Lung Cancer: What you should know

November is Lung Cancer Awareness Month. Cleveland Clinic specialists talk about symptoms of lung cancer, how lung cancer is detected, what diagnostic tests are used to stage lung cancer or determine best treatment, and what patients should know about treatment options. 15 percent of patients who have lung cancer never smoked – so it is important to know the symptoms and talk to your doctor. Early detection is important – as well as a team approach for best outcomes.

Hear from specialists:
Peter Mazzone, MD, MPH – Pulmonologist
Gregory Videtic, MD – Radiation Oncologist
Usman Ahmad, MD – Thoracic Surgeon

Learn about Cleveland Clinic’s Lung Cancer Program

Transcript

Announcer:
Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell & Arnold Miller Family Heart, Vascular, and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic, and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Dr. Usman Ahmad:
Good afternoon, everyone. Thank you for joining us. As you know, November is Lung Cancer Awareness month. Is important to highlight the importance of this disease, as our attention is focused to other areas in healthcare right now, and we cannot forget that lung cancer is a silent and a very notable cause of death in this country. Every year in the United States, close to 140,000 or more patients die because of lung cancer at various stages of the disease.

Today, we're going to spend a few minutes discussing how lung cancer presents, what patients may feel when they have lung cancer, how is lung cancer detected in this day and age, and how can we treat early stage lung cancer effectively if we can find it and diagnose it in early stage.

It is my pleasure to introduce Dr. Peter Mazzone, who is an eminent pulmonologist at the Cleveland Clinic, and Dr. Gregory Videtic, who is a radiation oncologist and is involved in treatment of lung cancer at various stages using state-of-the-art radiation technology. My name is Dr. Ahmad. I'm one of the thoracic surgeons at the Cleveland Clinic. I'm the director of the Robotic Plastic Surgery Program and the associate director of the Lung Transplant Program here. I am intimately involved in managing lung cancer with my colleagues at Cleveland Clinic.

Let's start our discussion, and as we kick off, I would like to ask Dr. Mazzone to share his thoughts about what he can tell our patients in terms of how lung cancer presents. What should people be looking out for if someone has a family history of lung cancer, and they're worried in the back of their heads that this may be a possibility, or they've been smoking for a long time. What is it that they should really should be looking for?

Dr. Mazzone:
Thanks very much for the question, Usman. There are really, I'd say three ways that someone might find out they have lung cancer. And the first of those is they develop some symptoms. They have something new pop up as a result of having the lung cancer. That most often would be a new cough that just doesn't go away. It could be that you're more short of breath, more short-winded than usual. If the cancer's moving on a little bit, you might notice pain or pressure in your chest without another good explanation, unintentional weight loss. Anything that's really just doesn't seem normal or otherwise easy to explain, should make you consider lung cancer, particularly if you have some risk factors. If you've ever smoked cigarettes in your life, if you've had a family history of lung cancer, if you've had some worry, some exposures through your occupation, such as exposure to asbestos, those risks combined with new symptoms that can't be well-explained should make you concerned enough to speak to your physician.

The other two ways lung cancer might present are unrelated to symptoms. One may be that you've had a scan for a different reason. You had shoulder and neck pain, something came up in that scan happened to take some pictures of your lungs and that a small spot, what we call a nodule, or even something bigger, a mass, might've shown up before it ever caused you to have any symptoms at all. If that's found just by happenstance, then that should be evaluated to make sure that you don't have a cancer.

The final way is something we call screening. Screening is a way to find lung cancer early in someone with risk factors for cancer but who have no symptoms or signs of that cancer. Screening nowadays considered standard of care for a well-defined high risk group. This test that's done is a low radiation dose chest CT scan looking for those early signs of lung cancer when the cancer is much easier to treat.

