Melanie Cole, MS (Host): Lung cancer is the leading cause of cancer deaths in the United States, with a less than 25% five-year survival rate, primarily because symptoms don't appear until the disease is at an advanced stage. Even so, many of the symptoms are mistaken for a virus or even smoking effects.

Welcome to Bryan Health Podcast. I'm Melanie Cole. And joining us today is Dr. Lance Bezzina. He's a cardiothoracic surgeon with Bryan Heart. Dr. Bezzina, thank you so much for joining us today. I'd like you to start. I just spoke about the prevalence a little bit, but tell us about the trends that you're seeing in lung cancer today. Are more people getting the message about smoking, do you think? Are we seeing more of a countrywide awareness or not?

Dr. Lance Bezzina: Yeah. Well, thanks for having me. I would say so that we are starting to have a little bit more awareness of smoking. But unfortunately, what we're seeing is that the young people don't think that vaping is smoking, so there's increasing in vaping, which ultimately will increase business that I do, which may not be necessarily lung cancer, but it does increase that, but also cardiovascular disease. But I know we're talking about lung cancer today.

As you kind of alluded to, 90% of lung cancer is related to smoking, either from smoking itself or secondhand smoke. And the problem with lung cancer is that usually symptoms appear kind of later in the disease process. And with all cancers, the earlier you get it, the better your survival is. So with lung cancer, the symptoms are usually related to things that people think are flu or cold such as coughing, chest pain, shortness of breath, wheezing, things like that.

And there is, however, a good screening test, and it's recommended by the National Cancer Society and the Chest Foundation and other societies. And it's for people to get a screening chest low-dose CT scan. It takes only a few minutes. It's not painful. But hopefully, if the patient has cancer, we can catch it a lot earlier. And we have been seeing a lot more cancers that are getting operated on at an earlier stage because of this screening test. So, we're pretty pleased with that, but we need to get the word out so we get more people screened.

Melanie Cole, MS: Well, I'd like to just touch on the screening for a minute and we will get into lung cancer itself. But the screening, the low-dose CT scan, please explain because it can be confusing for people that don't understand who is at risk, who is able to get this screening. Who are you all in the guidelines set out by the Preventive Task Force saying should get this screening every year?

Dr. Lance Bezzina: Yeah. So, it's anyone that's had 20-pack year history. So, what we do is you multiply years of smoking times the packs per day. So if you smoked one pack per day for 20 years, then you've reached the 20-pack year mark. And it's any current smoker with that pack year history or anyone that's quit within 15 years that had a 20-pack year history or has a 20-pack year history. And we're really looking for the 50 to 80-year-olds that are in that range. So, it seems kind of specific. But you know, when you talk to people that smoke a lot of people in the 50 to 80-year-old range fall in that 20-pack year history. Actually, most of them have quite a greater pack-year history. And those are the people that we really are trying to get that low-dose chest CT scan. Because like we talked about before, since let's say, you know, the '60s and '70s, all the other cancers, their survival rates, five-year and otherwise, have gotten better because we do colonoscopies for colon cancer. We do mammograms for breast. But for lung, up until just the last few years, there was no real screening test. But now that we have one, we really want to get the word out to get these people the chest CT that is recommended here.

Melanie Cole, MS: Do you recommend that people who smoke or who fit into these categories ask their providers about this low-dose CT scan and that they bring it up at their annual wellness? Because we don't want to wait until their symptoms are showing up, right? This is something you want to start. And at what age?

Dr. Lance Bezzina: Absolutely. While you're primary care physician should be recommending these things, patients also should be taking healthcare into their own hands, especially somebody that smokes, because, you know, I've been doing this surgery for 10 years. I've never met a lung cancer patient or a smoker who's not concerned about lung cancer. So, anyone that has that 20-pack year history, at their next physical or maybe that should prompt them to go to their primary care physician and ask for that. It's no different than a 50-year-old that should be getting a colonoscopy or any other screening.

