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Lung Cancer: Risk Factors, Updated Screening Guidelines and Next Steps
Lung cancer is responsible for the most cancer deaths. However, if caught early, the prognosis is significantly better. Dr. Ryan Martin explains the latest lung cancer screening guidelines and options.
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Learn more about Ryan A. Martin, MD, FCCP
Ryan A. Martin, MD, FCCP
Dr. Ryan Martin is a pulmonologist with Nebraska Pulmonary Specialties and currently serves as the Pulmonary Division Chair for Bryan Medical Center.Learn more about Ryan A. Martin, MD, FCCP
Transcription:
Lung Cancer: Risk Factors, Updated Screening Guidelines and Next Steps
Melanie Cole (Host): Lung cancer is responsible for so many cancer deaths. However, if caught early, the prognosis is significantly better. My guest is here to explain the latest lung cancer screening guidelines and options.
Welcome to Bryan Health Podcast. I'm Melanie Cole, and joining me today is Dr. Ryan Martin. He's a pulmonologist with Nebraska Pulmonary Specialties, and he currently serves as the pulmonary division chair for Bryan Medical Center. Dr. Martin, it's a pleasure to have you with us as we get into this topic. It's such an important topic.
Tell us more about lung cancer in Nebraska today. What's the prevalence? Are people getting the message? And then kind of segue into the trends that you're seeing around the country.
Dr Ryan Martin: Absolutely. Thank you for having me. So when we look at, lung cancer as a whole, it'd been a very interesting trend in the last couple of years. And in fact recently in Nebraska, we actually had an epidemiology study that came out that told us what we were seeing in terms of our mortality.
And the results are interesting. We've been taught many times over that lung cancers are obviously the most deadly of the cancers. It is the third most prevalent cancer behind breast and prostate cancer. But it is far and away the most deadly, and we can talk about that in terms of why that is.
Lung cancers, generally speaking, are just caught late, and that's really a big part of it. We see them in our later stages of cancer. We do not typically find them as stage one or a very early cancer, and a lot of that has to do with screening.
Everybody, I would say, is fairly familiar with the concept of mammograms, and pap smears and colon cancer screenings. People would be familiar with prostate screenings. All of those things people, I think, are very familiar with. That's a routine part of health care and health care maintenance. But what we have not seen is a very concerted effort in terms of really pushing lung cancer screening. And that's really, I think, a big part of why lung cancer is so much more deadly than its counterparts.
That's really one of the biggest things I think that's out there is how do we really improve our screening. And what's going on right now is we do have a screening program, and one of the toughest things about it is actually only about 7% of patients nationwide that are eligible for lung cancer screening are screened.
That's a very low number. When you look at that and consider the number of people who are eligible for colonoscopies that are getting them done and people who are getting mammograms on time, it really, it just shows a very big gap in terms of the screening.
Melanie Cole (Host): Why do you think that is? I mean, if people are willing to get their colonoscopies and women, we go for our mammograms. Do you think that maybe there's a stigma that people think if they go for that low dose CT screening —which we will talk about —that, that says something about them or their behaviors? Why do you think that is?
Dr Ryan Martin: Absolutely. I think some of it is a stigma. And one of the things that's probably the most interesting in this — just almost anecdotally — but I think a lot of people just don't really want to know. And that's a part of it is, people who are longtime smokers, I think there's some of that, that there's a stigma associated with it and they just feel like if they don't know about it, it won't hurt them, and that is exactly the opposite approach. We need to be screening people sooner to catch diagnosis at an earlier stage where it improves our opportunities for cure.
Melanie Cole (Host): Dr. Martin, we've all known for a long time that lung cancer and that smoking really go hand in hand. Big high risk factor. Are there other risk factors? Is lung cancer considered like pancreatic or certain breast cancers? Is this considered genetic? Some people that have never smoked, get lung cancer, and we can't really screen them for no reason.
As we're gonna talk about, these screening guidelines are very specific, what are some of the risk factors that you can point to other than smoking?
Dr Ryan Martin: When we look at lung cancer, 85% of patients typically are driven by or attributed to cigarette smoking, but that obviously isn't all of them. The most common additional factors that are identified clearly are going to be really radon. That is the biggest one, and that is a gas that's emitted and is typically found in basements and can be mitigated.
