Melanie Cole, MS (Host): Welcome to GW Hospital HealthCast, an informative health podcast from The George Washington University Hospital. I'm Melanie Cole. And joining us today is Dr. Sora Ely. She's an Assistant Professor in the Division of Thoracic Surgery at The George Washington University School of Medicine and Health Sciences, and she's affiliated with The George Washington University Hospital. And she's here today to tell us about lung cancer screening and what's new in lung cancer.

Dr. Ely, thank you so much for joining us today. I'd like to start by asking what you're seeing as far as incidents and awareness of lung cancer. Are more people getting the message? Are more providers discussing smoking cessation with their patients? Speak about the prevalence as well as the benefits to patients from screening.

Dr. Sora Ely: Great. Thank you so much for having me to talk about this really important topic. There is a bit of a good news, bad news situation to answer your question. So, the good news is smoking rates have been down nationally for both men and women for several years now and continue to decline, which is fantastic. However, In terms of people getting the message and providers talking about screening with their patients, we have not gotten there.

Just to give a little bit of background, screening was recommended by the U.S. Preventative Services Task Force way back in 2013. And so, it's been more than a decade. And in that time, we have only achieved 4.5% screening rate nationally based on the American Lung Association's estimates last year. That's crazy Compare that to other cancers that we screen for and are well known, like breast cancer and colon cancer. The screening rates for those cancers nationally are over 76%. So, we are way behind the ball on lung cancer screening.

For incidence of lung cancer, it actually occurs less commonly. The three most common types of cancer in the U.S. for incidence are breast and prostate cancer, colon cancer, and lung cancer. However, the number of deaths in the United States caused by cancer is the reverse order. Lung cancer is the number one cancer killer in the United States and actually in the world. Every year, lung cancer kills more patients than breast cancer, prostate cancer, and colon cancer combined. We really have a long way to go on increasing our screening rates for this deadly cancer.

Melanie Cole, MS: Wow, those are some sobering statistics. Speak about low-dose CT lung cancer screening. What's that screening like? Because people hear the word screening, they're not so sure they want to go through with it. Tell us a little bit about it.

Dr. Sora Ely: So, one of the things that we like to focus on is that the foundation for the recommendation for lung cancer screening with the low-dose CT scan actually came out of a huge randomized trial here in the United States that showed a 20% reduction in lung cancer mortality for folks that got screened. And that was only with two screening cycles. And the study was so promising it was stopped early because it was considered unethical to leave patients in the control arm not getting these scans.

I honestly think today that the survival benefit would be even greater with the new therapies and techniques that we have. Nevertheless, even with the older data, that is the statistic. The actual screening is pretty quick and painless, especially considered to other types of screening. The low-dose CT scan, all that means is that we use techniques to use a very low radiation dose for the CT chest compared to a standard diagnostic CT chest. It takes less than a minute in most scanners. It's not an enclosed space, you just pass quickly through the donut. And there's no IVs, no special preparation, no fasting, no procedures involved. It's just one CAT scan one time a year.

Melanie Cole, MS: Wow, it really doesn't sound that difficult. Again, questions that patients might want to know is their radiation exposure associated with this screening. Are there any risks to it at all?

Dr. Sora Ely: Yes. So, all CAT scans do involve a little bit of radiation. But with the low-dose techniques we use for these low-dose CT scans, you get only about one-fifth the dose of a standard CT chest. So, that amount of radiation is about the same as an average American gets just by walking around living for six months in the world. So, it's very low, even when you consider that they have to keep getting the scan every year. Now, there is surely always a risk associated with increased and prolonged radiation exposure, but this is not the level that we're typically worried about.

Another thing that gets a lot of attention in terms of risk is risks associated with additional diagnostic procedures that may occur following a screening. So while procedural risk of a major complication can be about 10% for patients that were ultimately diagnosed and treated for a lung cancer. When you look at patients from that big screening trial I mentioned who didn't end up having lung cancer, the risk of a major complication was only 0.04%. And when you consider that against a 20% mortality reduction, I think all of us would strongly recommend that still the risk-benefit is there for screening.

Melanie Cole, MS: So, who gets screened? That's the big question. What are the current screening guidelines, Dr. Ely, as set out by the U.S. Preventative Services Task Force? Who should get screened? And you mentioned every year, but tell us that whole thing.

