work, but a solitary pulmonary bigger deal than if you have five nodules. Because most people don't get five cancers. They get one, and for us, if we want to find that guy who's got the one nodule that we can take care of and cure the problem. So one pulmonary nodule is more of a workup. And then they have size criteria under 3 1⁄8 of an inch is usually not anything to worry about. anything over a half an inch we start to worry about. And then we can do follow-ups. That's the annoying part to a lot of people. You can get CAT scans three, six months yearly to make sure that it's stable. There are other tests that can be done, which I don't know whether you want me to go into the weeds. Why is cancer bad? Cancer is bad because it grows faster than the rest of your body. We use that against it by taking sugar, which is what the body uses to grow. and putting radiation on it. So if you put the radiation in and then all of a sudden this nodule glows, we get the idea that it's growing. And then that raises the risk factor, and then we would want to figure out what it is a little more strong.

Michael:

So you're actually, you're feeding sugar to cancer to see at the rate at which it

sox:

Yep.

Michael:

consumes it.

sox:

That's

Michael:

Interesting.

sox:

called a PET scan.

Michael:

Oh, I've heard of those, but I didn't understand how it works. I should have gone to medical school.

sox:

Yeah.

Paul Roach:

You'd have been a star, Mike.

Michael:

Yeah.

Paul Roach:

Way

sox:

I should

Paul Roach:

to

sox:

have

Paul Roach:

go,

sox:

gone

Paul Roach:

Mike.

sox:

to

Paul Roach:

So,

sox:

graphic school.

Michael:

Good.

sox:

Yeah, that would be.

Peter Schlegel:

Hehehehe

Paul Roach:

yeah. So, you work up this spot and you do a biopsy and it's gonna come back because it's a cancer podcast, this spot comes back as a cancer. Then the first thing is you have to tell the patient basically what kind of... type of cancer it is. It's either going to be a small cell lung cancer, which is about 15 out of a hundred, or it's going to be other than that, a non-small cell, which is like 85 out of a hundred.

Michael:

Wouldn't that just be large cell? Or is this something

Paul Roach:

Ah,

Michael:

else? I'm like...

Paul Roach:

very good

sox:

There

Paul Roach:

question.

sox:

is one

Paul Roach:

Very

sox:

called

Paul Roach:

good question.

sox:

Large

Paul Roach:

Yeah.

sox:

South.

Paul Roach:

But then people could easily take our jobs if we made it that.

Michael:

Yeah

Paul Roach:

Yeah. You know, so no small cell is a specific type and it's a different kind of creature than the others, uh, if I've got this correctly guys and small cell in fact is what my father had small cell back in, in 1985. Um, And it's a, it's its own type and it, it comes about also through smoking, but through a different pathway. And then it's treated kind of differently, mostly with chemotherapy, is that right? Peter.

Peter Schlegel:

Correct. Radiation and chemotherapy. Surgeons are becoming more and more involved with any early stage of lung cancer, but for the most part, the small cell tends to have a really bad behavior and spread pretty quickly, such that it's rarely found in an early stage of small disease. It can be simply

Paul Roach:

And it tends to start really centrally too in your chest, I think, which makes

Peter Schlegel:

Often

Paul Roach:

it hard.

Peter Schlegel:

it does, yes.

Paul Roach:

Okay. And then, so we'll concentrate on the non-small cell of which the two major players. As in for most cancers is either squamous or adeno. So Michael, you don't need to remember. There's no quiz at the end of this,

Michael:

I've

Paul Roach:

but

Michael:

been

Paul Roach:

it's

Michael:

writing

Paul Roach:

sort

Michael:

notes.

Paul Roach:

of, okay, good. But it's sort of like, uh, uh,

sox:

In gland.

Paul Roach:

Squamous cells are, yeah, skin and gland. So your skin cells are squamous and the gland cells in your body are adeno.

sox:

So the inner lining of your windpipe is the skin, right? It's kind of exposed to the air. So that's the squamous type cells, the skin type cells. And then in between those, there are gland type cells. So every now and then one of those goes haywire. And then when they do, they make the tumors.

Michael:

What about the lungs themselves with all the, if I'm remembering my biology correctly, the alveoli. They're just

Paul Roach:

Oh sweet!

