Usman Ahmad, MD
Peter Mazzone, MD, MPH
Gregory Videtic, MD
Thursday, November 9, 2017 | Noon
Lung cancer is a very challenging cancer to treat. The most critical factor in determining the survival rate is the stage at the time of diagnosis. Using a multidisciplinary approach to lung cancer care is vital to managing the disease. Take this opportunity to have your questions answered by thoracic surgeon, Usman Ahmad, MD, pulmonologist, Peter Mazzone, MD, MPH, and radiation oncologist, Gregory Videtic, MD.
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salander: My husband was a smoker for 20 odd years. He recently quit and had a CT screening. They found a small nodule on his lung but said not to worry about it. Shouldn't all spots on your lungs be watched and tested? I just don't want to find out it is something and we caught it too late. What is the standard process when a spot is found?
Peter Mazzone, MD, MPH: Almost 9 out of 10 adults who have a CT scan performed will be found to have a lung nodule. Most of them are very small. These very small lung nodules have a very, very low chance of being cancer. If they are small enough we suggest following them in a year with another screening scan. If the nodule is larger, it may require sooner follow-up or additional testing.
FlyBird668: I had a chest x-ray and they found a 2cm nodule. My next appointment isn’t for a month. I’m scared its cancer. What are the chances it is based on the size? I have never smoked.
Peter Mazzone, MD, MPH: We determine how likely it is that a nodule is cancer based on a few things. Your age and smoking history as well as any history of prior cancers, as well as the way the nodule looks on the x-ray (size, shape and location). Sometimes we can tell right away that even a 2 cm nodule is not cancer. More often we will need a chest CT scan to help determine how likely it is to be cancer and what the best next steps would be. It would help to see your doctor as soon as he/she can visit with you.
brendaR: My mom had a nodule that was being followed and it actually turned out to be small cell cancer? Is that common? Can a nodule turn into cancer or was it missed to begin with? If you have a nodule how often should it be checked? I also have a spot that has been diagnosed as nodule and I am anxious that they may be missing cancer?
Peter Mazzone, MD, MPH: There are many reasons that someone might have a lung nodule. Most of the time, lung nodules are related to an area of inflammation or scarring in the lung. This often is the result of something we breathe in. Our body handles it and leaves a small mark behind. Sometimes nodules are signs of a cancer. Your doctor uses information about you (age, smoking history, etc.) and the nodule (size, location, shape) to determine how likely it is that the nodule is cancer. The need for additional testing is based on this assessment - there may be no need for further testing, or a repeat chest CT scan might be recommended months later, or a biopsy of the nodule - all based on how likely it is that the nodule is cancer.
Ocanada: Can a chest CT tell if a nodule is cancer or not? My mom has no symptoms but the doctor has ordered a CT of her chest to determine if the nodules he is seeing is cancer or not.
Peter Mazzone, MD, MPH: This is a common question. A chest CT helps your doctor determine how likely it is that the nodule is cancer. Based on information about you (age, smoking history, etc.) and the appearance of the nodule (size, shape, location) your doctor judges how likely it is that the nodule is cancer. Advice about further testing is based on this assessment.
owen: How serious is surgical removal of small lung module that may or may not be cancerous?
Peter Mazzone, MD, MPH: Surgery that removes a piece of the lung can be quite serious. Prior to suggesting surgery for a lung nodule, other tests, such as scans and biopsies should be considered. If surgery is still felt to be needed, your doctor usually talks to you and does some tests to be sure your heart and lungs are strong enough to tolerate the surgery. With a healthy patient and good surgical team removal of a lung nodule can be done quite safely.
Lung Cancer Screening
kennyl: What is involved in lung cancer screening appointment? Who should do that?