Dr. Sora Ely: Right now, the current guidelines, which were last updated in 2021, recommend that individuals between the ages of 50 and 80 who have smoked at least 20 pack-years, and people get sometimes hung up on pack-years. All a pack-year means is that you take the number of packs per day you were smoking and multiply that by the number of years you were smoking. People also get hung up because they're like, "Oh, well, I smoke different amounts over the time that I smoked." No big deal. Take your best guess average or take the amount that you were smoking for more of the time and multiply that by the total number of years you were smoking. So, an easy example is let's say a person was smoking a pack per day for 20 years. One pack times 20 years is 20 pack-years, and they qualify for screening. Another example is let's say you're someone who smoked only a half pack a day, but maybe you smoked for 40 years. So, one half times 40, you still hit the 20 pack-year mark.

And then, the last qualification is that you have to still be smoking or have quit less than 15 years ago. In other words, you can't have quit more than 15 years ago. The reason for that is that your lung cancer risk does gradually decline after you quit smoking, although it does not ever return to never-smoker rates. So, just to recap, very simple criteria between ages 50 to 80, have you smoked a total of 20 pack-years, and have you quit less than 15 years ago? That's it.

Melanie Cole, MS: I love the way that you cleared that up for us and the way you described that, because people do get confused about what those pack years mean, and I've heard that a lot of times. So, thank you so much for stating it so clearly. And if we start at age 50 with the annual CT lungs screening among eligible patients, do they ever discontinue screening? And is it every single year? Or is that based on risk factor and everything that made them eligible to get it in the first place?

Dr. Sora Ely: Well, everyone, no matter their risk factors, currently the recommendation is to get screened every year. And that's really important for achieving the risk reduction that we see with lung cancer screening. It's very important that patients don't just come for one scan and stop, or that they don't miss scans, that they should come back every year. Just like you would for a mammogram, just like you would for a stool test if you're not doing colonoscopies, just like a lot of other tests that we do every year with our doc, it's one time a year.

As far as when to stop, this is an area of some discussion. So, strictly by the guidelines, right now, we should be stopping either when they're more than 15 years after quitting. So, for instance, if someone quit when they were 50, they were eligible for screening at the start, but they would technically lose their eligibility at age 65 after it had been more than 15 years since they quit. The other factor is the upper age limit, or 80 years old. So by current guidelines, right now, USPSTF recommends stopping screening at 80 years old. However, for a lot of other cancers, honestly most other cancers, there's no hard stop age or date for screening in the recommendations. More so, recommendations for other cancers look at things like how healthy is the person in question. Just because the person is over 80 years old, if they're very healthy, robust, and someone who could easily withstand a curative therapy for their cancer, there's no reason that we shouldn't be screening them. So right now, by strict guidelines, the short answer is more than 15 years after quitting, if that occurs before the upper age limit, or at 80 years old, the USPSTF guidelines indicate that you should stop screening.

Melanie Cole, MS: So, we've talked about screening. Now, the dreaded results, Dr. Ely. What happens if something is found on the CT? And you and I have discussed lung nodules before. So, I'd like you to speak about whether those are what's found or if it is something worse, tell us a little bit about what those results show, who reads them. Tell us about that.

Dr. Sora Ely: This is one of the scariest parts for our patients who are considering entering screening or who are continuing with their screening. Everyone's always afraid of them finding something. Now, I think the fear is greatest on the first scan, because you haven't had a bunch of scans to prove that you were healthy and clean before that.

But the short answer is all of our scans are read by expert radiologists and a majority are actually read by a fellowship-trained chest radiologist who specializes in that area. All of our radiologists use something called the Lung-RADS system. This is basically a formalized way of reporting the findings and categorizes the findings into a risk stratification. So, the Lung-RADS score is really important in how we manage those findings. The first step is that we talk to the patient and let them know what was found and what to expect. The next step is that we evaluate those findings, either in our thoracic surgery clinic with me or my partner by a thoracic surgeon and/or we present that patient at our thoracic tumor board and get a multidisciplinary expert consensus opinion before we even see them in clinic.

Most of the patients eventually, if they have a concerning finding, will ultimately get presented in our thoracic tumor board so that we can get those multidisciplinary recommendations. Those are associated with better outcomes and better survival. The multidisciplinary board includes people like Pulmonology, Interventional Pulmonology, Chest Radiology, Medical Oncology, Radiation Oncology, and myself, Thoracic surgeons. After we either see the patient in clinic and/or present them at that board, we communicate again with the patient and let them know what the recommendation was. And if anything else is needed, we tell them how to get in touch, schedule them for any procedures that are needed, and make sure that they know what next steps are at every step of the way.

