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The Inflection Point: Changing Lung Cancer Survival

Lung cancer kills more Americans than the next three cancers (breast, colon and prostate) combined. Typically caught in its later stages, survival rates beyond five years are often in the single digits and unlike other cancer diagnosis, outcomes for lung cancer patients have only slightly improved in decades.

Evidence-based diagnostic and treatment approaches capable of significantly impacting survival rates have yet to be widely adopted, but a handful of comprehensive lung cancer treatment centers are demonstrating the way forward.

Daniel Oh, MD, FACS, a board-certified thoracic surgeon, Associate Professor of Surgery at Keck School of Medicine of USC and Medical Director of St. Jude's Center for Thoracic and Esophageal Diseases, discusses advances and shortcomings within the field.

Lung cancer is almost universally caught in its later stages. How do we change that?

Low-dose CT screening can catch lung cancer in its earliest, most treatable phase, stage-shifting a cancer diagnosis from late-to-early in much the same way mammography and colonoscopy have done. By identifying cancer before there are clinical signs or symptoms, low-dose CT screening has proven to result in a 20 percent decrease in lung cancer deaths among those most at risk: heavy smokers.

Despite this success, fewer than five percent of heavy smokers are referred by their physician for screening nationwide. In part, the reluctance to make the referral comes from confusion over which patients should be screened as well as confusion over Medicare-requirements, which include a documented patient conversation of benefits and risks.

We created the St. Jude Lung Cancer Screening Program to relieve primary care providers of the time consuming burden of determining which at-risk individuals meet criteria, which CT scan is most appropriate, correctly documenting required patient conversations, and then putting the results into an appropriate context. The program offers turn-key simplicity and convenience for referring physicians.

Who should be referred to the Lung Cancer Screening Program?

Anyone who might benefit from screening is welcome to be referred, and the program will ascertain eligibility. Medicare and NCCN criteria include current or former smokers, ages 55-77, who have smoked the equivalent of one pack of cigarettes a day for 30 years—or smoked for 20 years and have an additional risk factor, such as COPD, occupational exposure to asbestos or diesel fumes, or a family history of lung cancer. Heavy smokers who have quit in the last 15 years should also be screened.

Annual low-dose CT screening for lung cancer is now fully covered by Medicare and private insurers, and is recommended by all major oncology, pulmonology, and thoracic surgery societies.

What about patients with pulmonary nodules? What's the right balance between unnecessary testing and missing a cancerous growth?

Pulmonary nodules need to be evaluated, but when, how, and what follow-up is appropriate is not always clear. Expert consensus and guidelines for monitoring pulmonary nodules continue to evolve, making it extremely difficult for physicians who are not dedicated to lung disease to review scans and sort through conflicting recommendations, while also managing other medical issues the patient may have.

While the vast majority of pulmonary nodules are benign, the concern that an early-stage lung cancer could be missed by neglecting a small nodule is a common and anxiety-producing issue for physicians—who often face pressure to reduce "unnecessary" testing.

Through the St. Jude Pulmonary Nodule Program, we provide expert assessment and ongoing monitoring of pulmonary nodules or suspicious imaging abnormalities. For patients enrolled in this free program, their imaging is reviewed by a thoracic surgeon, pulmonologist and radiologist—a multidisciplinary review that is essential to deciding the optimum next step, while also eliminating the need for the referring physician to determine which specialist the patient should see.

By integrating current guidelines with the judgment of this experienced multi-specialty team of lung experts, patients benefit from today's best evidence-based approaches to managing nodules, tailored to their individual history, risk for malignancy, and imaging characteristics.

How can I enroll a patient in the Pulmonary Nodule Clinic?

Any patient with a significant lung nodule (6 mm or larger) found incidentally on CT imaging or x-ray should be referred—simply call (714) 446-5900. Our thoracic nurse navigator will call the patient to gather a relevant medical history as well as coordinate with the physician's office to obtain necessary medical records and imaging studies.

The information is reviewed by the program's multidisciplinary panel and all findings, along with any monitoring and treatment recommendations, are communicated to the referring physician. This "virtual" evaluation typically does not require a patient visit and is provided at no-cost.

