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Scott Webb (Host): Lung cancer claims the lives of roughly 140,000 Americans every year. And because it's so deadly, early diagnosis and treatment is essential. And joining me today to discuss the revolutionary Monarch Robotic Assisted Bronchoscopy that's being used at Genesis to diagnose and treat lung cancer, is Dr. Emily Brawner. She's a Pulmonary and Critical Care Medicine Specialist at Genesis. This is Sounds of Good Health With Genesis brought to you by Genesis Healthcare System. I'm Scott Webb. So Doctor, thanks so much for joining me today. We're going to talk about the Monarch Robotic Assisted Bronchoscopy, but before we get there, let's talk about lung cancer. And maybe you can just tell us why is lung cancer so deadly?

Emily Brawner, DO, FCCP, IFMCP (Guest): So, lung cancer can be deadly in part because most people don't have symptoms unless it's already advanced. Most times when patients present the nodule, starting from a small lesion, has advanced to a larger lesion that is now causing symptoms, whether pain or cough or coughing up blood or shortness of breath. So, a lot of the times, really, most patients in the early stages don't have any symptoms. So, that is a big part of why it can be deadly.

Host: And so in the context of what we're talking about today, about the Monarch System, I'd like to have you describe that. Describe using the Monarch Robotic Assisted Bronchoscopy and what that system is like, and really we'll get into as we move along here the advantages, but upfront here, just tell us what's that system like, what's it like to use a robot, if you will.

Dr. Brawner: So, currently what we have is a chest CT or computed tomography of the lungs, which I would say is a 3D picture of the lungs in patients who are at risk for lung cancer. So, those are patients who are age 55 to 75. They have a smoking history of what we call it a minimum of 30 pack years. So, we calculate pack years by how many packs per day multiplied by their years of smoking. So, a simple example would be someone who smoked one pack per day for 30 years. And so they're either a current smoker or a previous smoker who has quit 15 years or less at the time of the CAT scan. So, this is an annual CT of the lungs. So, a 3D picture of the lungs utilizing low dose radiation so that we can screen.

So, it's a screening test for patients who meet criteria, meaning they're at risk for cancer. So the patients that we see in the office where we see nodules. So, nodules are spots in the lungs that are measuring two centimeters or less. And a lung mass is a spot in the lung that's two centimeters or more. So, when we see patients in the office they either have a low dose CT screening or a low dose CT that comes back as abnormal or it's a finding that was incidental. So, for example, a patient may come into the ER for a separate complaint. Maybe let's say the chest pain is very common. The physicians in the ED determine that a chest CT is needed to evaluate them. And incidentally, there's a nodular mass identified.

So, as a pulmonologist, so a pulmonologist is a lung doctor, one of our tools is called a bronchoscopy. So, what I tell my patients is a bronchoscopy is a flexible tube that has a camera at the tip. So, very similar to a colonoscopy, but definitely much smaller and going into the lungs. So, that's one of our tools to look inside the airways to look into the anatomy of the bronchial tubes. And how I describe this to my patients is if we were to think of the lungs as a tree, so the windpipe is the trunk of the tree, and then it branches off to the right and left, so right and left lungs.

So, the right trunk and the left trunk, now it branches off into branches and twigs. So, the standard flexible bronchoscopy we go down into the lungs or the bronchial tubes, but we can only go as far as maybe the first or second generation branch, because after that the diameter or the size of the scope is now much bigger than it than it could go further. So, that's the standard bronchoscopy.

So, let's talk about electromagnetic navigational bronchoscopy. So, navigational bronchoscopy is appropriate for those nodules or masses that are located in the middle to the outer portion of the lungs. So, if we were to think of the lungs again, as an upside down tree, let’s say the nodule or the mass is an apple on the tree, and that apple is either in the middle of the tree or in the outside very far tips of the tree. So, electromagnetic navigational bronchoscopy uses the CT images of the patients and in real-time at the time of the procedure, those CT images are fused by the computer with a patient's anatomy using an electromagnetic field generator.