Dr. Ahmad:
Thank you, Peter. That's great. Now what I'd like to mention here is something you just mentioned briefly is the symptoms of lung cancer. I think all of us have to be cognizant, whether there is exposure to smoking or asbestos or not, and realize and understand the fact that the biology and the picture of lung cancer nationally is changing, in about 15% of patients we see for lung cancer have never touched a cigarette in their life. I think this is something that we're learning more and more every day about, about how the disease presents, especially in people who've never smoked. Again, going back to your point, it's important to keep those symptoms in mind and not ignore any new or worrisome symptoms, regardless of that history
The other thing that I think that is very important that all of us are dealing with today, as we speak, is the fact that the symptoms can arise from many different diseases. Now, as our country is in the wraps of a viral infection, a lot of those symptoms can be quite similar to any other lung disease. My point here that I tell my friends and patients is that a new symptom should be worked up appropriately. Your physician should be informed about a new breathing that arises and should not just be ignored, thinking that it might be a flu or a cold or something else that might go away over time.

So as we think about treating lung cancer in this day and age, Dr. Videtic, what are your thoughts, if you'd like to share with us on how you like to evaluate someone who has been recently diagnosed with a spot in the lung or what we more commonly known as nodules, or a new abnormal finding in the lung?

Dr. Videtic:
Well, Usman, thanks for asking me to take part in this really important discussion. I think it's enough of a thing to find something abnormal, and I think a lot of times people, their first response is when they hear something's wrong, they want something done immediately, which is a normal reaction. Our job is to kind of walk through a stepwise process that'll help us understand what we're dealing with. And that can be as simple as finding exactly what the nature of that nodule is. A lot of times that may entail doing a number of procedures to get a sample out of the spot in the lung, so to speak, and there are different ways that that can be accomplished nowadays. Usually the goal of whatever we're doing is trying to be both helpful and minimizing the amount of time or injury that it takes to get an answer.

Still, to this day, we use things like needles that we put with scanners, CT scanners, maybe into a spot in the lung to get a sample right away that might trigger further testing, or else there are other procedures that are a little less direct, where we actually take a device that the pulmonologist or the surgeons use, as you know, called the bronchoscopy tool, and we look into the airways and we are looking for the lesion, and we can take a sample from within the lung using that procedure. Then at the same time, we can also evaluate other parts of the chest, the spaces lying between the lungs, where the drainage of the lungs goes. And that helps us understand whether or not the particular behavior of that lesion might involve things such as lymph glands or lymph nodes, which drain the lungs.

All of these processes are called staging, and staging really matters to help us define what's the best care for an individual. So besides knowing the name of the cancer, we also use other tools such as PET scanners, and PET scanners help us look at the whole body in order to try and make sure that there's nothing hidden or unaware that we should be aware with a particular cancer. So they help again clarify the disease extent.

Then lastly, depending on the particulars of a patient, we may also choose to do other higher level tests, such as brain scans or MRIs, again, not to delay care, but to try and better understand the extent of the disease. Even though a single nodule sometimes could show up on a screening scan, it could entail a number of procedures before we actually have a plan of care.

And I always find it's really good when we meet somebody at the beginning to kind of lay that out for them so that they don't feel like the process is taking longer than it should. I always have the mindset that once we know what we're dealing with, it's very easy to start treatment, but the steps have to be followed in a fairly rigorous way so we don't miss anything.

So as you know, and you've already stated, the complexity of cancer and the range of what we're seeing and the numbers we're seeing are dropping because people are smoking less, but unfortunately the behavior of cancer is still something that's troublesome, because a lot of people still show up with symptoms, and usually that entails understanding that the cancer is probably more widespread than we would like it to be. So usually the core issues at that point is managing to understand the extent of their cancer and then managing their immediate symptoms, and a lot of times that involves a team of surgeons, medical oncologists, and radiation oncologists, to help understand that.

Likewise, with respect to even early stage disease, where maybe as Peter was mentioning, we're picking something up on a CT screening scan, and by chance that person has a solitary lesion in their lung, and it may appear that that's the only extent of their disease. Again, there may be a process for us to determine whether or not that patient is suited for different kinds of treatments such as surgery or radiation based on their health, their lung function, other medical issues that could put them in difficult positions for handling different kinds of therapies. Again, one of the big themes that we like to emphasize is there's a team approach early on with respect to understanding the extent of a cancer in the lung and how to best approach it with respect to treatment.