Patients will continue to be monitored for as long as indicated, while keeping the primary physician fully in the loop. If needed, specialists from the St. Jude Crosson Cancer Institute can be seamlessly included in evaluation, monitoring and treatment planning.

Isn't over-treatment a risk?

Yes. The guiding principle of the Pulmonary Nodule Program is Primum non nocere: "First, do no harm."

Unnecessary biopsies and surgeries to remove nodules that are not cancerous can create as many complications as failing to provide appropriate monitoring. Even non-invasive monitoring can be harmful if an inappropriate imaging modality is chosen or the frequency of scans is too close. One of the only programs of its kind, the St. Jude Pulmonary Nodule Program is at the forefront of offering the right care at the right time. Our rate of negative surgical lung resection—removal of a nodule that turns out to be benign—is less than 5 percent.

Are there new ways to diagnose, stage and remove pulmonary nodules?

Yes. We are one of the few centers in California to offer electromagnetic navigation bronchoscopy—a minimally invasive diagnostic technology that uses GPS-like technology to locate and biopsy a suspicious pulmonary nodule without performing surgery and with a fraction of the risk of conventional CT-guided needle biopsy.

Another example is the assessment of mediastinal or hilar lymphadenopathy is now regularly performed using endobronchial ultrasound or EBUS. This bronchoscopic technology allows the visualization and direct biopsy of lymph nodes that appear suspicious on CT scan, and has almost completely eliminated the need for cervical mediastinoscopy.

You were one of the first to routinely perform robotic lung resections. What are the benefits?

Lung cancer surgery cure rates have not improved significantly in decades. Robotic lung resection is allowing us to finally change that by giving us the tools to more aggressively and completely remove the cancer.

By providing greater vision, maneuverability and precision, the da Vinci surgical robot is improving outcomes while reducing complications and recovery times, even compared to mini-thoracotomies or a thoracoscopic/VATS approach. Robotic resection has replaced the thoracotomy's large incision, rib cracking and week-long hospital stay, with a few tiny incisions and a two-day hospitalization—allowing patients to begin the next phase of treatment sooner.

St. Jude is one of six hospitals in the western United States to be designated an Epicenter for robotic-assisted lung resection, a recognition intended to distinguish the small number of hospitals offering experienced surgeons, dedicated robotic surgical teams, and low complication rates. We serve as a formal case observation site for the procedure, hosting surgeons from around the world.

Utilizing this technology in a fiscally responsible way remains a priority and St. Jude is one of the most efficient centers in the nation for robotic lobectomy, with operating costs in the lowest decile in the country.

What's the future of lung cancer treatment?

The two bookends of care—increased screening and improvements in treating cancer on a molecular level after surgery—are where we will continue to create significant, even dramatic improvements. Our medical oncologists are using next-generation sequencing on lung and other common cancers to identify genetic defects or markers that can be used to target and eradicate cancer cells. By identifying the cellular signature of an individual's cancer, patients are increasingly benefiting from clinical trials that attack the specific genetic mutation driving a tumor's growth—or improve the immune system's ability to destroy it.

St. Jude was one of a small number of hospitals in Southern California to participate in a landmark clinical trial demonstrating the superiority of immunotherapy over chemotherapy in treating advanced lung cancer—research that is changing the standard of care. Monoclonal antibodies were used to create "immune checkpoints," blocking the pathways cancer cells use to avoid the body's immune system and increasing the body's ability to recognize and kill the cancerous cells.

About the Author

Daniel Oh, MD, a nationally-recognized and Harvard-trained thoracic surgeon, is the Medical Director of the St. Jude Center for Thoracic and Esophageal Diseases and an Associate Professor of Surgery at Keck School of Medicine of USC. Published in peer-reviewed journals and surgical textbooks, Dr. Oh is a national leader in expanding the role of nonsurgical, minimally-invasive and robotic options in the diagnosis and treatment of lung cancer.

Dr. Oh offers extensive experience in the full spectrum of general thoracic surgery, including minimally invasive lung resection, minimally invasive esophageal surgery, advanced non-surgical endoscopic and bronchoscopy techniques, and the treatment of uncommon thoracic malignancies.

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