It's important to recognize that not all the findings on these screening scans will actually end up being cancer. In fact, even though we do importantly detect cancers with these screening scans, a majority of the findings will end up being benign. Oftentimes when we have new findings on these scans, all that's needed is a CT scan a little sooner than the next one-year CT scan. But regardless, we make a full assessment of each finding, talk to the patient, and make sure that we have the best management strategy for them.

Melanie Cole, MS: Dr. Ely, can someone refer themselves for a CT to screen for lung cancer? Does that have to come from their primary care?

Dr. Sora Ely: This is a great question and a little tricky. There's two parts really to the question you just asked, so do they have to be referred by their primary care? The answer to that part is no. Any provider, your nurse practitioner that you see in your general practice, your primary care physician, yes, your emergency care doctor, your orthopedist, many of those people may not be comfortable referring you to a lung cancer screening program, but any provider of any specialty can absolutely refer you to lung cancer screening.

Now in terms of self-referrals, this is a bit of a trickier area because we do need a provider to order that first low-dose CT scan by Medicare criteria. So in cases where patients really don't have a primary doc and they're interested in self-referring and can't get another provider to do that order, they can still call our program. And in those cases, we can bring them into clinic and do the full history and physical. Probably, I would see the patient. And we can place the order once we've done a full assessment. We can't do it if no provider has seen the patient is what it comes down to. So yes, you can sort of self-refer, but really any provider can refer you to screening.

Melanie Cole, MS: Well, thank you for clarifying that. And another important question patients want to know, is it covered by insurance?

Dr. Sora Ely: This is a very important question. The short answer is yes. So, not only is it covered by almost all major insurance carriers, as well as Medicare and D.C. Medicaid, and actually Medicaid in a majority of states. But most of those also cover it without any co-pay or cost-sharing required by the patient. So really, there's no money out-of-pocket for the majority of people.

Melanie Cole, MS: That's so important that you pointed that out and that's the way to get people in for this very important screening. As we wrap up, what can we do to help increase lung cancer screening and awareness? What do you want the listeners to take away from the important messages you've been giving us here today and why it's so important that they pay attention to these messages?

Dr. Sora Ely: I think one of the biggest things is to dispel some of the myths about lung cancer screening, which hopefully we've done today. And just to add on to, number one, who qualifies, 50 to 80, quit less than 15 years ago, and 20 pack-years. But also, just a reminder about how easy it is to be screened. It's only once a year, the scan takes less than a minute, there's no IVs, no nothing. And like we just talked about, this is fully covered by almost all insurances.

So, I think some of it is just remembering those key factors, but a huge part of this is getting the word out because, unlike mammograms or colonoscopies, people just don't think about these in their routine screenings. So, I would encourage anybody listening to this that, if you yourself may qualify, even if you're not sure, call and find out. We can work that out with you. Additionally, if you don't qualify yourself, but maybe you have a family member or a friend who is or was a smoker, please let them know about this. You can reach out to them and they can call our program directly, or you can share what you learned today about the eligibility criteria for screening.

And lastly, for providers, if there's anyone listening to this, you're already getting a smoking history for almost every patient that you see. So if you think they qualify, please just place the referral. And the last thing, I would say is for any patient calling in because they've been referred, or to find out more for our lung cancer screening program here at GW Hospital, when you call, it's not a long drawn out process. We can screen you for eligibility to make sure you qualify right then on the phone. And if you do, we can actually schedule you for your scan in most cases, right there during that same phone call instead of a drawn out process.

Melanie Cole, MS: Thank you so much, Dr. Ely, for joining us and sharing your incredible expertise for patients so that they really learn about this low-dose CT screening and the benefits that they can get from it. Thank you again. And to schedule an appointment, please call 1-855-GW-LUNGS, option 1, or 1 888 4GW Docs , or you can visit our website at GWHospital.com. Thank you so much for joining us on GW Hospital HealthCast, an informative health podcast from The George Washington University Hospital.

Physicians are independent practitioners who are not employees or agents of The George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any procedure. Speak with your physician about these risks to find out if this procedure is right for you.