Michael:

little little air sacs and stuff. Is that, that doesn't sound like either skin or gland. What is

sox:

Again,

Michael:

that?

sox:

if you go out far enough, there's going to be a little bit of an airway and they're all sort of intermixed. I don't know where we would call bronchoalveolar, which is a big word for kind of a diffuse sort of spongy tumor. That might be more of an alveolar type spread, but it doesn't really matter. It matters more for Peter when you get to chemotherapy. For me, I'm just a hands guy. If it's bad, it comes out no matter what's the diagnosis. The big issue for us, sadly, as we mentioned, is if cancer is a weed, has it gone to seed yet? And if it's gone to seed in the liver, well, we aren't going to be able to necessarily pluck that weed. Although today, in 2023, we are being more aggressive with us. solitary weeds that have sprouted elsewhere. But those are different therapies. But if you have a nodule in your lung, the most common site for it to hop to is the lymph nodes. So we find that out by that sugar test, the PET. And then we can now sample those very easily with a pretty painless test called They use a bronchoscopic examination where they stick a little tube down your throat and they take samples that way. They show that the weed is jumped, then we go into a different category of therapies. When we talk about cancer, we think there's three ways to talk about it. One is local, regional, and distant spread. or stages, one, two, three, and four, is the more medical way of thinking about it. So stage one and two, most people are gonna get surgery. There's some new studies that are showing that if you're in stage two, you may be better off with this fancy new stuff called immunotherapy before surgery. And if you're stage three, most people would either do all chemo radiation stage three or four or you would do chemo radiation chemo plus or minus radiation and then surgery.

Peter Schlegel:

Yeah, from the patient point of view, that's probably the most nerve racking

sox:

Absolutely.

Peter Schlegel:

part is the staging and to determine how far advanced the cancer is and therefore what your prognosis is and what sort of treatment that you get. As was just discussed at the early stage, if it's small, the surgeon can take care of it. If it's regional, it's spread to lymph nodes and it's kind of well. Sometimes things turn out well. Sometimes they don't. and we're gonna bring in everybody we can to see if we can salvage the situation and actually cure the patient. And at this point, 2023, we count on radiation, not only to radiate where it started from, but some of the lymph nodes in that area. And that promotes having a big field of radiation through your chest, but yet it can encompass all of the lung cancer. To oversimplify radiation, it's like taking a magnifying glass on a summer day where you can focus all the sun's beams into a very hot spot. So the radiation oncologist is very adept at focusing those x-ray beams at the critical cancer sites, the lymph nodes where it started from, but avoiding the spinal cord, the heart, some structures at the lungs, blood vessels, and so forth. And that actually can be very complicated, very technology heavy, but it works out very well for a lot of patients. We sometimes mix it with systemic therapies, drugs, chemotherapy, and or immunotherapy, which I could spend a lot of time talking about. Then if the cancers move beyond the lymph nodes, then we call it stage four. If it's in the bones, it's in the internal organs, even if it's in the brain, that basically we've said, gee, the cat's out of the bag and the best we can do is slow it down. Now there are exceptions to all those rules that occasionally people who have one or two spots that have spread out. even though they're metastatic, are cured. And I have at least half a dozen people that have been diagnosed with metastatic lung cancer and have survived. And it's not a miracle, but it's

sox:

The data,

Peter Schlegel:

statistically

sox:

if you have

Peter Schlegel:

unlikely.

sox:

a single brain, brainweed from a lung cancer, is you can almost have a 25% chance for five-year survival by getting treated. And the treatments today are, he mentioned radiation. It's important to talk about, you know, radiation has changed dramatically from what it was 30 years ago, or even 10 years ago, 15 years ago. three x-ray or flashlights because that's all they could get and they would do three beams and then they would you know focus those all in the same location so the toxicity between the skin and your tumor had to be very it was very close to each other nowadays they have fourteen hundred flashlights so instead of getting thirty days of treatment you can get three to five days of treatment And that is about 85% as good as surgery for local control. So those

Paul Roach:

Wow.

sox:

are, stereotactic radiation has been a game changer for people. So if your doctor told you, hey, you really don't need any of these tests because your lungs are so bad, well, that's not, I wouldn't agree with that.

Michael:

So even if you're in a late stage, you're saying that the state of radiation therapy now, with its, that's an amazing statistic.

sox:

100% like let's say you're scared of surgery. I have people that

Michael:

I'm sorry.

sox:

don't want x-rays, don't want screenings, because they're afraid of surgery. And they say, I don't even wanna know because I'm never gonna let you cut on me anyway. Well, that patient can still get 85% with no surgery, just local control. I don't advocate that personally because I think that 15% is 15 people. over five years but I think that's it's still better than the alternative which is eighty-nine people if they don't get therapy.