So, at Genesis, we've been doing electromagnetic navigational bronchoscopy for over 10 years. So, I've been practicing at Genesis for, this is my 11th year. And when I started, a couple of my partners were already doing the navigational bronchoscopy, but a different platform. So, what happens is, as we go down into the lungs and we only see as far as the first or second branch, then after that, what’s called a working channel is inserted through the bronchoscope and using kind of a GPS system, we kind of twist and turn this working channel to drive towards this apple, this nodule, but it's completely kind of using a cartoon depiction of the patient's lungs. And the cartoon is the fusion of the CT images and the patient's electromagnetic reconstruction. So, we're getting to the nodule with GPS type system, except if you can imagine me driving in a car, let's say, I'm blindfolded. So, I'm just kind of following with a prompts of okay go 90 degrees or maybe 180, advance forward, you know, follow this cartoon depiction. And not only that I was holding the scope while manipulating this working channel. So, my other hand, which is the left hand, holding the scope is not very stable, right? And then, as I pass tools through the working channel tool, such as needles or biopsy forceps, I can easily move my other hand and potentially lose the spot where I was.

So, we were using that technology before investing into the, in the Monarch Platform and we would have good yield, but it would have to be in lesions that are much bigger. We would need to see that there's a nice pathway on the CAT scan to tell us that there is a road leading up to the nodule or the apple, if you will. And if it takes a while to navigate to that area, now we're subjecting our patients to longer time under general anesthesia. And because most of our patients may have lung disease, they may not tolerate longer time under anesthesia. So, there's a point where you have diminishing returns. So, we have amped up our game with a Monarch Robotic Platform because now the working channel, so, imagine the same system, but the working channel has a camera at the end of it. So, instead of driving blindfold, I'm actually seeing my working channel go right and left and twist around all the smaller branches and twigs of the lungs. And then of course, there can be some visualization problems once you get into the smaller airways, but for the most part in the let's see, 40 plus that we've done, from what I can gather, we really have not lost visualization until after we've done biopsies. So, not only do I have visualization getting to the end, getting to that target or nodule or apple, if you will, what is even better is that the robot is holding the bronchoscope steady for me. And all I'm doing is moving the working channel, navigating the working channel, using an X-Box type controller to kind of weave my way in and out of the bronchial tubes.

So, not only do we have better visualization or visualization, then there's also stability and much more precision and confidence in getting to that nodule or to that target, much more than where we were before.

Host: When we talk about the advantages, what are the real advantages to patients from this Monarch robotic platform as you say?

Dr. Brawner: So, it's an outpatient procedure, which means that they go home the same day, as long as there are no problems or complications afterwards, which are not common. But we of course watch out for it as with any types of biopsies, if you will. So, it's the same day procedure. They're under general anesthesia. I usually tell my patients, it's a duration of about two hours sometimes longer just because what we do is we compliment the navigational bronchoscopy with another type of bronchoscopy, which is called the endobronchial ultrasound. So, it's a completely different bronchoscope, but it has an ultrasound at the end of it so that we can sample lymph nodes inside their chest so that we can provide more information as far as if this spot or nodule or mass was a cancer, has it involved the lymph nodes inside the chest.

So, we are providing some staging information to the patient without having to undergo surgery, thoracic surgery as much as possible to the limitations of what our technology can do. We've also found that to me having the system, it has expanded kind of my toolbox, if you will of looking at a problem. So, a problem can be an abnormality in someone's CAT scan or chest images and say how can I get there safely and most accurately. Whereas before without the system, I could again, blindly just take biopsies, but not necessarily know where I am, because I don't have that 3D relationship, if you will.

And in the past, for people who have let's say severe lung disease, where they are deemed too sick or to advanced to undergo surgical procedures, to find out what that nodule or mass is you know, before, if they have significant emphysema and they were deemed to have severe disease, they may either have the lesion, wait a couple of months for it to potentially grow more before having the diagnosis so that the means of diagnosis can be done in a more safer way, I guess.

