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Statewide Initiative Seeks to Advance Lung Cancer Control

January 17, 2019

Nirmal Veeramachaneni Hope Krebill

Two members of The University of Kansas Cancer Center, Hope Krebill, Midwest Cancer Alliance director, and Nirmal Veeramachaneni, MD, thoracic surgeon, have joined a State-Based Initiatives task group to reduce the incidence of mortality from lung cancer. This initiative was formed by the National Lung Cancer Roundtable (NLCRT).

Established by the American Cancer Society, NLCRT is a collaboration of public, private and voluntary organizations committed to reducing the incidence of and mortality from lung cancer. The NLCRT aims to rapidly advance lung cancer control through efforts to increase public and professional education, prevention and early detection, quality assurance, access to care, effective health policy and optimal diagnosis and treatment for cancer patients.

Lung cancer is the leading cause of cancer death among men and women in the United States. According to the American Cancer Society, nearly 1,500 Kansans died from lung cancer in 2018. The task group will focus on addressing lung cancer screening challenges at the state-level by working with leaders across the nation. This task group’s first meeting was held during the National Lung Cancer Roundtable meeting in December 2018.

“Access to lung cancer screening can be a challenge in rural Kansas due to the distance individuals may need to travel,” Krebill said.

Krebill added that she looks forward to learning from others focused on state-based approaches for lung cancer screenings and to sharing approaches that have worked well in Kansas.

“At KU Cancer Center, we are fortunate to have a state-of-the-art lung cancer screening program, capable of addressing lung cancer even in medically high-risk patients,” Dr. Veeramachaneni said. “Through the State-Based Initiatives task group, we hope to bring the same level of care to patients in other parts of the state.”

A Focus on Lung Cancer

Dr. Nirmal Veeramachaneni and Dr. Alykhan Nagji, discuss all things lung cancer - from screening, to minimally invasive procedures, to follow-up care.

Speaker 1: Welcome to Bench to Bedside. A weekly series of live conversations about recent advances in cancer from the research bench to treatment at the patient's bedside. And now your host and the director of the University of Kansas Cancer Center, Dr. Roy Jensen.

Dr. Roy Jensen: Good morning. I'm Dr. Roy Jensen, director of the University of Kansas Cancer Center. Thanks for joining us for today's episode of Bench to Bedside. With me today are Dr. Nirmal Veeramachaneni and Dr. Dr. Alykhan Nagji, thoracic surgeons who specialize in minimally invasive surgery to treat lung cancer. Thank you both for being with us this morning. Lung cancer as you both know is the leading cause of death for both men and women. Each year, more men and women die of lung cancer than colon, breast, prostate cancer combined. In 2018, about 234,000 new cases of lung cancer will be diagnosed. Overall, lung cancer makes up about 14% of all new cancer diagnoses. So, while these statistics are pretty sobering, if caught at a very early stage, we can often treat lung cancer patients effectively with surgery. So, Dr. Veeramachaneni, there seems to be a growing number of female non-smokers who are being diagnosed with lung cancer. Do you have an explanation for this phenomena and is there anything that these patients have in common as far as their clinical characteristics?

Dr. Nirmal V.: Well, you raise a really important point. One is that not everybody who gets lung cancer is a smoker. There's a lot of stigma associated with lung cancer so patients don't talk about it. They don't talk to their primary care physician. They don't talk to their family because there's so much stigma associated with smoking and lung cancer that it's sometimes a barrier to care. Fully 20 to 30% of new cases of lung cancer are in patients who are never smokers. You raise a good point that worldwide, there's a rising incidence of women who were never smokers. Globally, epidemiologists have looked at this. There are data to suggest it might be due to cooking fuels, for instance. Exposure in India or China, but that's not so true in the US. In the US it might simply be for second hand smoking exposure. Honestly, we don't know. But the one common characteristic of this patient population is they're often driven by single mutations. So, what has changed in the last 20 years is that we have targeted molecular therapy for these patients, especially women who are never smokers who get diagnosed with lung cancer. So, even at later stages, they don't behave like patients with the same stage of lung cancer if they were smokers. They are sometimes easier to treat and more responsive to the treatment that we have. I would say in the last 10 years there are at least a dozen new drugs that have come on the market that have shown efficacy. It's all driven by the molecular basis of their cancer.

Dr. Roy Jensen: So, one of the primary reasons for this session is we really want to talk about screening and it's such an important part of early detection obviously. Can you tell us a little bit about the lung screening process? Who is this appropriate for? What do the patients go through?

