Melanie Cole, MS (Host): Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole and today we're highlighting the Lung Cancer Screening Program at Henry Mayo Newhall Hospital with Dr. May Lin Tao. She's the Clinical Associate Professor of Radiation Oncology at the Keck School of Medicine and Medical Director of the Keck Medicine of USC Henry Mayo Newhall Hospital Cancer Program.

Dr. Tao, thank you so much for joining us again. You're a great guest. So I'd like you to speak to the listeners and tell us what you're seeing as we get into this important topic; as far as incidence, awareness of lung cancer, are more people getting the message. Are the awareness campaigns getting the job done? Do you see people quitting smoking?

May Lin Tao, MD, MS: So there are a couple of things to unpack here. There's the activity that leads us to a situation in which we're higher risk for lung cancer, which is of course smoking. That is by far the dominant risk for why one would develop lung cancer. But there's also the knowledge about if we either have a history of smoking that was significant or unfortunately are continuing to smoke and smoking cessation hasn't quite hit home, what would we be doing to actually screen to make sure that given our increased risk for lung cancer, we pick it up as early as possible and have the highest chance of being cured. In terms of the predominance of smoking, certainly in the United States, I think there is more awareness

about the risks associated with cigarette smoking and lung cancer and all the other morbidities or comorbidities that can be associated with it, meaning diseases that can be a consequence of smoking. Things like vaping, which is of course, most of us are aware is happening a lot in the adolescent and young adult population.

There probably is a significant risk for not only other diseases of the lung, but also lung cancer. It's just not as well understood or quantified what that risk is, because it's a relatively new phenomenon. Smoking cessation has been discussed for many, many, many years. Having said all of that, there's still a significant population in the United States of people who smoked back in the 70s and the 80s when it was much more socially acceptable and common even for professionals to be doing it in the home or in restaurants, in public places. So that history of having had that much smoking puts you at a lot of increased risk. And then there's, still a significant population that started when they were very young and it's just really hard to quit.

It is one of the most highly addictive things that we do that is generally been considered socially acceptable or appropriate, certainly in the past, that is just really, really hard to shake. So, what we're trying to focus on is not only the education about don't start, number one, although that word is kind of out, and make yourself knowledgeable about what the cessation, but having gone through those steps, and you can't erase a history, even if you have quit, there is a history.

What should you be doing in terms of screening for a disease as deadly as lung cancer? So that's kind of what the focus of our lung cancer screening and lung nodule evaluation program is at Henry Mayo.

Host: Thank you for that. So tell us about lung cancer screening, this low dose CT screening. Tell us what it is, a little bit about it because you know, people hear low dose, they're not sure what kind of radiation. Tell us a little bit about this screening.

May Lin Tao, MD, MS: Technology in imaging is such that we can deliver really very low doses of radiation to the lung. It's done without IV contrast. So one, there's no placement of an IV, there's no injection of a contrast, which is another exposure. And it's been shown in large populations of national studies in this country and in Europe, that if you screen a risk population, so a population that has a smoking history, and the current guidelines are 20 pack year history of smoking. So on average, one pack a day for a cumulative exposure of 20 years, and it could be broken up in intervals. And within the last 15 years, because there is a little drop off in the risk if you haven't been diagnosed with lung cancer, the further away you get from the time that you quit, and in an age population which you're still young enough and healthy enough that it makes a difference to actually screen. So of course, if you have a significant smoking history and you're 95, the truth is your life expectancy is relatively short.

So it probably doesn't make sense to undergo these screening modalities. So, in that population what we know is that you will not only find things much earlier, so literally a dot as opposed to a huge mass that's causing you to be short of breath or bleeding or wasting away from just like general decline because of this cancer in your body to just a dot and having a substantially higher chance of cure.

So, we're talking about 80 to 90 percent chance of cure versus 10 to 20 percent chance of cure, and typically with far less treatment than what you would need if you were detected in a more advanced state. So that's kind of the thrust behind why it's really important to undergo these low dose scans on an annual basis because the risk continues to be there, even if you had one year in which we didn't see anything, it doesn't mean that the body can't develop a lung cancer that's now visible on a scan a year or the next year or the next year afterwards, similar to the way we think about breast cancer screening.