But beyond that, we really don't have a clear identification of additional factors that we see that cause lung cancer specifically.
Melanie Cole (Host): That's so interesting. So let's talk about the screenings. As we know that early diagnosis is key, tell us about the screenings that are recommended to detect lung cancer early and who is eligible because I think that, Dr. Martin, that is where people find the most confusion about eligibility in criteria for these screenings.
Dr Ryan Martin: . So the number one thing that we look at for someone who is eligible for a lung cancer screening CT scan is the age over 50 And these guidelines have changed a little bit, and patients have to have at least a 20 pack-year history.
So to break that down a little bit, what that means is you have smoked one pack of cigarettes a day for 20 years. So there's multiple ways you can get to that number, right? You can smoke two packs a day for 10 years, and that equals 20. You can smoke a half a pack a day for 40 years, and that gets to 20. So 20 pack years is the minimum threshold for tobacco use.
And then the last is that we screen people as long as they were smoking last within the last 15 years.
Now, that is probably the biggest reason why we do have some confusion in terms of getting screening done on that. It's always been that there is no exact threshold in terms of, you do screenings just because you turn the age of 45 or 50. This is one of those where you have to have a few other things that go into the equation for screening purposes.
Melanie Cole (Host): I understand a low-dose CT scan is what’s done to screen for lung cancer. It’s painless and quick, where you just lie on a table that slides in and out of a machine and takes pictures of your lungs. Can you tell us what to expect from the results of this screening?
Dr Ryan Martin: There are people that will show up with an abnormal finding. And abnormal findings may mean small pulmonary nodules, which is present in approximately 24% of people. So, if I scanned a hundred people and I turned 24 nodules up, those are not 24 cancers. Those are 24 nodules.
So if you have a nodule, then you have to determine whether or not that individual has a nodule that is over six millimeters. And if it is, then it has to have an appropriate follow-up. The follow up timeline obviously is dependent upon the size of the nodule, and if a nodule is large enough, you would potentially proceed to a biopsy. And again, not every nodule that we biopsy ends up as a malignancy.
So this is really the biggest part of this, is we have to have people understand that in order to do the screening, there is a distinct possibility of finding a pulmonary nodule or an abnormality in about one out of four patients that we would screen. Of those, 96% of these are actually non-malignant. So on average we would scan people and find abnormalities, and more often than not, these are simply old scars or small little inflammatory nodules that are very common in both smokers and in non-smokers, and that is really the biggest reason that we have to do the scanning and have a conversation about what we may find on those.
Melanie Cole (Host): That's very encouraging. That statistic you just cited, that all those nodules that you might find are not all cancerous. Because that is just what's so scary to all of us who get any of these screening tests, but that was so encouraging, Dr. Martin. So the next steps, you mentioned the possibility of a biopsy.
Speak a little bit about robotic bronchoscopy or other biopsy methods that you might use, and just briefly tell us about those.
Dr Ryan Martin: Absolutely. So there has been an evolution in our diagnostic capabilities that really has been able to limit and mitigate our risks for complications. And it's a robotic bronchoscope. This device is the most significant advancement in bronchoscopy that we've had in quite some time. It is able to be driven into a very peripheral portion of the lung.
So it would be done under general anesthesia, which means that you’re asleep for the procedure. We use a patient's airways as essentially the streets, so to speak. And it's essentially like using a map to find the airway and drive out to the peripheral pulmonary nodule. Once you get to the peripheral nodule, we're actually able to dock this robot or dock this scope where it will stay where I put it.
And at that point we are able to begin the process of sampling the nodule. And typically with sampling, what that means is a needle poke directly into the lesion, to use a little forceps or a pincher to take a larger chunk of tissue, which really the big thing there is they give more tissue to the pathologist so they're able to make an accurate diagnosis. Oftentimes when we do this, the pathologists are right there working hand in hand with us in the room. So as we are doing the case, and a lot of times we are getting, if not a diagnosis, at least confirmation that the tissue that we are obtaining is exactly what they need to see.