Peter Mazzone, MD, MPH: Lung cancer screening appointments may vary depending on where you have them. At our center the appointment includes a discussion about your overall health, lung cancer risk, and the benefit and harms of lung cancer screening. We also discuss what to expect from the scan and what type of follow-up could be required. These visits are often delivered by an advanced practice provider. A primary care provider or pulmonologists can also perform the visits. After the visit you are sent for a low-radiation dose chest CT scan. The screening team then communicates the results to you. Currently, individuals age 55-77 who have smoked at least 30 pack-years (e.g. 1 pack per day for 30 years, 2 packs for 15 years) and have been a smoker in the past 15 years, are eligible for screening.
Victorylast3: My father smoked for years and quit about 10 years ago. When he gets a cold, it will often last for a while and will be real raspy. I worry that the amount of years he smoked compromised his lungs. How long do the effects of smoking last within your body?
Peter Mazzone, MD, MPH: It is great that your father was able to quit. This will keep his lungs as healthy as possible over time. Smoking can lead to long-term injury to the lungs, such as COPD (e.g. emphysema). Your father's doctor should be able to determine this with a simple breathing test and/or picture of his lungs.
ellwood: Does black mucus mean that you have lung cancer?
Peter Mazzone, MD, MPH: Black mucus can be present for many reasons. Breathing dusts (such as working in a foundry) may lead to coughing up black mucus. If the mucus is new to you it would be helpful to see your doctor. He/she may suggest a chest x-ray or other testing based on how you are feeling.
BETHELMOM: I have a chronic cough which produces phlegm, sometimes yellow? Is this my asthma or a sign of lung cancer?
Gregory Videtic, MD, CM, FRCPC: Chronic cough can be associated with many conditions. Especially concerning is chronic cough that changes or is associated with other particular symptoms. The best person to help guide how to manage this cough should be your primary care physician who knows you and your medical history.
Types of Lung Cancer
indigal522: Are there different types of lung Cancer? What are the treatments?
Peter Mazzone, MD, MPH: There are many different types of lung cancer. Treatment today is based on the type of lung cancer that one is found to have. Even within one type of lung cancer we have learned that each person's tumor can behave differently. Testing is available today to determine what the best treatment is for you, matching the details of your cancer to the best treatment. If lung cancer has not spread beyond the lung, treatment is usually surgery or radiation. If it has spread outside the lung, treatment is usually chemotherapy or therapy that helps your body's immune system fight the tumor.
daisy33: My husband was diagnosed with mediastinal lung cancer, the doctor said the only option is chemo and radiation to shrink the tumor to keep it from spreading. We were told it is slow growing but is there no surgery to remove this?
Gregory Videtic, MD, CM, FRCPC: When a lung cancer spreads to the middle of the chest (mediastinum) this means that the cancer is involving the lymph node drainage of the lung. Because of that, it puts the patient at a very high risk of spreading outside of the chest. Therefore chemotherapy which addresses not only the cancer in the chest but also potentially undetected cancer outside of the chest is very important as a component of his care. Because of that risk of cancer outside of the chest, any treatments that are directed at looking after the cancer that we can see have to balance safety and efficacy. For this reason it is very normal to not be offered surgery for the treatment since the physical burden of surgery may outweigh its benefits. Therefore radiotherapy which has the same goal as surgery of dealing with the visible cancer in the chest is typically then the treatment of choice since it doesn't have the same burden of side effects in order to achieve the same goal.
Usman Ahmad, MD: As Dr. Videtic explained, once lung cancer involves the lymph nodes in the middle of the chest, the role of chemotherapy and radiation becomes more important. At most institutions in the US, chemotherapy and radiation treatment are offered for such cancers. However, in some cases surgery remains an option. This has to be determined by the treating physicians and surgeons. Most of the prominent cancer centers in the country do entertain surgery as part of advanced lung cancer treatment. At the Cleveland Clinic, surgery can be an option if the cancer has not spread to the lymph nodes on the opposite side (stage IIIB). However this has to be determined carefully after thorough evaluation.
michellev: What is disease free survival and 5 year overall survival comparing hypo fractionated radiation therapy versus surgical removal of tumor and lymph nodes of right middle lung diagnosed with NSCLC stage T1b tumor?