Melanie Cole, MS: So important to raise that awareness on those screenings. Now, doctor, tell us a little bit about treatment. Speak about a tumor board, the multidisciplinary team of board-certified specialists, and how you all work together to determine treatment.

Dr. Lance Bezzina: Exactly. Yeah. So, this is something that, I think, we should be very proud of here at Bryan, because the vast majority of patients that have lung cancer are presented at a tumor board. And what that is, is all of the specialists that are involved in lung cancer meet every other Wednesday and we discuss all of the patients. And what we go over is what their stage is and what we can offer from oncology, from the pulmonologists, from ourselves, the surgeons, the pathologists are there, the radiation doctors are there and also, the radiologists. The radiologists and the pathologists kind of guide us as to the stage. And then, we kind of discuss what kind of treatment options. Because some people, they're very early and they're very amenable to surgery. We've got other patients that maybe they've had surgery in the past, or maybe they're not healthy enough for that, so we have to do radiation and chemotherapy. But we kind of hash that out at those meetings and then we will present our recommendation to the patient. And you have probably five, six different opinions, but we kind of come to a consensus and present best practice for their care. And I think that the patients benefit quite a bit from that. And we, at the minimum, will come out of the tumor board with a plan for each patient. So, when we talk to the patient next, it's not like, "Oh, well, we're going to do this or do that." Like, "No, we've talked about it. Everyone's put their head together and this is what we recommend." And then, it's up to the patients to ultimately decide. But it's a real good thing for the patients. And it also is good for us because we're kind of in our silos. Like I know a little bit of what the oncologists do and the radiation doctors do, but you know, they will speak very specifically as to how they can help the patient and vice versa. It's kind of an interchange of ideas there.

Melanie Cole, MS: Well, it's so comprehensive when you have that multidisciplinary approach to cancer, to really any condition. But once surgery is determined as a treatment option, speak about what are some of the options available to you. It's a pretty exciting time, a lot of advancements. There are so many different ways to perform these procedures. Now, speak about some of those to the listeners.

Dr. Lance Bezzina: Sure. Yeah. So, once surgery gets determined, then myself and the other two surgeons, we have pretty much every possible way of doing the procedure between the three of us. We've got open surgery. We've got video-assisted, almost similar to how they take out gallbladders nowadays where we make small incisions and put the camera in the chest, and then we do the procedure through very small incisions. And then, we've also just recently started doing robotic lung surgery, which is an advancement of the video-assisted. So, we've got literally every way of doing lung cancer surgery here. And I think it's great for the patients.

But what the patients should remember is that each one of those surgeries is for very specific situations. So, they might come in and say, "I want the robot surgery," but they might end up with a bigger incision just because of anatomy or that's what's best for the patient. So while we have these options and it's wonderful to offer every single way of doing lung surgery, what we're still going to determine how we do our incision is what's safest and what's best for the patient. So, it's nice to have options. And I think it's great for the patients of this community to not have to go to a university, because there's no other option that the university has that we don't have here.

Melanie Cole, MS: Well, it is shared decision-making, and as you say, it is certainly patient specific. Now, I'd like you to speak about life after surgery for these patients, what can they expect? I mean, maybe you've had to take a lobe out, maybe you've had to take a whole lung out, maybe they need chemo, maybe they need radiation, who knows? And that's all certainly not something you can speak specifically to. But when you see patients after they have had this kind of treatment, are they changing their lifestyle? What's it like?

Dr. Lance Bezzina: Yeah. So, well, I can kind of walk you through it a little bit, just kind of an overview there. So usually, what happens is, is they've met with an oncologist or the pulmonologist. They've met with me. We've discussed them at the tumor board. I present them with the surgery. And if they are amenable to that, we'll pick a surgery date. And then, on the day of surgery, they'll meet the anesthesiologist. And If the anesthesiologist can place an epidural, then when those epidurals work good, I have to literally show the patients their incision and their chest tubes to prove I did a surgery, because it just kind of numbs everything up and it works really good. If for some reason the epidural doesn't work or they can't get it in or whatever, then we'll give them a pain button to hit that'll give them medicine through the IV, and that'll be for a few days.