Once this portion of the procedure is completed, this is where I think the world gets more interesting. We can do biopsies on people's lungs. We could do potentially both sides at the same time. We can do one lung and then move along and get a nodule on the other side, which really has not been a possibility to do on the same day at the same procedure previously.
Additionally, we're able to complete the sampling of a nodule peripherally, and if it is abnormal, we then can use a different type of scope at the same procedure at the same time to do sampling of any of the lymph nodes that may or may not be involved within the chest as well. This is of tremendous benefit because in a single anesthetic attempt we are able to do, not just potential diagnosis, we are able to get potentially diagnosis of more than one lesion at a time and do what's called pathologic staging.
Melanie Cole (Host): That is so comprehensive and so fascinating. Dr. Martin, before we wrap up, tell us a little bit about what else you would recommend to the public about lung cancer prevention, screening, smoking cessation, lifestyle, anything that you would like to summarize.
Dr Ryan Martin: So I would start with number one, I think the biggest thing is if you're a smoker, the first thing to do is to put them down. And we all know that that's very hard. And if there's difficulty with it, this is where you really need to seek out help. And there are multiple locations that you can do that, whether it be through your primary care physician or Quit Nebraska, which helps with tobacco cessation. Anything that needs to be done to quit smoking is obviously the first step in a lot of instances, and that's a big step.
Beyond that, I think the big thing there is to also just understand that screening is not meant to be scary. It's actually meant to prevent the more advanced stage malignancies.
The one thing that we are acutely aware of — and this is some information that I also think is not very well disseminated — but lung cancers really have a pretty good five-year survival rate. It's very dependent on if you catch it early. We really need to be able to move the needle on catching these cases long before they end up with somebody who comes in coughing up blood or having unintentional weight loss or a chronic cough that they've just had for several months. We really need to be moving that forward.
Those would be some things that I would tell you are hands down what we need to be looking at.
Melanie Cole (Host): Great information. So informative. Dr. Martin, thank you so much for joining us today and sharing your expertise about lung cancer recommended screening, and the options to get a diagnosis faster and then treatment if cancer is found. To learn more about lung cancer and screening scans, please visit bryanhealth.org/lung cancer, and I'd like to thank our Bryan Foundation partners, Inpatient Physician Associates and Sampson Construction, for making this podcast possible.
That concludes this episode of Bryan Health Podcast. Please always remember to subscribe, rate, and review this podcast and all the other fascinating Bryan Health podcasts. Until next time, I'm Melanie Cole.
Lung Cancer: Risk Factors, Updated Screening Guidelines and Next Steps
Melanie Cole (Host): Lung cancer is responsible for so many cancer deaths. However, if caught early, the prognosis is significantly better. My guest is here to explain the latest lung cancer screening guidelines and options.
Welcome to Bryan Health Podcast. I'm Melanie Cole, and joining me today is Dr. Ryan Martin. He's a pulmonologist with Nebraska Pulmonary Specialties, and he currently serves as the pulmonary division chair for Bryan Medical Center. Dr. Martin, it's a pleasure to have you with us as we get into this topic. It's such an important topic.
Tell us more about lung cancer in Nebraska today. What's the prevalence? Are people getting the message? And then kind of segue into the trends that you're seeing around the country.
Dr Ryan Martin: Absolutely. Thank you for having me. So when we look at, lung cancer as a whole, it'd been a very interesting trend in the last couple of years. And in fact recently in Nebraska, we actually had an epidemiology study that came out that told us what we were seeing in terms of our mortality.
And the results are interesting. We've been taught many times over that lung cancers are obviously the most deadly of the cancers. It is the third most prevalent cancer behind breast and prostate cancer. But it is far and away the most deadly, and we can talk about that in terms of why that is.
Lung cancers, generally speaking, are just caught late, and that's really a big part of it. We see them in our later stages of cancer. We do not typically find them as stage one or a very early cancer, and a lot of that has to do with screening.
Everybody, I would say, is fairly familiar with the concept of mammograms, and pap smears and colon cancer screenings. People would be familiar with prostate screenings. All of those things people, I think, are very familiar with. That's a routine part of health care and health care maintenance. But what we have not seen is a very concerted effort in terms of really pushing lung cancer screening. And that's really, I think, a big part of why lung cancer is so much more deadly than its counterparts.