Gregory Videtic, MD, CM, FRCPC: To the best of our understanding the results from stereotactic radiotherapy for cancers of your stage are equivalent when they're compared to the results from surgery with respect to how long a patient lives and the control rates of the cancers themselves. These results however are based on comparing results from different treatment series and so far there is no formal study that has proved this impression of equivalency between radiotherapy and surgery for early stage lung cancer. Therefore it’s very important for patients to discuss each of these therapies with their specialist prior to making any choices about their care.
Curious123: What are the innovations in radio therapy which can help patients with early stage lung cancer?
Gregory Videtic, MD, CM, FRCPC: Over the past decade, there has been a significant development in the field of radiotherapy with respect to its role in looking after patients with early stage lung cancer (which are cancers confined to the lung and which have not spread within or outside the chest). For patients where it is judged unsafe to undergo a surgical resection, for example when COPD or a heart condition might make the surgery very high risk, it is now considered standard of care for these patients to be referred to a radiation specialist to discuss stereotactic radiotherapy, which is also called radiosurgery. This is a specialized form of concentrated, extremely focused x-ray treatment which is delivered to the lung cancer over a very small number of sessions (typically less than 5 days) and is remarkable for the very limited side effects associated with it. This is especially reassuring for patients who have important medical conditions which might make more vulnerable to side effects. Just as important however is that the cure rates with this kind of treatment appear to be equivalent to those achievable with surgery so that the patient knows that the treatment is not considered as "second best" in their care. The Cleveland Clinic has been privileged to have been one of the leading institutions involved in developing and researching this specialized treatment since the inception of its stereotactic program in 2003. The most recent studies which it has taken part in has demonstrated that there is now a group of patients who can be treated for cure in a single session of radiotherapy. So this has had tremendous impact of the experience of the person who comes here for lung cancer treatment and who is physically limited. It is important to note again that this approach to care is primarily for patients who cannot have surgery. However there is ongoing work looking at its appropriateness in patients who might be considered for surgery but have some medical issues that might raise concerns about safety.
RonaldKCoy: Can you talk about immunotherapy? I’ve had chemo and unfortunately I found out it has come back. I’d like to see if immunotherapy would be beneficial this time. Are there any cons to it? I know there are a couple different types. Checkpoint inhibitors seems to be the most effective – do you agree?
Gregory Videtic, MD, CM, FRCPC: I'm sorry to hear your cancer has come back. Immunotherapy is becoming increasingly used in patients who have had other chemotherapy who have shown it was not effective. In general, for lung cancer, the important driver on whether or not immunotherapy is appropriate will be the type you have and the other characteristic that will influence the decision on immunotherapy is the mutational status of the tumor. In general, the class of drugs that are used for lung cancer immunotherapy are based on what is called PDL1 status and therefore checkpoint inhibitors which act in a different way are not the standard drugs we would use for someone who has failed chemotherapy.
michellev: What about using immunotherapy as the first line of treatment (instead of surgery or radiation) for a type 1 tumor if the PDL1 status is know?
Gregory Videtic, MD, CM, FRCPC: Immunotherapy has only been tested in patients who have more advanced form of cancer than stage 1. Therefore it would not be considered appropriate to offer immunotherapy alone in that setting even if the PDL1 status was known. The chances of cure are well established for surgery and therefore it must be always considered as part of the care program.
Surgery for Cancer
BarbCY: I have been told I need surgery for my lung cancer. I have an appointment in two weeks to discuss options but he initially said probably resection. I see that there is also lobectomy. And while that scares me, I want to make sure this cancer is gone! I assume it’s based on the size of the nodule, but how do you know which procedure is best and which technique is the best? I’ve been reading about VATS.
Gregory Videtic, MD, CM, FRCPC: The form of surgery that the surgeon recommends will always want to accomplish 2 things - ensure that all the cancer has been removed and be as safe as possible for the patient. The standard of care for most patients is lobectomy. What VATS accomplishes is it allows the surgeon to do a lobectomy in a way that's less invasive to the patient. The choice of VATS or more conventional lobectomy has to reflect what the surgeon feels he needs to accomplish. Typically the nodule size is not a critical factor for this choice.