Paul Roach:

And to back up just a sec on how radiation therapy does it's, you know, does it's work. So imagine you've got an ultra powerful flashlight and you're just, you've got one sensor and you're going to send all the radiation out through that sensor. And it's like a flashlight. Well, that's kind of like a lightsaber going straight through from front to back, whatever you aim it at. So that's too much. The treatment is gonna, is, is going to be worse than the disease, but by. Breaking it up into three separate ones, which is what they used to do. And they're all coming at different angles only in that one spot where all three beams converge, does the tissue get the full dose of those photons. or the X-rays. And now what Keith, you know, Keith is talking about is they can do it from how

sox:

I think

Paul Roach:

many

sox:

it's

Paul Roach:

different

sox:

1,440.

Paul Roach:

sources?

sox:

Yeah, I mean, or more.

Paul Roach:

Holy cow. 1,440 different sources. So, so each, you know, brain cell, let's say it's a lesion in your brain. Is only getting a one 1,400th of what it would have if it was a single beam, because it's all coming from different angles. And again, only in the spots where it wants to converge, does

sox:

And they

Paul Roach:

it get

sox:

can

Paul Roach:

the

sox:

do

Paul Roach:

full

sox:

within

Paul Roach:

dose,

sox:

millimeters.

Paul Roach:

so that's how they're able to do this.

Michael:

Is this delivered in like one of those big MRI machines or something where it's all around your body and it's focusing beams from

Peter Schlegel:

Yeah.

Michael:

every angle, like back,

sox:

So

Michael:

front,

sox:

the kind

Michael:

side,

sox:

of the

Michael:

all over?

sox:

cool

Peter Schlegel:

The term

sox:

thing

Peter Schlegel:

that

sox:

about

Peter Schlegel:

we...

sox:

this is the story about how it evolved, which I, again, I'm a surgeon, so I like surgery, but this neurosurgeon was driving into San Francisco after one of the big quakes, and he saw these civil engineers with X-ray machines on their shoulders, and they were checking the bridge abutments for... you know, subclinical fractures. And he said, oh, huh. So then they literally took that and they put it on a, one of the car, you know, manufacturing robots so it could move around and, you know, focus

Michael:

Huh.

sox:

it all on the middle. And it's just fascinating technology.

Peter Schlegel:

The term that I've heard thrown around is linear accelerator. That's the big machine. You have to go to a radiation center. The specialist that delivers the radiation is called the radiation oncologist. There's a whole profession of people who work there with dosimetrists and therapists. There's just the amount of technology and computer powers is amazing at those radiation centers.

Michael:

Well, let me ask then when I was a kid, uh, a couple of my aunts had cancer and they were wiped out. I mean, they, the cure was as bad as the disease in a lot of ways. And you know, they're, their hair fell out and I think that still happens. But now I see, you know, there's a, there's a Senator on the floor right now who's undergoing cancer treatment and his hair is gone, but he's still very active in his job and he's on the floor and he's debating. My aunts never could have done that 40 years ago. Is the, and I'm asking this as, I think there is a lot of fear. I'm old enough that, that's like, oh my God, I have cancer, I hear that from you guys, and then I'm like, oh my God. And radiation, I remember, I remember radiation for my relatives and it's horrible. And they're basically laying in almost vegetative state most of the day because they're recovering from it. It sounds like... That might not be the case anymore, and I don't need to be as afraid of radiation therapy as I remember seeing it. Is that true?

Peter Schlegel:

Yeah, I think the side effects for most of these treatments are less, although they still can be severe and they can be life threatening. Patient selection is very important that we want to have people that are healthy and not consumed by their cancer by the time they start treatment. We actually have a very strict objective criteria about who can tolerate chemotherapy, who can tolerate immune therapy, who can tolerate radiation and so forth. And having said that, we do a good job of making sure that the treatment is suitable for the illness. And one of the points that I will make as a medical oncologist is that it is very important from the get-go or early in your journey with lung cancer, whether you know that the goal is to cure you of the cancer, whether that's realistic and possible in 2023, or whether the best we can do is slow it down and give you a good quality of life. And from that division point, that can really drive how aggressive or not aggressive we're gonna be. If we're in a case where the cancer is all over the body, the best we can do is slow it down, well, we have to accept that reality and we don't wanna cause more harm than good. On the other hand, if we say, by going through this treatment, we could remove this from your body, you'll never have to suffer from end-stage cancer if this is successful, we're gonna go down that route. So it's really important. that we know what the stage is, that the patient is realistic about what expectations and we go down the correct path.

sox:

I think the big words are curative versus palliative. And if you're going for cure, you may be willing to put up with some more upfront pain than if you really don't feel bad and we're just trying to make it so your life is better longer.