That's really one of the biggest things I think that's out there is how do we really improve our screening. And what's going on right now is we do have a screening program, and one of the toughest things about it is actually only about 7% of patients nationwide that are eligible for lung cancer screening are screened.
That's a very low number. When you look at that and consider the number of people who are eligible for colonoscopies that are getting them done and people who are getting mammograms on time, it really, it just shows a very big gap in terms of the screening.
Melanie Cole (Host): Why do you think that is? I mean, if people are willing to get their colonoscopies and women, we go for our mammograms. Do you think that maybe there's a stigma that people think if they go for that low dose CT screening —which we will talk about —that, that says something about them or their behaviors? Why do you think that is?
Dr Ryan Martin: Absolutely. I think some of it is a stigma. And one of the things that's probably the most interesting in this — just almost anecdotally — but I think a lot of people just don't really want to know. And that's a part of it is, people who are longtime smokers, I think there's some of that, that there's a stigma associated with it and they just feel like if they don't know about it, it won't hurt them, and that is exactly the opposite approach. We need to be screening people sooner to catch diagnosis at an earlier stage where it improves our opportunities for cure.
Melanie Cole (Host): Dr. Martin, we've all known for a long time that lung cancer and that smoking really go hand in hand. Big high risk factor. Are there other risk factors? Is lung cancer considered like pancreatic or certain breast cancers? Is this considered genetic? Some people that have never smoked, get lung cancer, and we can't really screen them for no reason.
As we're gonna talk about, these screening guidelines are very specific, what are some of the risk factors that you can point to other than smoking?
Dr Ryan Martin: When we look at lung cancer, 85% of patients typically are driven by or attributed to cigarette smoking, but that obviously isn't all of them. The most common additional factors that are identified clearly are going to be really radon. That is the biggest one, and that is a gas that's emitted and is typically found in basements and can be mitigated.
But beyond that, we really don't have a clear identification of additional factors that we see that cause lung cancer specifically.
Melanie Cole (Host): That's so interesting. So let's talk about the screenings. As we know that early diagnosis is key, tell us about the screenings that are recommended to detect lung cancer early and who is eligible because I think that, Dr. Martin, that is where people find the most confusion about eligibility in criteria for these screenings.
Dr Ryan Martin: . So the number one thing that we look at for someone who is eligible for a lung cancer screening CT scan is the age over 50 And these guidelines have changed a little bit, and patients have to have at least a 20 pack-year history.
So to break that down a little bit, what that means is you have smoked one pack of cigarettes a day for 20 years. So there's multiple ways you can get to that number, right? You can smoke two packs a day for 10 years, and that equals 20. You can smoke a half a pack a day for 40 years, and that gets to 20. So 20 pack years is the minimum threshold for tobacco use.
And then the last is that we screen people as long as they were smoking last within the last 15 years.
Now, that is probably the biggest reason why we do have some confusion in terms of getting screening done on that. It's always been that there is no exact threshold in terms of, you do screenings just because you turn the age of 45 or 50. This is one of those where you have to have a few other things that go into the equation for screening purposes.
Melanie Cole (Host): I understand a low-dose CT scan is what’s done to screen for lung cancer. It’s painless and quick, where you just lie on a table that slides in and out of a machine and takes pictures of your lungs. Can you tell us what to expect from the results of this screening?
Dr Ryan Martin: There are people that will show up with an abnormal finding. And abnormal findings may mean small pulmonary nodules, which is present in approximately 24% of people. So, if I scanned a hundred people and I turned 24 nodules up, those are not 24 cancers. Those are 24 nodules.
So if you have a nodule, then you have to determine whether or not that individual has a nodule that is over six millimeters. And if it is, then it has to have an appropriate follow-up. The follow up timeline obviously is dependent upon the size of the nodule, and if a nodule is large enough, you would potentially proceed to a biopsy. And again, not every nodule that we biopsy ends up as a malignancy.
So this is really the biggest part of this, is we have to have people understand that in order to do the screening, there is a distinct possibility of finding a pulmonary nodule or an abnormality in about one out of four patients that we would screen. Of those, 96% of these are actually non-malignant. So on average we would scan people and find abnormalities, and more often than not, these are simply old scars or small little inflammatory nodules that are very common in both smokers and in non-smokers, and that is really the biggest reason that we have to do the scanning and have a conversation about what we may find on those.
