intro: Duly Noted, a Health and Care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners re-imagine and better understand an extraordinary health and care experience.

Amanda Wilde (Host): Lung cancer is the leading cause of cancer related deaths worldwide. We're talking about how to assess your risk, what's available in terms of screening and early detection, and the latest technology to treat this disease with Dr. Viveka Boddipalli, Pulmonary Medicine and Critical Care Physician at Duly Health and Care. This is Duly Noted, a Health and Care podcast from Duly Health and Care. I'm Amanda Wilde, Dr. Boddipalli, welcome.

Viveka Boddipalli, MD: Hi, Amanda. Thanks for the intro.

Host: Great to have you here. As a pulmonologist, can you explain how lung cancer risk is assessed and what factors contribute to an individual's risk level?

Viveka Boddipalli, MD: Certainly. So while we haven't identified every element that increases a person's risk of developing lung cancer, by far and away, the most common risk factor is tobacco use or exposure. This is followed by radon exposure, occupational exposures such as asbestos, or other known carcinogens in the workplace, a family history of cancer or a personal history of cancer, as well as, a history of active lung disease such as COPD or pulmonary fibrosis.

Host: What role does family history play in determining lung cancer risk and how can individuals with a family history of lung cancer be proactive about their health?

Viveka Boddipalli, MD: So, just to be clear, when we talk about family history of lung cancer, we're primarily talking about first degree relatives. That would be your biologic parents, children, or siblings, brothers or sisters. And there's a lot of interesting research in the area, but the overall role of genetic factors that lead to lung cancer is still relatively poorly understood compared to some of the other factors.

 And we know that 1st degree risk associated is also increased if that lung cancer developed at an early age. So, under the age of 50. While we don't have specific genes we can point at, we know there is a strong association between 1st degree relatives who developed lung cancer early.

Host: And how can those people at risk be more proactive about their health?

Viveka Boddipalli, MD: Absolutely. The first and most important point there is, if there is a family history, avoiding smoking is probably the biggest preventative measure we can take. Secondary to that, if you already are an active smoker; quitting as soon as possible can alter that risk over time. We know that even as early as five years out from the last cigarette, your cancer risk can start to drop.

And so, especially those at higher risk with a family history, it's really important to A, not start smoking, but B, quit as soon as possible.

Host: Now, another thing you mentioned were occupational and environmental factors. What are those specific factors that can increase the risk of lung cancer? And again, what can individuals do to protect themselves in those settings?

Viveka Boddipalli, MD: Yeah, asbestos is something we commonly see in the news and on billboards, but that is one of the more common environmental exposures, especially occupational exposures that we see. It has a long lag time and wearing protective equipment when in these areas or when in potentially exposed to asbestos is super important. The most common household exposure, especially in this area is radon exposure. It's a radioactive element that occurs naturally in the ground, colorless, tasteless, odorless, and for homes that have basements, you just want to be sure that you have your home tested so I would encourage radon testing at home and mitigation if levels are above the EPA recommended four pico curies per liter. Mitigation is as simple as installing a fan with a PVC piping to vent that air out of the house.

Host: So we've talked a little bit about what we can do in terms of prevention. Let's talk about early detection in improving outcomes for lung cancer patients. I mean, lung cancer has been notoriously difficult to detect early, but what are the screening processes and what are available for people that may be at risk and looking for possibly early detection?

Viveka Boddipalli, MD: Yeah, really important question. We know that the clinical outcome for the vast majority of lung cancers is directly related to the stage at the time of diagnosis. Unfortunately, lung cancer is one where most patients present with symptoms at an advanced stage or at a metastatic stage, which makes cure much more difficult. Part of that is there are no pain fibers in the lungs, and so it's hard to feel that until it grows to a certain size.

In the right patient population, i. e. those at risk for lung cancer, screening can improve cancer detection rates, the stage at detection, survival, and even overall mortality. Right now, we currently have one screening method that's recommended, beyond a clinical history. It's the one that's recommended by most medical societies, which is called a low dose CT, or commuted tomography of the chest.

This LDCT screening, is really important in that it's meant to detect lung cancer early in an asymptomatic high risk population.

Host: Yeah, which is a great stride forward. How often should patients be getting screened for lung cancer? Is it strictly for those at risk or is it open to all patients?

Viveka Boddipalli, MD: So, it is recommended for patients at risk. The National Lung Screening Trial, which was a study of over 53,000 high risk patients, really evaluated patients or adults aged 50 to 80 years who have a 20 pack year smoking history and currently smoke or have quit within the past 15 years and that's reflected in the U.S. Preventative Task Force recommendation as well. So, I'll say it again. It's adults between the ages of 50 and 80, have a 20 pack year smoking history and currently smoke or have quit within the past 15 years. We generally screen once a year. Sometimes we'll ask patients to come back for an earlier screening, depending on what that initial CT scan finds.

Sometimes as frequently as every three to six months, but most commonly it's a once a year test.

Host: Has medical imaging technology, x-rays for the chest and CT scans improved our ability to identify lung cancer earlier?

Viveka Boddipalli, MD: Yeah, well, chest x-rays remain very easy and low risk and very readily available test. Unfortunately, they don't play a significant role in lung cancer screening. However, CT scans, particularly low dose CT scans, where we reduce the radiation delivered to the patient has come a long way in being able to detect very small nodules early and improve our ability to diagnose these in the last, especially in the last decade.

Host: Well, that is very hopeful. I'm wondering if you run across some common misconceptions about lung cancer or myths that you encounter with your patients.

Viveka Boddipalli, MD: Absolutely. One of the most common misconceptions we hear or myths is that it's only a smoker's disease. In fact, 15 to 20 percent of lung cancers occur in non-smokers, and those are generally related to radon exposures or occupational history, even secondhand smoke exposure. The other really common one is that once you smoke, or have a history of smoking, your risk is fixed and there's nothing you can do to then lower that risk, going forward. But we do know that you see a relatively quickly reduction in risk from quitting smoking as early as 5 years from abstinence. And for those who quit for more than 15 years, and this is again reflected in the USPTF guidelines, they have an almost 80 to 90 percent reduction in risk of lung cancer when compared to a current smoker.

So a big change that's still in your hands. And then another common one is that all lung cancers are the same and everyone receives the same treatment. And really with some of the advances in the last decade, decade and a half in diagnosis and therapy, treatment is increasingly personalized to the patient and really establishing care with a high volume provider is important.

Host: If a patient is concerned about their lung cancer risk level, what should they do? What's the first thing they should do and kind of the trajectory they might follow? Just with some concerns.

Viveka Boddipalli, MD: Yeah, the first is to speak with their physician about their specific concerns and to assess their risk factors. There are some risk factors, like we talked about earlier, that we can modify and some we can't, and really, assessing those risk factors, both modifiable and non modifiable, with your health professional, will go a long way to addressing those concerns.

Host: Well, Dr. Boddipalli, thank you so much for giving us all a better understanding of risk factors, detection, and dispelling some of the myths about lung cancer.

Viveka Boddipalli, MD: Great. Thanks so much, Amanda.

Host: That was Dr. Viveka Boddipalli, Pulmonary Medicine and Critical Care Physician at Duly Health and Care. For more information visit DulyHealthAndCare.com. If you found this podcast helpful, please share it on your social media and check out our full podcast library for topics of interest to you. This is Duly Noted, a Health and Care podcast from Duly Health and Care.