Dr. Nirmal V.: Right. So, I'm going to stress that if you meet the criteria for lung cancer screening, don't ignore it. Because for the first time in the last 100 years of smoking prevention efforts, we can say that by doing a noninvasive test, you can potentially save your life. So, about 15 years ago the national lung cancer screening study came out. That demonstrated that in high risk smoking patients, by going through the screening process you can catch lung cancer at an earlier stage and decrease the risk of dying from the lung cancer. The American study that was the basis of our recommendation showed a 20% reduction in lung cancer death. 20% is huge. Now the Europeans presented their data last month which showed that in high risk men, there was a 40% reduction in dying from lung cancer if they went through the screening process and that effect is probably even greater in women, in the high risk women population, there's an almost 60% reduction in dying from lung cancer. This is huge. In 2018, the patients that we are looking to screen are those over the age of 55 who smoked at least 30 pack years. That's where the math gets a little confusing. 30 pack years means smoking a pack a day for 30 years or two packs a day for 15 and also patients who have been smoking who spending 15 minutes on a CT scanner without an IV or anything else for every year well into your 70s. But it's a simple intervention and it's enough to save your life.

Dr. Roy Jensen: What about people who qualify in the pack years but no longer smoke?

Dr. Nirmal V.: So, the current evidence suggests that if you have been smoking within the last 15 years, you're still at risk for lung cancer. Smoking in general is bad for you for a number of reasons. It increases cardiovascular disease, lung disease and other problems. So, we want to capture the patients who have been smoking within the last 15 years and also smoking a lot.

Dr. Roy Jensen: So, Dr. Nagji, could you walk us through what happens once a lung nodule is found? What's the next step in the process?

Dr. Alykhan N.: So, fortunately here at KU, we actually have a robust team of nurse practitioners that run our lung cancer screening program and those lung cancer screening nurses actually have a direct tie to us. So, I think that communication that we have with them is the most important thing. Once they find a nodule that seems concerning, what they'll do is they'll call our nurse navigation team. We have two dedicated nurse navigators for our lung cancer program and their job is to make sure that we get all of the up front information, we get the appropriate testing for the patient and that they are appropriately placed in our clinics to make sure that they're seen in an appropriate amount of time. I think that that's important that we're getting these soon then we're following up with them very closely. So, our nurse navigation program I would put second to none. I think that they're a very good group of people who want to make sure that we are seeing our patients and caring for them in an appropriate manner.

Dr. Roy Jensen: So, both of you are obviously very well versed in minimally invasive surgeries for the removal of lung cancer and you, specifically Dr. Veeramachaneni are one of the few thoracic surgeons in the United States and Canada performing this so called uniportal vats minimally invasive surgeries for lung cancer and we're going to have you explain all of that so it's not a big bunch of gobbly gook there. But what are the benefits of having that expertise here at the KU Cancer Center and why do you want to try to minimize the invasiveness of this procedure?

Dr. Nirmal V.: For the last 100 years of thoracic surgery, patients were getting fairly large incisions on their side. They'd use a rib spreader to spread the ribs apart. It was maximally invasive. Patients typically used to be in the hospital for 7 to 10 days if not longer and it would be a full month to two months before they really recovered from the pain associated with a major incision. In the early 2000s, things were revolutionized. An Italian surgeon came up with the idea of minimally invasive lung cancer [inaudible 00:09:04], similar to how gallbladders are taken out with multiple small incisions. He was doing the same thing for lung cancer. Well, it's taken off and unfortunately in the United States, only about 40% of lung cancers resections are still done minimally invasively. The standard minimally invasive approach usually involves anywhere from two to four incisions on a patient's side and patients generally do well. Compared to an open operation, it is head and shoulders above. The recovery is much less. We've shown that the degree of inflammation that the body experiences is less. Patients who are at high risk for an operation are better able to tolerate it. For those patients who need chemotherapy afterwards that are able to tolerate the chemotherapy and actually get to the chemotherapy because they're not in pain. There are different modalities of dealing with minimally invasive surgery. So, in a traditional thoracoscopic approach, surgeons are placing two to four incisions. With the robot which my partner has expertise in and he'll talk about, it's essentially using multiple incisions, but using robot assistance and it has some advantages which he's going to talk about. But for a lot of lung cancer patients that I see, we've taken minimally invasive one step further. So, instead of multiple incisions, it's a single incision about two finger breadths wide that are placed right underneath where most women would put their bra straps and what we found is with a single incision about two finger breadths wide, recovery is 48 hours from the hospital. So, that's a real advantage.

Dr. Roy Jensen: That is a tremendous advantage. So, I want to thank our audience. If you're just joining us on Bench to Bedside. We're talking with thoracic surgeons, Dr. Nirmal Veeramachaneni and Dr. Dr. Alykhan Nagji who specialize in minimally invasive lung cancer surgery. Remember, if you have any questions, you can post them in the comments section. So, Dr. Nagji, we're discussing the benefits of minimally invasive surgery. What additional options are there for patients who want to explore a minimally invasive procedures and could you tell us a little bit about them?

