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VO: It's another edition of the Erie County Medical Center podcast series, True Care HealthCast

Prakash Chandran (Host): You might have heard of thoracic surgeons before, but few of us know what they actually do and the diseases they treat. Today, we'll learn all about them and when it might make sense to see one. We're going to talk about it today with Dr. Robert Qaqish, a Thoracic Surgeon and Director of Thoracic Surgery at Erie County Medical Center.

This is the True Care health podcast, the official podcast from Erie County Medical Center. My name is Prakash Chandran. So Dr. Qaqish, it's really great to have you here today. Thank you so much for your time. I wanted to get started by asking just I guess a broad question. What exactly does a general thoracic surgeon do?

T. Robert Qaqish, MD, MSc (Guest): Yes. thank you very much for having me. I'm very happy to be here today. A General Thoracic Surgeon performs surgery on the lungs, the esophagus, the heart SAC, or the pericardium and essentially the chestwall. We perform a wide variety of operations that stem from benign conditions of the chest, such as surgery for a collapsed lung or severe lung infection, to cases that involve malignant conditions such as lung cancer or esophageal cancer.

Host: Okay. And I just have one question to expand on that a little bit. It sounds like you operate within the chest cavity, but does, does that include the heart or that excludes the heart?

Dr. Qaqish: For the most part, Cardiac Surgeons perform surgery specifically on the heart, but General Thoracic Surgeons mostly do not.

Host: Okay. Understood. So talk to me a little bit about how somebody becomes a General Thoracic Surgeon.

Dr. Qaqish: Sure. There are two main pathways for somebody to become a General Thoracic Surgeon. After medical school, some institutions have training programs so that you can enter thoracic surgery residency, right away, which is usually a six year program of clinical training or more, if you do research. The other more traditional pathway is to complete medical school, then complete five years of general surgery and then pursue a two or three year thoracic surgery fellowship. I completed the more traditional route after medical school.

Host: Okay. And just give us a sense for after you become a thoracic surgeon and you're actually operating, what kind of diseases or what types of diseases do you treat?

Dr. Qaqish: Yes, General Thoracic Surgeons like myself, mainly treat lung and esophageal cancer. But I also treat many benign or non-cancerous conditions of the chest such as collapsed lungs. We call that a pneumothorax, infected fluid in the chest, that's called an empyema, hernias of the chest as well or upper abdomen.

And if a patient, for example, has a paralyzed diaphragm we correct that as well, just to name a few. I also treat patients who have rib or sternal fractures. Patients who have swallowing difficulties, such as those with a condition called achalasia. This occurs when the lower part of our esophagus has a difficult time relaxing to allow food to pass. Those are just to name a few.

Host: Okay. And you named a number of different things there. Is surgery more or less always required when you're treating these conditions?

Dr. Qaqish: Yeah, that's a great question. For the, for the most part, many of them do require surgery, but I often am asked to see a patient just for an opinion. And whether or not, they need surgery, depends on the severity of the actual disease they have, their overall condition or sometimes whether or not they can actually tolerate a procedure.

So depending on the condition, depending on the severity, it does not always require surgery. And of course, one of the most important aspects is also, whether or not the patient actually wants a procedure as well, which is probably one of the most important components of a, of a discussion I have with the patient.

Host: Yeah, And as you're having that discussion with them, what do you talk about? Do you talk about the different types of surgeries that you perform? The safety profile? Walk us through that discussion.

Dr. Qaqish: Yeah, it's a very important discussion to have with a patient. But it all comes down to the basics and the, the most important part of the discussion that is I think having a conversation with the patient, such that they understand in their own terms, what is actually going on.

Before I even jump into having a discussion about surgery, they need to understand what it is they actually have, how it happened and what we can do about it and all of the options, whether it's surgical versus nonsurgical. After we've had that sort of foundational discussion, then we can have a conversation about surgery. If we do make it to that point where we're having a discussion about surgery; we talk about everything in their own terms, the benefits, the risks and alternatives and what they can expect immediately before surgery, as well as after surgery as well. And often this conversation is performed in the presence of family members as well, which I think is very important because they're usually the ones caring for these patients afterwards. So they need to be just as informed.

Host: Yeah. That totally makes sense to me. I think oftentimes people don't realize the support that the family or the caregivers need to do after a surgery is performed. So I'm glad you mentioned that. You know, speaking of the dynamics of the surgery itself, can you walk us through how that's actually performed?

Dr. Qaqish: Yeah. Most of the surgeries I perform are completed minimally invasively. That is with a few small incisions between the ribs or the abdomen. We use a very small, very high resolution, long camera about the width of your little finger, to visualize what's inside the chest. For example, in the case of early stage cancer, we use minimally invasive surgery to remove a portion of the patient's lung that contains the cancer.

Host: Yeah, that's fascinating. And just because you touched on cancer of the lung, how common is lung cancer?

Dr. Qaqish: Yeah, lung cancer in the United States is the second most common cancer, second only to prostate cancer in men and breast cancer in women. I think the American Cancer Society estimates that in this year, in 2022, there'll be about 230,000 new cases of lung cancer in both, in both men and women. And unfortunately lung cancer is by far the leading cause of cancer related deaths. And it's estimated that about 120 to 130,000 people will die from lung cancer this year, unfortunately.

Host: Yeah, that's really sad. And I'm going to go out on a limb here and say the reason why there is so much lung cancer is because of our society's tendency or addiction towards smoking. Is that correct?