Dr. Ahmad:
Thank you, Greg. I think you said it very well, that when we find an abnormal finding in the lung on a chest x-ray or on the CT scan, the two big questions that loom in front of us is what is the problem, and if it is a cancer, how far it has spread, and we go through all these steps of trying to figure out whether it has spread to the lymph glands in the middle of the chest or outside the chest, or if it's limited to the lung itself, so that we can figure out the best treatment option, like in provide the optimum quantity of life and quality of life, which is really the two main goals of treatment that we give to our patients.
As all of us know very well, that for limited disease, that is really the area of very early stage lung cancer, that's really the area where we can make a difference in really providing curative intent treatment therapy that will have lasting effects and hopefully provide treatment and control of the disease so that the cancer does not come back at all, or has a very long and drawn-out period where the patient remains free of cancer.

These modalities that we use to treat these early stage cancers work very nicely in this day and age. And as we briefly mentioned in patients who are otherwise healthy and can tolerate surgery, surgery remains sort of the first line of treatment, and in this day and age can be performed minimally invasively, robotically, laparoscopically, and so on and so forth. But we've also come up with really fantastic and outstanding radiation techniques that can be utilized in patients who either choose to go with radiation or have limited lung disease that limit their ability to, excuse me, limited lung capacity, that limits their ability to have surgery. So, Dr. Videtic, would you share with us some of the newer radiation techniques that perhaps we can use in this day and age to treat early stage lung cancer?

Dr. Videtic:
I think you brought up one of the most relevant points, which is lung cancer doesn't exist in isolation, and the unfortunate baggage you feel like that comes along with a lung cancer diagnosis, often carries with it the history of either lung disease or heart disease, which makes people vulnerable to whatever the interventions are that we might be thinking about for them. I completely agree with you that surgery appropriately has always set the standard for how to help people with respect to potentially curing them of their lung cancer, especially if it's an early lung cancer. The reality, as we all know, is that even historically, when we would have thought of surgery as the only chance for curing someone, that inevitable patient would come where the risk of the surgery would be far greater than the chance of cure. And so that often presented a huge dilemma for surgeons as well as a very difficult scenario for patients where their options were extremely limited, and essentially there were no options besides surgery.

What's happened in the world of lung cancer care has been in the same way that surgeons try and do better by causing less harm, that was always the issue with radiation doctors as well, that even though we would want to have treated, often our tools were limited because of our inability to control how the treatment would affect normal body parts besides the cancer. But then there's been a revolution that happened about 15, 20 years ago. And at the clinic, we've been really lucky to be part of that by being early-on users of a particular technology of delivering radiotherapy, which is based on super precise aiming so that we both see what we're aiming at as well as we're able to aim the doses so carefully that we're protecting the normal body parts, particularly the lungs, as well as heart and other organs in the chest.

So what we've learned at the clinic over the last 15 years is that the patients who would go to a surgeon who would tell them, yes, I'm glad you have a curative cancer, but I'm worried about the risks of putting you under anesthesia or your recovery from the surgical procedure itself. They've asked us to see those individuals and talk to them about the alternative, which is doing very effective high-dose radiotherapy to eradicate the cancer but preserve if you like the integrity of somebody's lung, even in patients who had otherwise very fragile lungs.

What's been particularly gratifying is because of the relationship between all the disciplines, we've been able to treat a large number of these patients over the last 15 years, and the remarkable awareness that we have is that the cancer care part is very effective. We're able to cure cancer with this particular form of radiation in these vulnerable patients, but pretty well as remarkable as the fact that these patients are not in any way injured in the long-term, especially with respect to lung function.