Usman Ahmad, MD: The amount of lung to be removed (wedge resection, segmentectomy, lobectomy, bilobectomy, pneumonectomy) depends somewhat on the size of the tumor and lymph node involvement (stage of cancer). Your surgeon should be able to discuss these options with you.
Lobectomy is the standard operation for stage I and II non-small cell lung cancers.
Robotic or thoracoscopic (VATS) lobectomy is the standard of care and can be performed very safely.
sunfish: What is the treatment of tumor of the lung - do they remove the tumor? The lung? I am being seen next week by my doctor to discuss and I want to make sure I have the right questions in mind.
Gregory Videtic, MD, CM, FRCPC: When we make decisions on how to treat lung cancer, we have to take into consideration whether or not it has left the lung and we also have to take into consideration the physical status of the patient. In general, the 3 tools that are used to look after patients with lung care are surgery, chemotherapy and radiotherapy. However patients will not necessarily require each of them since again, the choice will be based on the extent of their cancer. The process by which we determine the extent of a patient’s cancer is called staging. Whether or not we remove the lung will depend on the stage of cancer and that would be something your physician would discuss with you.
Usman Ahmad, MD: The treatment of lung cancer has significantly improved and evolved over the last few decades. Depending on the extent of the cancer (stage), the treatment may include surgery, chemotherapy and radiation (one, two, or all three). This has to be decided by your treating physicians and surgeons. At Cleveland Clinic our routine is to have the patient evaluated by a surgeon, an oncologist, pulmonologist and a radiation oncologist to get a complete evaluation. If surgery is involved, for early stage cancer majority of the surgeries at Cleveland Clinic are performed minimally invasively, specifically robotically.
louisville: The surgeon we have seen has recommended a wedge resection or lobectomy of the upper left lobe depending upon if there is any lymph node involvement. (My dad had a needle biopsy which showed no lymph glands involvement.). Do any of your surgeons do minimally invasive or robotic surgery for this condition?
Gregory Videtic, MD, CM, FRCPC: Our surgeons do minimally invasive forms of surgery and this includes techniques that involve robotic approaches to surgery. But, as you might imagine, they choose this approach to surgery when they think it is in the best interests of the patient since the goal of the surgeon is to be able to remove the tumor completely while minimizing the amount of lung removed as well as the physical burden of the surgery. A whole range of factors including tumor location, tumor size, type of cancer and overall lung fitness of the patient will be part of the decision making process regarding the optimal form of surgery.
Usman Ahmad, MD: It is difficult to give a clear answer to this without reviewing the biopsy results and CT/PET scans. The vast majority of lung cancer operations including wedge resection, segmentectomy or lobectomy are performed robotically at the Cleveland Clinic. However the disease stage should dictate the type of operation. The Cleveland Clinic thoracic surgery program is one of the few top tiered (3 star) surgical programs for lung cancer as determined by the Society of Thoracic Surgeons.
Moderator: Dr. Ahmad, you mentioned three star rating for lung cancer surgery - what does that mean?
Usman Ahmad, MD: The Society of Thoracic Surgeons is the largest national and international society of cardiothoracic surgeons. This society keeps track of surgeries performed at participating centers and hospitals. Recently, Society of Thoracic Surgeons has reviewed the outcomes of this data and has made it public. All heart and lung surgery programs are reviewed and ranked based on safety and quality of outcomes. A three star ranking suggests the top most tier level among the participating centers.
lungquestion: What determines if you can have minimally invasive or robotic surgery?
Usman Ahmad, MD: As part of our effort to do appropriate lung cancer surgery, we also try to minimize the morbidity of the operation. For most stage I and stage II lung cancers, the surgery can now be performed in a minimally invasive fashion (using camera, small instruments, no need to spread ribs).At Cleveland Clinic, the patients are thoroughly evaluated by the thoracic surgeons and the vast majority of stage I and stage II lung cancer surgeries are performed robotically or thoroscopically. This has really allowed us to perform high risk surgeries very safely. The minimally invasive and robotic surgery causes less pain. Most of the patients are able to be home in 2-3 days with excellent performance status.