So, after the surgery, they'll go to the recovery room, then they go to the surgery floor. And then, we'll start letting them or encouraging them to be up, walking, moving, doing things. The quicker we get them back doing activity, the quicker they go home, less of a chance having a blood clot, a pneumonia, a stroke. Something you could kind of catch at a hospital. So, we kind of let him rest the first day. Then the next day, we kind of turn into drill sergeants and get them up and going and in kind of a race to get them back to themselves.

Now, well, they're at the hospital for a few days, hopefully, the path report will come back. Now, when the path report comes back, the oncologist will determine if they would need further chemo or radiation or things like that. Now, if they were to need that, I still don't let them do that for about five to six weeks, because I need everything healed up nice and solid from my incision before any further treatments. But then, they will see myself in the office after and they'll see the oncologist also after whether or not they need chemo. Because if they were to need chemo, then clearly the oncologist will be the ones to kind of direct that care. And if they do not, then the oncologist will need to follow up with these patients to make sure that the cancer doesn't come back or it doesn't come back on the other side. So, they'll be getting a serial CAT scans at specific intervals through the oncologist.

Melanie Cole, MS: Wow, there's a lot that goes into this and you're giving us such great information, Dr. Bezzina. As we get ready to wrap up, I'd like you to speak not only about awareness and lifestyle screening, those sorts of things, but how important it is to have a support person with you, to have that support if you are someone that has been diagnosed, because it can be dizzying, confusing, terrifying, all of those things. So, give us a great summary of this episode today.

Dr. Lance Bezzina: Yeah. I would say more ears, the better. It's always great to have someone that's kind of an advocate for you in the exam room when we go over the surgery. But what's, I guess, a next second best thing is, if someone was on the phone, a vast majority of my office patients have a family member either videoed in like by Zoom or they're just on speakerphone, that would be, I would say, a close second.

But even if the patient doesn't have someone to be there in person or on the phone, what's nice about Bryan is, since I've been here, 100% of the cancer patients that I see have an oncology nurse navigator present with them to listen to everything I say. And then when I leave, after I've presented everything, then they'll go over it with them again and go over and kind of be their advocate. After the surgery, they see them also in the hospital and then they also connect with them as to making sure that they don't get lost to follow up at the oncologist's office or the pulmonologist's office. So, we have wonderful oncology nurse navigators that kind of substitute in as almost a family member for these patients. And it's quite a benefit to the patients to have that.

The other thing, if I were to talk about the benefits of being here at Bryan, is that we're about to really launch this new cancer center. And that's going to be quite a great thing for the patients because what's going to happen is all of us, all of the specialists will be under one roof for the patients to come and consult with us. So, it'll almost be like a tumor board with the patient present and they can kind of get all of our opinions in one office visit.

So, that'll be coming after the new year. And we're very, very excited about getting that started. So that way, the patient and their family won't have to come to my office. Then a few days later, go to the oncologist's office. Then, they were just at the pulmonologist's office. Then, they're going to have to schedule another test at another office. So, this will just kind of be like one-stop shop. And in addition to that, they'll be able to hear all of our opinions in the same appointment.

Melanie Cole, MS: That's excellent, Dr. Bezzina. And I love to hear about those nurse navigators, caring, so helpful, it really is such a support system. And thank you so much for joining us. And be sure, listeners, to talk to your primary care provider to schedule the low-dose CT scan lung cancer screening. It's really, really important.

I'd also like to thank our Bryan Foundation partner, Credit Management Services. And to listen to more podcasts from our experts, you can always visit bryanhealth.org/podcasts. And that concludes this episode of Bryan Health Podcast. I'm Melanie Cole. Thanks so much for joining us today.