Dr. Qaqish: It is by far the, as you suggested, the most significant contributor. It is smoking by far leading risk factor for lung cancer is smoking. About 80% of lung cancer deaths are thought to result from smoking. But secondhand smoke is also a risk factor. Radon gas, actually, it's an element found in rock and soil and poorly ventilated areas. Burning of coal, for example, and other fossil fuels, they release radon. And that is also a risk factor for lung cancer.

Host: Okay. And so that portion of it is more of an occupational hazard. So for example, if you're working in a mine or somewhere where you might be exposed to that, that's something that you should be aware of. Is that correct?

Dr. Qaqish: Yes. Yes. And sometimes patients that I see are in their sixties and seventies and they have had occupational exposures to radon or asbestos actually is another. It can increase your risk of cancer and it can be found in stove insulation, furnace insulation, piping insulation as well. And some, some of the patients that I do see have had occupations in their early twenties or thirties, where they were exposed.

Host: So let's talk a little bit about getting ahead of the cancer. If someone wants to get screened, who exactly qualifies for lung cancer screening?

Dr. Qaqish: Right. So the United States Preventative Services Task force is, is comprised of a group of national experts in disease prevention and evidence-based medicine. And they put together, amongst other very reputable organizations, they've recommended yearly lung cancer screening should be performed in people who are between 50 and 80 years of age, have a 20 pack year or more smoking history and are current smokers, or have quit within the past 15 years. When, when I said the term pack year, a pack year is smoking an average of one pack of cigarettes per day for one year. For example, a person could have a 20 pack year history by smoking one pack a day for 20 years or two packs a day for 10 years.

Host: So I, I'm 40 years old and I have friends that definitely meet that pack year criteria and they're not yet 50. Do you recommend that they get screened for cancer beforehand?

Dr. Qaqish: There are some patients who have a very strong family history for many other types of cancers and get screened for those types of cancers. For example, colon cancer. If they have a very strong family history and there are guidelines to get screened much earlier than 50, for example. As it relates to lung cancer, in general, screening starts when the patient is 50, right now. Things may change as we progress, but the majority of patients who do have lung cancer are usually above 50. So at this time screening is only recommended for that age group that have that significant pack year history. For your friends or for your colleagues who, who do have a significant smoking history, the best thing for them to do is to quit smoking.

Host: Yeah, totally makes sense. And I have told him that many times. You know, talk to us broadly about what screening looks like, like is that something where they go in and it's a full day affair. What exactly happens during a screening?

Dr. Qaqish: Right. This is important to know. So right now to get screened for lung cancer, what's required for the patient is to get a low dose CAT scan or CT scan of the chest. And as a very quick examination that the patient gets. They don't need to be fasting at all. And doesn't require any significant sort of pre-procedure planning apart from scheduling and showing up for the CAT scan.

So typically what's required is they schedule an appointment through their primary care doctor for them to place the order for the CAT scan, if they qualify. And they could go to various hospitals or various radiology clinics to get the low dose CT of their chest. And the CT of the chest essentially can look for any masses, any abnormalities in the lung tissue. And the resolution is far greater than a standard chest x-ray to help us see if there are any lesions.

Host: So if an abnormality or lesion is found, what are the different treatment options for someone who might have lung cancer?

Dr. Qaqish: So in 2022, the treatment for lung cancer is complex and requires typically a large team of specialized providers to help make the best decision for the patients. We often have a multidisciplinary team to help guide the decision when a patient has the diagnosis of a lung cancer. But in general, if the lung cancer is found early and the patient is a good candidate for surgery, we perform a surgical resection of that part of their lung that has the cancer.

During that surgery, we also take lymph nodes, which are the small little organs that are pretty much everywhere in our body. And drain excess fluid, but also drain cancer cells and whether or not cancer is found in lymph nodes often determines whether the patient needs any therapy after surgery, such as chemotherapy.

But in general, if the lung cancer is found early, we call that an early stage cancer. Surgery is recommended to them. If the patient has an early stage lung cancer, but is not fit for surgery, they aren't a candidate, either, they have really poor lung function or they may have other comorbid conditions in their medical history that really wouldn't allow them to tolerate surgery, or considered high risk; radiation therapy targeting the specific area of the lung cancer is an alternative option for them. For advanced stages of lung cancer, we treat patients with chemotherapy alone, or sometimes both chemotherapy and radiation therapy together.

Host: So just before we close, if someone is listening to this and is thinking, you know, I really need to get screened for lung cancer, what should they do? Or how can they get screened?

Dr. Qaqish: Yeah. The first step is talking to your primary care doctor, seeing if you qualify. The majority, if not all primary care doctors are very familiar with lung cancer screening and the criteria that patients need to meet before getting a low dose chest CT. So that would be the initial discussion as well as exploring what the primary medical doctor options for patients in terms of quitting smoking as well.

Host: So the final question that I always like to ask all my guests is given all of the experience that you have as a thoracic surgeon, what is one thing that you just know to be true, that you wish more patients knew?

Dr. Qaqish: I think that smoking is by far the leading risk factor for lung cancer and that we have resources now as well as avenues for patients to get screened for lung cancer, such that the earlier it is that the lung cancer is found, heaven forbid if it is found, patient can be potentially cured if it's found early and they have an operation for that.

Host: Well Dr. Qaqish, this has been a truly informative conversation. Thank you so much for your time today.

Dr. Qaqish: Thank you very much.

Host: That was Dr. Robert Qaqish, a Thoracic Surgeon and Director of Thoracic Surgery at Erie County Medical Center. For more information, you can visit ecmc.edu. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been another episode of True Care Health. Thank you so much for listening and we'll talk next time.