Host: It just to me sounds like some really innovative stuff. And I'm wondering, I guess that is this common at Genesis to perform such innovative procedures?

Dr. Brawner: I've been here 11 years. I trained at a University Hospital in Columbus, Ohio State University. And I would say that we are very lucky here because whenever one of us suggests a piece of technology because from where we were before, they have experience with it and they've had good experiences with it, or if a new technology comes on board, Genesis is very open to really examining what it can bring to the table and what it can offer to the community and to our practice. I alluded to the other advanced bronchoscopy, which is endobronchial ultrasound and in a community hospital of our size, not a lot of hospitals our size have the availability of these advanced bronchoscopies.

So, we're really offering something that's not even actually available to the larger hospitals around us. We are the second to purchase the Monarch Robotic Assisted Bronchoscopy in Ohio. And so we're very lucky to be able to offer this technology to our community for sure.

Host: Yeah. And I think it sounds to me like the patients are really lucky as well. So, as you say, the community and just in Southeastern Ohio in general, right?

Dr. Brawner: Right. Absolutely. We launched our program the first week of October and one of our cases was a patient I think she was in her sixties and incidentally found a nodule that was measuring 1.4 centimeters, because she presented to her local ER for back pain. And this nodule was sitting right next to the heart. Now the other means of biopsy is for an interventional radiologist to go from the outside. So, using a CAT scan, to visualize the needle going from the outside of the chest. So, a needle is going in between the ribs into this area. That's another form of biopsy that, that can be done for these nodules now, compared to us, we're going from the inside.

So, I talked to our interventional radiology colleagues and they of course also felt that this was a high-risk nodule because of its proximity to the heart. So, she was one of our first cases during our launch week and with the system, we navigated to that area less than five minutes. And we got a diagnosis with our first pass of the needle with no complications. It was the case that for me solidified how great of a technology we have here at Genesis and how it's really improved our game in terms so navigational bronchoscopy.

Host: Anything else you want to tell people as we wrap up? Any other takeaways about the Monarch platform?

Dr. Brawner: Again, personally, it has increased my toolkit of how I see lung disease, because I've even used the platform for doing biopsies of lesions that my suspicion for lung cancer is low, but some other diseases like either infection or inflammatory diseases, because instead of biopsying it blindly, why not get there, you know, accurately. I really don't look at it as just one purpose, meaning just lung cancer, but it's any lung abnormalities. How do we get there more accurately, more precisely and less invasively? And then at the same time, we have the benefit of sampling the lymph nodes with the other bronchoscope that I was talking about, and also get more samples let's say to send for cultures, if an infection is suspected or a smoldering infection is suspected, which can be common in some patients.

I can see it expanding in terms of possibilities. So, there can be therapeutics down the line. So, let's say if we diagnose lung cancer, and now we have the ability to, to deposit, let's say focal radiation beads, or chemotherapeutic agents right there, because they're not surgical candidates or, you know, things like that. That's one application. I think it has brought the practice of bronchoscopy in a different level I can see it expand and it will have to take those genius engineers to help us figure that out.

Host: And they probably will and let's hope they do. And I think, you know, for all of us patients and that includes doctors, we want our doctors and the medical system, medical teams to have all the tools as you say, every tool, you can have to treat patients. We want you to have them and you certainly have them at Genesis.

So, know, the folks in the community, in Southeastern Ohio in general, this Monarch Robotic Assisted Bronchoscopy is just amazing. And I've really enjoyed this conversation. So, Doctor, thanks so much for your time today and you stay well.

Dr. Brawner: Thank you so much. Thanks for having me. You too. Take care.

Host: Call (740) 586-6888 to learn more about the Monarch procedure. And thanks for listening to Sounds of Good Health With Genesis brought to you by Genesis Healthcare System. If you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. I'm Scott Webb. Stay well.