Joey Wahler (Host): It is helping many patients that have the disease. So, we're discussing advanced surgical lung cancer treatment. Our guest is Dr. James McPherson III. He's medical director of thoracic surgery, and also co-director of the Lung Center of Excellence at Capital Health Cancer Center.

This is the Health Headlines podcast series from Capital Health. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. McPherson. Welcome.

James McPherson, III, MD: Thank you, Joey. It's a pleasure to be here.

Host: Great to have you aboard. So, first, tell us what types of lung cancer cases typically require surgical intervention in the first place.

James McPherson, III, MD: Sure. Well, lung cancer is the leading cause of cancer death in our country. More people die of lung cancer than all other forms of cancer. And so, we have found that early diagnosis is the key to getting great outcomes with lung cancer. So at Capital Health, we are on a campaign to try to diagnose lung cancer early and also to try to provide minimally invasive techniques to treating this awful disease.

Host: Yeah, you mentioned how common it is in the fact that it's the number one killer. That's been the case it seems forever. It never changes, unfortunately, does it?

James McPherson, III, MD: That's true. When I talk to patients about lung cancer, I often use the number 16. Only 16% of patients who are referred or diagnosed with lung cancer are surgical candidates. So, that means that the vast majority of people are diagnosed at a late stage when the treatment options are limited. So if we can make the diagnosis earlier, then we can provide patients with many more options and also get better outcomes for survival.

Host: Absolutely. So, doctor, even if people are non-smokers, are there steps they can take to lower their risk of lung cancer in the first place?

James McPherson, III, MD: Well, that's a great question. Over 83% of newly diagnosed cases of lung cancer are associated with cigarette smoking. So certainly, if we can cut down the number of people who smoke cigarettes, that is going to be a huge influence. That being said, there are patients who present with lung cancer who do not smoke or are not exposed to secondhand smoke. So, we still haven't figured out all of the causes of lung cancer, but smoking certainly is the most major influence on lung cancer and many other forms of cancer as well.

Host: So, what role does screening play in eventual lung cancer treatment and who should be getting screened?

James McPherson, III, MD: Screening really started about 30 years ago. Lung cancer, unlike breast cancer, does not have a self exam, and unlike prostate cancer, there is no blood tests that you can get that would tip you off that you had lung cancer. That's part of the reason that many people present at a late stage. For years, the only screening test we had was a chest x-ray, but small tumors are often missed on a chest x-ray.

So, the whole concept behind lung cancer screening is to get low dose CAT scans, which are far more accurate than a regular chest x-ray to try to pick up lung cancer at an early stage. So if you have a 15-pack year history of smoking, if you're over the age of 50, then you would qualify for getting a screening CT scan. And many studies have shown that the screening CT is far more sensitive in picking up early lung cancer.

Host: So that being said, what would make someone a candidate for this advanced surgical lung cancer treatment? And we'll get into the details further in a moment.

James McPherson, III, MD: So, at Capital Health, we actually have two great pieces of technology. I say technology, part of it is the physician staff. Both Dr. Diana Coleman, who is the co-director of the lung cancer program, as well as myself, we work very closely to try to get patients in to make their diagnosis early.

One of the bits of technology that we have is called an ion robotic navigational bronchoscopy. It's a mouthful, but basically it's a very minimally invasive procedure that we can do to diagnose a person who has an abnormal CAT scan. It's an outpatient procedure, meaning they come into the hospital, they have this special procedure done, and they go home the same day. And there are no incisions involved with an ion robotic navigational bronchoscopy. So, that's one thing that we do at Capital that is growing around the country, but we're one of the few places that has that technology now.

The second thing that we have is a da Vinci robot, which enables us to remove these cancerous lesions through minimally invasive incisions. Anytime we're doing a robotic operation, the patients enjoy a shorter hospital stay, a more rapid return to active living, less bleeding, less transfusions. It's really the cutting edge of thoracic surgery.

Host: All right. So, you gave us some information there about what's actually available. What would make someone a viable candidate for that?

James McPherson, III, MD: So when either Dr. Coleman or myself see a patient in our lung nodule clinic, we review their images. We look at their CAT scans, their PET scans, and we're really looking to see that the disease has not spread. And if we have what appears to be an early lung cancer, we first establish a diagnosis. We make sure that the patients have lungs that are healthy enough to undergo an operation, and then we offer them a number of options. Among them, surgery. The best outcomes with lung cancer are with early diagnosis and surgical therapy. But there are some patients who are not candidate for surgery or they may not want surgery. And if that's the case, we do have other modalities that can be used to treat them, from chemotherapy to targeted radiation therapy. We have what's called a multidisciplinary team here at Capital that helps to treat lung cancer, and it's been shown nationwide that the best outcomes with lung cancer are with a multidisciplinary approach.

Host: Well, you mentioned there, doctor, that some patients unfortunately are not candidates for these advanced techniques. Would that simply be someone whose cancer is further along or might there be another factor? And how far along would it have to be to take them out of the mix for this?

James McPherson, III, MD: Well, when we're looking at a patient with CAT scan that shows, let's say, a tumor in the lung. Beyond the tumor, we look to see if there has been spread to any of the lymph nodes. Sometimes you can get an idea of that with a regular CAT scan. But often, we use other imaging techniques such as a PET scan to determine if there has been lymph node spread.