Paul Roach:

So let's just say we're gonna go for cure. Let's say it's a stage one or stage two. And again, that means stage one, it's just that spot, that cancer, and it's local. And stage two, it's moved a little bit into the lymph nodes right next to it, correct? Or it's a little bigger spot, but it hasn't moved

sox:

Like

Paul Roach:

centrally.

sox:

I said, I thought the cancer society, local, regional, and distant. So if you're local,

Paul Roach:

Okay,

sox:

then

Paul Roach:

great.

sox:

that's therapy. Now,

Paul Roach:

So let's say.

sox:

there's some very good studies that are being done with, again, it's very important to find out where your stage is or what's going on before you jump into surgery or radiation or chemo. And I think that we're getting very good at doing that without a lot of discomfort. One thing that we should talk about, one of the reasons why there's a difference between that radiation we were talking about and a surgical approach or medical therapy is because when we do surgery, we sample those lymph nodes and about 15% of the time we find that even though we didn't see that. the weed has spread, we actually find it on those diagnosis. So then those people were actually being more aggressive today in sending them for additional therapies. The other thing is to talk about immunotherapy, adding immunotherapy to some of the people before surgery. If they have that local or regional, like if it's gone from the... lung to the lymph nodes, they're finding that that seems to have a fairly significant improvement.

Paul Roach:

And I

Peter Schlegel:

There's.

Paul Roach:

think we'll do a whole episode next month on the difference between chemotherapy and, and biological therapy and small molecule and immunotherapy. So we don't have to get too into the weeds on exactly what that is right now. I'll just tell everyone to tune in next month, but, uh, when it comes down to doing surgery, let's say you're going to operate, you propose to a patient, you know, I think we can remove this. This is local through surgery. What actually do you do? You know, what can they expect is your method for how you're gonna take out some of their lung and you know, what kind of decisions

sox:

I was going to

Paul Roach:

do

sox:

bring

Paul Roach:

you

sox:

a

Paul Roach:

have

sox:

model,

Paul Roach:

in that process?

sox:

but basically the lung is like a cluster of grapes. So you have a stalk and it goes down and it spreads into other sub-stocks. And again, when we talk about the difference between that radiation and surgery is if you have enough lung function, and we can talk about that in a second, if you have enough You don't just pluck the bad grape. I say, lung cancer is a bad grape. You don't just pluck the bad grape. You take it down at the stalk so that you get any of the other grapes that it could have touched. Radiation pretty much just kills the bad grape. Whereas if there's any things that slip through, the fancy word is lymphatics, if it's gone through that lobe, so we take the whole cluster of grapes, and those are usually divided, the lung is divided into lobes. Data is pushing us to taking less, which are called segments. And those are people, in my opinion, that have marginal lung function. Normal person breathes out about three or four Pepsi bottles for every breath. We want you to breathe at least 0.8 or one Pepsi bottle after you're done. There are two ways to do the surgery. One is the old-fashioned way we spread the ribs. Everybody has to be ready for that. But statistically nowadays 95 times out of 100 surgeries are done minimally invasive in my hands and I think many people's hands. Statistically, it's going up through the roof and that's either with a scope, video assisted approach like the old lap gallbladders, or robotically.

Michael:

You're saying how much it's taking, you're going to take a stock. Is that, you know, I mean my image of the lungs is it's two halves connected by a bunch of pipes. Am I losing a half of a lung of one side, so a quarter of the total, or is it an eighth? How much is usually going out if I'm having surgery?

sox:

So there's the left and the right lung, and then there are segments in each of those. But I would just say the left side has three major branches, subdivisions, upper, middle, and lower. The left sort of has 2 and 1 half, upper, lower. And there's this thing called a lingula, which is kind of in the middle. But so when you take, if you're going to do a lobe, I'd say you're taking about 30% of one side of the lung. Did that answer the question?

Michael:

Yeah, absolutely. About a sixth, if it breaks out into three and two and a half.

sox:

Yeah.

Michael:

And you're going to take one of those. About a sixth of my lung is going to go

sox:

Yeah,

Michael:

at that

sox:

and if

Michael:

point.

sox:

it's in the middle, we would take all three, but that's pretty infrequent.