Dr. Alykhan N.: Sure. As my partner already described, there are traditional vats surgery which is video assisted thoracoscopic which some patients sometimes call using the laser or camera in order to operate. That could involve anywhere from two to four small incisions and then additionally the uniportal approach that Dr. Nirmal Veeramachaneni specializes in and then my expertise would be in the area of robotic surgery. With robotic surgery, we make about four incisions that are less than a centimeter a piece and this allows us to have 10 times magnification within the chest cavity and allows for a lot easier, more facile dissection of lymph nodes and to help for better staging. Additionally, the recovery is fairly similar in that patients usually go home within 48 hours. Pain is a little bit more tolerated. We are able to get patients moving closer and further to home sooner. That's important and to their recovery to moving on to what they want to do in life. But I think the most important thing that we have to understand is that not every patient benefits from minimally invasive surgery. Not every cancer is the same. So, what we do here is that we make sure that we have the appropriate intervention for the appropriate type of cancer that we're dealing with. If we can do minimally invasive, we will. If we need to do something a little bit more invasive, then that's what we'll need to do, but we're going to make sure we tailor that therapy appropriate for the patient to get the best oncologic outcome for the patient so that they can move on with life.

Dr. Roy Jensen: So, it sounds like we have a pretty nice variety of different types of minimally invasive surgery and you've touched on this a little bit, but why is that so important to have so many options available to us?

Dr. Alykhan N.: I think that each patient is different. As we look at each individual, they have different wishes, different goals in life. I think that each individual cancer is also different. So, I think that as long as we as a group provide all the treatment modalities necessary in order to help a patient, then we are providing the optimal care for that patient. I think that's a benefit that we have here at KU in that we can provide all of those options for a patient.

Dr. Roy Jensen: So, Dr. Nagji, for patients that are seeking treatment with us, our cancer center offers some real strengths obviously including NCI designation, the academic culture. Is there anything else that patients are seeking surgical treatment for lung cancer need to know about that?

Dr. Alykhan N.: I think the most important thing as a patient, you want to make sure that the physicians, the nursing staff and the hospital cares about you. Cares for you in the way that you would want to be cared for. A member of the family if you will. I think that that's important. Here at KU, what we have are we have specialized nurses that are on our ICU and our floors that are dedicated to the care of lung cancer patients. When we see them in post operative settings, we have dedicated nurse practitioners that their sole responsibility is to care for the lung cancer patient. I think knowing that as a patient is comforting. That we will make sure that we treat you like family and family that we like so that we can help you move forward and have you do the things that you want to do in life.

Dr. Roy Jensen: So, I want to get back to the screening question. Where should if a patient or one of our viewers is interested in being screened, how do they access that program and which one of our campuses offers lung cancer screening?

Dr. Nirmal V.: So, it's fairly simple. If you're already part of the KU family for primary care, just chat with your primary care physician. We have the entire program set up so with a single click of a button in our electronic medical record, it automatically activates the entire process of our navigator or contacting the patient and then going from there. But if you're outside of the KU system and you still want to be taken care of here, we're happy to take care of you. Our website has the number to reach out to our navigator directly and she will take care of it.

Dr. Roy Jensen: Okay. The lung cancer screening involves scanning with what types of modalities.

Dr. Nirmal V.: So, lung cancer screening is meant to one, not be invasive and minimize the amount of radiation. We offer this protocol of the low dose radiation at two of our campuses. The main hospital here as well as in Indian Creek. Our program is set up so that patients don't have to wait for an extended period of time. We've actually timed it. From the time the patient sees our nurse and gets the appropriate counseling regarding what the process entails to then going over to getting their scan and then coming back, in under 20 minutes we can give you a report. So, we've timed it. We have three dedicated chest radiologists who read all of our scans to ensure quality and also we keep track of everyone. So, if you need follow up, we'll take care of it.

Dr. Roy Jensen: That sounds like a well oiled machine there. Well, I want to thank both of you. Dr. Veeramachaneni and Dr. Nagji. Any final thought for our viewers today?

Dr. Nirmal V.: The biggest thing I would stress is don't ignore this. If you're a smoker and you're over the age of 55, talk to your physician about your eligibility for lung cancer screening. Lung cancer screening efforts have been around for 40 years, but it's only with the advent of appropriate CT scans that we've actually shown that we can decrease mortality. The latest date indicate a 40% reduction and chance of dying from lung cancer if you get screened if you're a male and perhaps up to 60% if you're a woman. So, don't ignore it. You can save your life.

Dr. Roy Jensen: Yep. Absolutely. Well, thanks so much for being with us today and that's it for this morning's program. Thank you so much for joining us. For more information on minimally invasive surgical procedure to treat lung cancer, please visit kucancercenter.org. We hope you'll join us next week. Wednesday at 10:00 AM. Thanks for watching.

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