Treatment of Secondary Cancer
Noelle: My primary cancer was treated by Cyberknife a few years ago. Recently had a biopsy that reveals that I have lung cancer the same as my primary cancer of colorectal origin. Cancer is confined to one area of the lung and no symptoms. The doctor is not recommended repeating Cyberknife Can you tell me what the approach would be to this secondary cancer? Why no cyberknife? Is that not used for a second time? Is the secondary cancer treated as a colorectal type cancer?
Gregory Videtic, MD, CM, FRCPC: When it comes to looking after patients who have a cancer that has spread to the lung from another body part or organ, the primary treatment is typically based on chemotherapy because of the concern even when it appears there is only one isolated area of disease, there could be undetected areas of cancer that have spread elsewhere. Therefore we want to make sure the treatment addresses what we see and what may not be seen. Having said that there are specific circumstances when a patient who has been treated with chemotherapy and appears with time to have an isolated spot of disease for which the option of a local therapy such as cyberknife or other form of stereotherapy is appropriate for discussion. This obviously has to be addressed on a case by case basis.
SusanG: If you have stage 4 lung cancer that has metastasized to the liver - are there opportunities for treatment
Gregory Videtic, MD, CM, FRCPC: In general, lung cancer that has spread to the liver will be treated with some form of chemotherapy. The exact time of chemotherapy will depend on the type of cancer as well as some other features which will help guide the correct selection of treatment.
baz159: Where do you find clinical trials for small cell lung cancer? Are there clinical trials that would pay for treatment?
Gregory Videtic, MD, CM, FRCPC: In general any patient who is interested in learning about clinical trials available across the country could access that information by going to the national cancer institute website which has a list of all cancer clinical trials in the country, including specifically small cell lung cancer. Also academic medical centers where the patient lives usually also provides lists of clinical trials that would be of interest if you have small cell lung cancer. Regarding payment, patients are not paid to go on clinical trials, however often the experimental treatment is paid for either by the institution or the company testing the new treatment.
annieS: Do you have trials for small cell lung cancer that have already had some chemo? If you live far away can you still participate in a trial?
Gregory Videtic, MD, CM, FRCPC: Cleveland Clinic is one of a group of institutions involved in clinical trials testing new drugs for patients who have previously received chemotherapy and whose cancer unfortunately has come back. Here is a link to our lung clinical trials: https://my.clevelandclinic.org/departments/cancer/research-innovations/cancer-clinical-trial-results?disease=Lung. Participating in a clinical trial obviously has implications for patients who live far from the treatment center and is something we discuss with those patients if we make a decision for a clinical trial. there are resources that we would offer the patient to facilitate their being able to come to our Cancer Center for treatment and would be addressed at the time that they would agree to take part in such studies. Our social work department is a great resource for patients in that regard.
Sarcoidosis vs. Lung Cancer
abraham33: How do you tell the difference between lung cancer and sarcoidosis?
Peter Mazzone, MD, MPH: At times the pictures of your lungs (e.g. CT scan) can clearly distinguish between sarcoidosis and lung cancer. Other times what is seen in the pictures could be from either of these diseases. In this situation a biopsy of the lung or lymph nodes in the chest will be the best way to tell if you have sarcoidosis or lung cancer.
Moderator: We are reaching the end of our chat. Thank you for joining!
Gregory Videtic, MD, CM, FRCPC: Thank you for your interest and questions during this lung cancer awareness month. I hope we have provided you with helpful information that can assist you in understanding your care. Please do not hesitate to contact our lung cancer team if you would wish us to help you with your lung cancer care.
For questions or to schedule an appointment, please call our Cancer Answer line at 866.223.8100 or visit our Lung Cancer Program website.
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.