Host: Well, I certainly agree, and that's just what I was just thinking when you said that. I mean, we get our mammograms, we get our pap smears. There are things that we do, a colonoscopy, they're screening, and there's a reason that these screenings are so effective. So tell us about the screening recommendations.

You mentioned if you were a past smoker, even way back when, but I know that there are very specific criteria. for which these screenings will be covered by insurance. So tell us those criteria from the U.S. Preventative Services Task Force.

May Lin Tao, MD, MS: That's the most commonly used criteria that you just mentioned, the U.S. Preventive Task Force, and basically it's about, well, you have to be in an age group like I mentioned before in which it makes sense to detect, something that could threaten your life. So ages 50 to 77, if you are being insured under Medicare. Some of the commercial payers will actually extend that age to 80.

So again, this is something that is fully covered as an annual thing in that age group who also are either currently smoking, and have smoked what we call a 20 pack a year, so on average a pack a day for a cumulative period of 20 years. And if you're a prior smoker, meaning you quit, that it's within 15 years of the time that you quit because like I said it does peter out over time the further away it is that you had that exposure to the tobacco.

And that again, even if you're within that age range that you're just generally healthy enough to make it honestly worth your time and worth our society's time to be able to detect something this early and you're not too sick from something else that has to be prioritized.

Host: Does it then become an annual exam?

May Lin Tao, MD, MS: Yes, it's an annual exam, as long as you continue to meet those criteria that we just mentioned. And that's a thing that I think a lot of people kind of forget about, it's kind of like , a whew, there was nothing there and therefore I don't need to come back or, and I hear this even in women who undergo mammogram screening because we want to all be relieved.

Like it doesn't necessarily mean that doing the scan will actually prevent the lung cancer or in the situation of mammograms, the breast cancer. I often hear from women let's say who are diagnosed with an early stage breast cancer but I did my mammograms every year. I don't understand why I was diagnosed and the point is that is why you did them every year so we could actually diagnose it.

It's not a preventive thing so it's not sort of one and done after you get one clear scan and you can kind of sigh a long standing sigh of relief.

Host: Wouldn't that be nice if we could just get that one screening and then be done and go, okay, I'm never going to get lung cancer. I'm never going to get breast cancer. That would be awesome. Now, Dr. Tao, tell us about the lung cancer screening program at Henry Mayo Newhall Hospital, a little bit about what's involved in setting up the screening.

And when someone arrives there, what's that like? Is this an easy screening and a quick thing to do. You're in and out pretty quickly. Tell us about that.

May Lin Tao, MD, MS: So, I actually want to just mention, even before someone comes in, some of the challenges, that I think we as a society are meeting. There's probably a stigma behind lung cancer, and that probably originates from cigarette smoking, because it's something that we actively engage in, and like I said, it's a very addictive thing too, and so there may be a little shame sometimes, and because we all supposedly know that we shouldn't be smoking, that it puts us at risk for lung cancer and other lung diseases, and so just getting someone through the door, or even scheduled, or even on top of mind of a primary care provider who is the one who should be leading a patient to lung cancer screening, when they meet the criteria; is probably the biggest logistical and psychological and societal challenge. Um, just a quick fact, which is pretty sad when we mention it, but I think kind of underlines or underscores this point that I'm making. Something about 5 percent of folks who are actually eligible and therefore should be getting lung cancer screening with low dose CT actually get the screening study in the United States of America. And then when you look at in which states is it a little bit better or the worse, I hate to say this because we Californians think that, we are the healthiest in the country. California is at the very bottom. We are number 50 in terms of the percentage of patients who actually undergo a scan when they're eligible for a scan.