Paul Roach:

And then one thing to remember is as we age, our lung function slowly declines no matter what, and if, if we have been smoking, it declines a bit faster. Uh, and so removing a sixth or a fifth of a lung in somebody whose lungs are in great shape is one thing, but removing it in somebody who's very short of breath all the time anyway, is, is, is another. And Keith was talking about that earlier in terms of if we have a procedure, then we also have to match it to the person that we're in front of because maybe they're not in great shape to tolerate what we're proposing.

Michael:

So even at stage one, you wouldn't operate. You'd give them radiation or immunotherapy.

Paul Roach:

If it, let's just say, and I don't want to, uh, this is not my, I'm not a chest surgeon, but right anytime we're going to operate, we have to assess the patient and see if they can, if they can survive, if they can benefit from what we're proposing.

sox:

So I think the hardest part for a patient is they want everything done yesterday. Rightfully so. But what we wanna do as physicians is do it right the first time. And so when they come and see me, depending on at what time, you wanna make sure that they have the lung function test, that's a breathing test, it's pretty easy, they just blow into a machine. And that looks at, you know, again, a lot of them were smokers, so that's one. Then we want to know the same thing that smoker, you know, if you go to the gym, it says, go see your doctor before you start your exercise program. That's because people can have underlying heart disease. So lung surgery a lot of times is like running a marathon. So you want to have that evaluated. We also, like I said, we want to figure out the stage. Now if you have that patient that doesn't have good lung function. but they have a stage one lesion, that patient would be a good candidate for radiation. If they have stage one, but they have plenty of lung function, then they're better off with surgery.

Michael:

It seemed like from earlier podcasts that we've done that that surgery, if you can get to it in stage one, like that's that's the way to go. But it's interesting that this is the first time I think that we've heard based on well, no, I think Peter's actually said it before. Never mind, Peter, I think you said if you're not, you're going to you're going to assess everybody individually and you're going to decide what the what the right thing is. But you guys are leaning mostly towards surgery if you can.

Paul Roach:

Well, the other

Peter Schlegel:

I

Paul Roach:

issue is that...

Peter Schlegel:

think the important issue is that there's a multidisciplinary team. And when you're dealing with lung cancer, you generally need a surgeon, you need a radiation oncologist, you need a medical oncologist. You also need radiologists who know what they're talking about that have specialty of lung pathology and can help you to determine whether nodule is just a little spot from an infection that's been there for a long time. or whether it's new and has high risk features. But basically, once you get into the cancer world and you're introduced to a life threatening diagnosis, it's important that you get all your opinions before you proceed forward.

sox:

If I was going to give my

Paul Roach:

And then one.

sox:

mom advice about where to get her cancer treatment, it would be go to a place that has a multidisciplinary tumor board. Do you agree guys? You know, where,

Paul Roach:

Oh absolutely,

sox:

you know,

Paul Roach:

yeah.

sox:

it's a

Michael:

How

sox:

free

Michael:

would you find that out?

sox:

part.

Michael:

How would you know? How would you find out

sox:

You

Michael:

if a place

sox:

ask,

Michael:

has a multidisciplinary?

sox:

you ask, are you going to present this at a tumor board? And they there's actually recommendations for centers of excellence, things like that. But, you know, the VA has a tumor board that Peter, that Paul and I are on. But it's a free thing. We take your information and every you know, you have. Non. I don't want to use word non-interested, but non-biased parties all talking about a case trying to figure out what is the best pathway for you to have your best long-term outcome with the least discomfort.

Michael:

Is there a, does that happen for every tumor? Stage one, stage four, whatever, or... What, there

sox:

That's

Michael:

were...

sox:

two questions. It happened, there are breast cancer tumor boards, there are GI cancer tumor boards, and overall tumor boards, and each one of those would present people regardless of stage.

Paul Roach:

Yeah. And, and to back up a few minutes regarding another issue Michael was bringing up, which is, um, the subject of forgoing surgery and going straight to radiation. It strikes me that most of the cancers that we've been discussing have not been in what you'd call vital organs, whether it's bladder cancer or skin cancer, or even esophageal cancer, but when you're talking lung cancer, you need those lungs. every minute of every day, and you can only remove so much of them before you've taken too much. So like for a skin cancer, you can remove that skin and then you can just patch it or you can skin graft it or whatever. The bladder, you remove the bladder and you figure out ways to deal with life without a bladder or without esophagus. But your lungs, nope. That's a... That's a very fixed amount of, you need a certain amount of lung function in order to get through. So that's where that distinction comes in.

sox:

The rule of thumb for a surgeon without a lung function test is can you walk up one flight of stairs? If you can walk up one flight of stairs without getting short of breath, we can usually help.