Melanie Cole (Host): That's very encouraging. That statistic you just cited, that all those nodules that you might find are not all cancerous. Because that is just what's so scary to all of us who get any of these screening tests, but that was so encouraging, Dr. Martin. So the next steps, you mentioned the possibility of a biopsy.
Speak a little bit about robotic bronchoscopy or other biopsy methods that you might use, and just briefly tell us about those.
Dr Ryan Martin: Absolutely. So there has been an evolution in our diagnostic capabilities that really has been able to limit and mitigate our risks for complications. And it's a robotic bronchoscope. This device is the most significant advancement in bronchoscopy that we've had in quite some time. It is able to be driven into a very peripheral portion of the lung.
So it would be done under general anesthesia, which means that you’re asleep for the procedure. We use a patient's airways as essentially the streets, so to speak. And it's essentially like using a map to find the airway and drive out to the peripheral pulmonary nodule. Once you get to the peripheral nodule, we're actually able to dock this robot or dock this scope where it will stay where I put it.
And at that point we are able to begin the process of sampling the nodule. And typically with sampling, what that means is a needle poke directly into the lesion, to use a little forceps or a pincher to take a larger chunk of tissue, which really the big thing there is they give more tissue to the pathologist so they're able to make an accurate diagnosis. Oftentimes when we do this, the pathologists are right there working hand in hand with us in the room. So as we are doing the case, and a lot of times we are getting, if not a diagnosis, at least confirmation that the tissue that we are obtaining is exactly what they need to see.
Once this portion of the procedure is completed, this is where I think the world gets more interesting. We can do biopsies on people's lungs. We could do potentially both sides at the same time. We can do one lung and then move along and get a nodule on the other side, which really has not been a possibility to do on the same day at the same procedure previously.
Additionally, we're able to complete the sampling of a nodule peripherally, and if it is abnormal, we then can use a different type of scope at the same procedure at the same time to do sampling of any of the lymph nodes that may or may not be involved within the chest as well. This is of tremendous benefit because in a single anesthetic attempt we are able to do, not just potential diagnosis, we are able to get potentially diagnosis of more than one lesion at a time and do what's called pathologic staging.
Melanie Cole (Host): That is so comprehensive and so fascinating. Dr. Martin, before we wrap up, tell us a little bit about what else you would recommend to the public about lung cancer prevention, screening, smoking cessation, lifestyle, anything that you would like to summarize.
Dr Ryan Martin: So I would start with number one, I think the biggest thing is if you're a smoker, the first thing to do is to put them down. And we all know that that's very hard. And if there's difficulty with it, this is where you really need to seek out help. And there are multiple locations that you can do that, whether it be through your primary care physician or Quit Nebraska, which helps with tobacco cessation. Anything that needs to be done to quit smoking is obviously the first step in a lot of instances, and that's a big step.
Beyond that, I think the big thing there is to also just understand that screening is not meant to be scary. It's actually meant to prevent the more advanced stage malignancies.
The one thing that we are acutely aware of — and this is some information that I also think is not very well disseminated — but lung cancers really have a pretty good five-year survival rate. It's very dependent on if you catch it early. We really need to be able to move the needle on catching these cases long before they end up with somebody who comes in coughing up blood or having unintentional weight loss or a chronic cough that they've just had for several months. We really need to be moving that forward.
Those would be some things that I would tell you are hands down what we need to be looking at.
Melanie Cole (Host): Great information. So informative. Dr. Martin, thank you so much for joining us today and sharing your expertise about lung cancer recommended screening, and the options to get a diagnosis faster and then treatment if cancer is found. To learn more about lung cancer and screening scans, please visit bryanhealth.org/lung cancer, and I'd like to thank our Bryan Foundation partners, Inpatient Physician Associates and Sampson Construction, for making this podcast possible.
That concludes this episode of Bryan Health Podcast. Please always remember to subscribe, rate, and review this podcast and all the other fascinating Bryan Health podcasts. Until next time, I'm Melanie Cole.