So we now have options where there existed before no choices. For patients who are considered too high risk for surgery, but really desire cure, we're able to offer them that standard now, which is to use this particular form of radiation called stereotactic radiation, which gets rid of the cancer effectively, but also is very safe at preserving lung function. And over the years, as we've learned that this is very effective in inoperable patients, in other words, those who cannot tolerate any form of surgery, we've also start to recognize that in some patients where even surgery could be contemplated, we meet these patients with surgery colleagues, and we have discussions on appropriateness of doing this radiation therapy or surgery, and it allows patients to know that we're actually interested in their welfare as opposed to our individual  if you like disciplines, because, again, our main goal is to offer cure with minimal harm. And so it's been very interesting in that regard.

I share your thoughts and concerns. I also hear it from a lot of my patients that everyone is worried about losing the ability to perform daily activities, things that they like to do, whether they be household chores or hanging out with the kids or grandkids, or playing golf, the ability to maintain quality of life and provide effective therapy, I think is important. As a team, we really work towards striving to find the right treatment option, which would treat the cancer effectively and allow the patient to maintain their quality of life. Dr. Mazzone, you're on the front lines of seeing someone who's recently found out that they have an abnormality in their lung, and perhaps it's a lung cancer. You see them now, and you look at the value of their pulmonary function or lung function. You watch them go through either surgery, minimally invasive, or radiation therapy, and then you meet with them afterwards. With the newer technologies that are in place in both the surgical field and the radiation field, what are your thoughts on the functional outcome? Should patients really be worried about losing a lot of lung function afterwards?

Dr. Mazzone:
Yeah, I think the biggest takeaway from a lot of what we're talking about, many of us have been around long enough that we started our careers when lung cancer had a stigma of doom and gloom, and you get lung cancer, you're going to die, there's self-blame involved. Now all of these advances have made this scenario of tremendous hope. You can work towards early diagnosis, and if you're at high risk, you can be screened. If you're diagnosed with an early stage cancer, you've got options of less invasive surgery, perhaps less lung resected, you've got options that Greg spoke about with stereotactic radiotherapy and the excellent outcomes there. And with more advanced disease, there's tremendous changes in how cancer can be treated that have provided amazing amounts of hope. When we meet with someone who's diagnosed with an early stage lung cancer, we evaluate their lung function with testing, we hear from them of how much activity they're able to do.

We look into their value set, what is most important to them here, plus or minus functionality, or functionality above all else, and we try to coach them through decisions about what the best treatment may be, try to help them to optimize their lung function, whether it be through quitting cigarettes, smoking, if they're still smoking, using breathing medicines if they have other lung disease. That's a long answer to your shorter question. Certainly they should be concerned about what's going to happen to their lung function with treatment, but they should also recognize that's going to be part of our broad discussion. We're going to make sure that the treatment choice that's selected is the one that's best for them, best for them to get cured while maintaining a high quality of life and in their own value set is going to factor heavily into that decision.

Dr. Ahmad:
I think that's a great point. That's something that's not said enough, or perhaps not given enough importance, because when it really comes time to choose where you go for your treatment, if I were to go somewhere for my treatment, I want to go to a place where there's a lot of people thinking about it from multiple different aspects, and where they see a lot of that problem. So when it comes to choosing where your care should be performed, be it pulmonary care, regular lung care, lung cancer care, surgery for lung cancer, radiation for lung cancer, or chemotherapy for lung cancer, as we will discuss in a different episode of this discussion, I think it is important to keep in mind that high volume NCI certified cancer centers, NCCN certified cancer centers, should be the first choice.

And certainly we really enjoy having this multi-disciplinary thought process and care at the Cleveland Clinic, where all of us sit together around a table, virtually these days, if you may, and discuss at length the problems that our patients face, really trying to put our best foot forward and trying to think of ways how we can help them most with the least amount of harm, trying to treat and hopefully cure lung cancer.

I think that wraps up our discussion today. We'll be back and we'll have some more discussions about management of more advanced stage lung cancers with newer types of chemotherapies, immunotherapies, and more advanced techniques of radiation and surgery. Thank you.

Dr. Mazzone:
Thank you.

Dr. Videtic:
Thank you.

Announcer
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