Paul Roach:

All right. So in terms of, uh, uh, let's say you've, you've, you've operated and then he goes over to Peter, uh, or she goes over to Peter for. The medical oncology aspect, Peter, what are some of the key issues?

Michael:

or they Paul.

Paul Roach:

Yes. Or they are. They, uh, what are some of the key issues that you would bring up at that visit?

Peter Schlegel:

Yeah, assuming that they're a localized stage and that it's been removed, and I have a copy of the pathology, first of all, what type of lung cancer it is in terms of non-small cell, small cell, whatever, how large it is, and probably the single most important factor that you're looking at then is their involvement of lymph nodes. If the cancer is spread to the lymph nodes, we know that there's at least a 50% chance that there's some microscopic seeds elsewhere in the body that cancer. as one from the lung to the lymph node elsewhere. And at that point we would say, hmm, there may be some hidden cancer somewhere else in your body. Maybe we should think about doing additional therapy. Chemotherapy has been proven to be very helpful for reducing the risk. And studies are proliferating, we're finding the immunotherapy may be additive as well, depending upon what the cancer looks like under a microscope. But the first question is, would the patient benefit from additional systemic or whole body therapy? And sometimes we can, based on the tumor marker, we would do that preemptive. We would do the first treatment with the immune therapy first and then go to surgery. That's a little more complicated, but assuming you've had the surgery, then the medical oncologist can kind of come up with a plan in terms of, is there additional treatments we need now to treat any kind of... potential microscopic seeds. We call that adjuvant or preventative therapy. And the second is a survivorship program where people are being monitored. We call it surveillance where we're getting scans maybe twice a year or monitor them for headaches because occasionally one of these microscopic seeds can wind up at the brain and cause headaches, seizures, things like that. We have to be on top of that. But the fact is that during the medical oncology evaluation, we really want to make sure that we're doing everything we can to increase the risk, increase the chance of being a long-term cure. And then secondly, what kind of follow-up does the person need?

Paul Roach:

All right. All right. Well, and we will, we will get into the differences between chemo and, and biologic and immunotherapy, uh, next month, I believe. And, uh, are there any other saved rounds regarding lung cancer and treatment, uh, before we head out?

Michael:

I'm just going to say it again, man. Everything that I've learned over the last couple of episodes is you want it to be caught early. And the best way to have it caught early is to make sure that you're having your annual checkup and that you're directly talking to your physician about anything that's a little out of the ordinary for you.

Paul Roach:

Yeah, I think that's a fantastic take home point.

sox:

I think the important thing is between the ages of 50 to 80, smoked more than a total of again, pack years, that's 20 pack years, you should think about trying to find somebody to do a lung cancer screening, low dose test and stop smoking.

Michael:

Good

Paul Roach:

Yeah.

Michael:

call.

Paul Roach:

Good call. Yeah. And Keith and I just started a program for that at our hospital. It's been pretty successful so far. Very Peter. Any saved rounds?

Peter Schlegel:

We haven't discussed clinical research, but a lot of the progress that's going on between chemotherapy and better tolerance, better activity, the immune therapy, basically using the immune therapy is all built on research that's 10, 15 years old. But we're still proceeding far because the majority of people with advanced lung cancer unfortunately will succumb to their disease. So we need more effective treatments. We need to... organize them in a better way. We have to make them better tolerated for the patients. So a big plug for any kind of research or clinical trials for people with lung cancer is encouraged.

Paul Roach:

Well, outstanding gentlemen. Thank you all very much for being on the show and listeners. We really are delighted that you've dialed in and please feel free to write us with any questions that would be at letters at Paulbryanroach.com. And, uh, and if you have any topic you would like to have us discuss or comments or feedback, uh, you can log on to, uh, http://www.Paulbryanroach.com and click the about in contact page or just send them. to that email, letters

Michael:

That's Brian

Paul Roach:

at,

Michael:

with a Y, right?

Paul Roach:

yeah, my mom had to be different. She had to be different. And I would like to have a different email for you guys to use, something simpler, but I haven't figured that out yet. All right, thanks everybody. Thank you very

sox:

Thanks

Paul Roach:

much.

sox:

for having me.

Paul Roach:

Talk to you.

Peter Schlegel:

Thank you.

Paul Roach:

It's

sox:

Nice

Paul Roach:

been

sox:

to

Paul Roach:

a

sox:

meet

Paul Roach:

pleasure.

sox:

you guys.

Michael:

you too.

Peter Schlegel:

Likewise.