So unlike abdominal surgery where you often look inside and see that the cancer is so advanced, you stop-- that's called a peak and shriek-- that's very unusual in the chest. Most of the time for the lung cancer patients, we're very accurate about making a diagnosis before we operate. So if we determine that a patient is in an advanced stage, then the appropriate therapy in that situation is usually not surgery. Usually, it's chemotherapy and/or radiation therapy.

Host: When treating lung cancer in terms of surgical techniques, advancing in recent years, you touched on earlier, but just to expand on it a bit, how much have these advancements improved the experience of surgery, both for the patient and for the surgeon like yourself?

James McPherson, III, MD: Well, in the old days, that was 20 years ago, the majority of lung cancer operations were done through a large incision in the back called a thoracotomy. I've been doing surgery for almost 30 years, so this was standard and we got good outcomes with that. But the thoracotomy is associated with more pain since it's a bigger incision. We have to use a rib spreader, which helps us to gain access to the chest. Many times, it involves either cutting a rib or removing a rib to get into the chest.

But now, that we have robotic techniques, we're able to do the same, operation through a series of smaller incisions. Each incision is about the width of a writing pen. The da Vinci robot enables us to get spectacular pictures, or images of the inside of the chest because we're using a three-dimensional high-definition camera. So even though the incisions are smaller, you can actually see the chest with much greater accuracy. We also are able to remove more lymph nodes, which helps us to stage the cancer.

So with this approach, the patients experience less pain, a shorter hospital stay. Most patients who undergo a cancer operation are in the hospital for about two nights, or sooner than that. Some stay a little longer, but the average is about two nights. And as I mentioned, there's fewer blood transfusions. It's better all the way around.

And I think one of the most important things is that people are able to resume active living. That's a big deal for the patients and also a big deal for me. Lung cancer does not define these patients. They have lives, they have children and grandchildren and pets. They have plans to travel. And so, I want them to get back to that. And with a minimally invasive approach, which is what we're using with the Da Vinci robot, they are able to get back to their lives. Finally, if they need more therapy, they can start that therapy a lot sooner after a robotic operation compared to a more invasive approach.

Host: I am glad you mentioned pets there as well as getting back to their families because, for so many of us, pets are part of our family, right?

James McPherson, III, MD: Absolutely. I've got two dogs at home so I can relate.

Host: So a few other things, doctor. What can patients expect? Let's say they're undergoing the da Vinci robotic procedure for lung cancer. What can they expect in a nutshell before and during treatment? You mentioned the timeline. Anything else they should know?

James McPherson, III, MD: I would say that about 60% of surgeons in the country are using the robot to do lung cancer operations. That number is growing. As more thoracic surgeons are being trained, both in residency and fellowship, and then those who didn't get the training formally, they're learning it after. So, I think that numbers of surgeons who are using the robot are increasing. In my practice, I would say 95% of my patients are getting their surgery robotically. So, that's a good thing.

We talk to patients before they have surgery about what to expect. The operation usually lasts for about two or three hours, depending on what we're doing. The patients are in the hospital for about two nights. And after that, their recovery continues at home. Many people want to know what is the recovery time, and I tell them that usually it takes about a month to completely recover from this. It doesn't mean that they'll be bedridden for a month. But before they're chopping wood or doing Taekwondo again, it'll be about a month.

At that point, it's my expectation that they will resume normal activity. We, at Capital and most places, it takes our pathologists about a week to get a final pathology report. So, the pathologists here do a very detailed analysis of the tumor that we remove about the lymph nodes. And by the time that patients come back to see me in the office, about a week after they're discharged, that information is available and we discuss it. And we discuss whether they will need any further therapy. All of my patients are seen by an oncologist, and an oncologist is a cancer specialist. Sometimes the oncologist is the one who will quarterback the chemotherapy that's given after surgery. But even if patients don't need chemotherapy, I like for them to see an oncologist just as if they can get a different perspective on the cancer from what I'm telling them.

Host: And then in summary here, doc, if we could kind of circle back to where we started and add to it as we end. Stress, if you would please, for those joining us just how important early detection is in improving the surgical outcomes. Because not to be overly dramatic, but it is literally sometimes the difference between life or death, isn't it?

James McPherson, III, MD: What you're saying sounds dramatic, but it is so true. Every disease that we get is best treated early. And as I said, one of the reasons that lung cancer has been so deadly in our country is because it is diagnosed late. There is no self exam for lung cancer and there is no blood test. So, we have to select patients based on their history, based on their demographics. If they smoke, if there is a family history of cancer, then these are people that we would like to get to. I think there's a stigma about lung cancer because of the association with cigarette smoking.

I'm a huge fan of football. And in the NFL, you see eyes often wearing pink to bring awareness to breast cancer, which is really important. But the number of people who will die from lung cancer far exceeds breast cancer. Again, I think it's because there's a stigma associated with cigarette smoking. So if you smoke, if you are smoking or if you've quit less than 20 years ago, then you may be a candidate for a screening CT scan, which would help us to make an early diagnosis.

Host: Well, folks, we trust you are now more familiar with advanced surgical lung cancer treatment. As Dr. McPherson says, if all goes well, you can get back to things like chopping wood and Taekondo and perhaps even playing football as well as watching it at least recreationally, right, doc?

James McPherson, III, MD: Absolutely.

Host: Dr. McPherson, keep up all your great work. Thanks so much again.

James McPherson, III, MD: Thank you so much for having me.

Host: For more information, please visit capitalhealthcancer.org. Or to schedule an appointment, please call Capital Health Center at (609) 537-6363. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. And thanks again for being part of the Health Headlines podcast series from Capital Health.