So it's in the low single digits. So there's that. There's a whole education and honestly a whole like dissolving of a stigma that needs to happen about even getting people to undergo lung cancer screening. They feel like it's almost punitive, like, oh, you're a smoker, therefore you should undergo it.

Or they're going to make me try to quit smoking, which of course we want you to, but we also want to pick up something early if, you can't quit smoking. Anyway, it's a pretty easy ish process to get in. You do need a order from your primary care doctor, unlike for mammograms, you can just walk in, you do not actually need an order for mammograms.

 Again, this is what I'm saying about the societal acceptance of this and the understanding is it's so ingrained now and insurance companies understand this so well now that this is part of good general health preventive care, and early detection for women. You don't even need an order. You just walk in for a mammogram.

That's not the case yet for lung cancer screening. However, in a good program like we have at Henry Mayo, we have a formalized structure, we have a medical director, if somebody wants to get a scan and they come in, let's say, and they don't have a primary care that's referred them or they don't even have a primary care, our medical director for the program, who's a pulmonologist, so, physician trained in taking care of lung disease, will take on the responsibility of putting in the order and following up on it, because the key, which is why an order is important too, is that somebody needs to receive that report and act responsibly, meaning that if it's just a reminder that they need to come in for their next year to be screened again because this one was normal or that there's actually a nodule that needs to be worked up.

Somebody needs to be responsible for that. So in our program we consider this a, what we call a centralized lung cancer screening program. All of that happens centrally in our program and so people not able to bridge that barrier of getting an order but also more importantly making sure that they get a follow up on what needs to happen.

Host: So important. And before we wrap this up, speak about those results. So we've gotten the people in, we've gotten the low dose CT scan for lung cancer screening. If it finds a nodule or something else, what happens then? Who reads it? How fast does somebody get those results?

May Lin Tao, MD, MS: So, our program is multidisciplinary in the sense that not only do we have a program director, the medical director, not only do we have lead radiologists who are expert in reading these, who know how to report on them, and they use a standardized rubric and they make standardized recommendations, i. e. like, okay, come back next year for your screening, low dose lung cancer screening CT scan. But when there is a nodule picked up, their criteria for how that nodule looks, what needs to be done, maybe you just need a short interval scan, so like six months as opposed to annual if it's a very small lesion, if it's not very solid appearing because, you know, we get junk in our lungs that aren't necessarily lung cancer, but start to look like a nodule. And so we need to not necessarily jump the gun, but we need to survey maybe a little bit closer so that if it does turn out to be something that's real, we're on it as early as possible. And so that's the key part of our program is we have what I call active navigation.

So somebody is following up on those reports. We have a nurse who's one of her dedicated roles and then it goes back to the primary care doctor if there's a primary care doctor involved and they literally navigate through the doctor's office and then directly with the patient what the next step needs to be.

So if it's as simple as come back for your next, they get a letter, and then they get a reminder letter when that year rolls around and it hasn't been yet scheduled. But if it's a nodule, they'll get a follow up either through our nurse navigator or through the primary care or through our medical director about what the next step needs to be, maybe potentially even a biopsy.

And that is all coordinated so that, it actually happens. What the biopsy results are, that gets coordinated and fed back to both the responsible physician who put in the order, as well as the patient, and what needs to be done from there forward. If it turns out to be a diagnosis, who they need to see for treatment, again, that's part of the navigation process.

So we're really kind of trying to hold people's hands through this because it's scary, number one. And number two, they don't necessarily know what to do and primary care doctors can be very busy. And so we see that as part and partial to the program.

Host: So important. Thank you so much, Dr. Tao, for joining us again today and sharing your incredible expertise. We're listening to you and you just explain everything so very well. Thank you again. And to learn more about lung cancer and other cancer screening programs at Henry Mayo Newhall Hospital, please visit henrymayo.com/screening. You can also visit the free health information library at library.henrymayo.com. That concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. Please always remember to subscribe, rate, and review It's Your Health Radio on Apple Podcasts, Spotify, iHeart, and Pandora.

I'm Melanie Cole. Until next time, thanks so much for joining us today.