Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm Melanie Cole, and there are so many advancements in lung and pleural cancer care today, including clinical trials and high-risk clinics. And we're here to highlight the AHN Lung and Pleural Cancer Center of Excellence. Joining me is Dr. Benny Weksler. He's a thoracic and esophageal surgeon with the Allegheny Health Network. Dr. Weksler, thank you so much for joining us. I'd like to start by asking you, how has the landscape of lung and pleural cancer changed over the course of your career? Have you seen the incidence of smoking-related cancers change, esophageal cancers change? Tell us a little bit about that.

Dr. Benny Weksler: So, first of all, thank you for having me. I appreciate the opportunity to talk on the podcast. Second pretty complex question, over my career, there was a lot of changes. I can tell you that, even over the last five years, pretty much everything we do about lung cancer has changed.

When I started practicing, for example, all of our surgery was done open, meaning a big cut in the side, retractors spreading the ribs, hands inside of the chest. And today, the vast majority, over 98% of what we do is minimally invasive, meaning small incisions between the ribs and things like that. It used to be very common that our patients would stay in the hospital for five days, seven days was not unusual. Now, our length of stay is between two and three days for lung cancer patients. So, new change.

The other thing is that, after open surgery, many patients would be out of work for six to eight weeks. And now, it's very common that patients will go back to work in between 10 days and two weeks depending on the work they do. So, this part have changed completely since I started practicing.

The other thing that have changed is our approach to some of the locally advanced lung cancer and the use of neoadjuvant therapy, meaning treatment before surgery. With the advent of immunotherapy around 2017, treatment for stage III cancer patients, lung cancer patient completely changed almost in a revolutionary fashion. Those patients did not use to survive very much, and now we can get really great survival with immunotherapy. And after that, trials for the use of immunotherapy before and after surgery came, also showing a very significant impact on survival of patients.

Finally, we started doing a more personalized medicine, meaning we are looking more at specific characteristics of tumors for each patient. Sometimes finding gene mutations that we can target. The most common of those is EGFR mutation that, after surgery, depending on the patient's stage, instead of receiving chemotherapy or even immunotherapy, they can take a pill by mouth for three years, which is highly effective in preventing the cancer from coming back.

Another change that we have had, and again this is in the last two years, is the proof that we don't need to remove a lot of lung for small lung cancer tumors, and we can do surgeries that are smaller. There are three lobes on the right lung and two on the left lung. And knowledge used to be that if you have lung cancer in one of those lobes, you have to remove the whole lobe. Well, the right lower lobe, for example, is half of your right lung. And on the left side, either lobe is half of your lung. So, patients were losing a lot of lung. And now, today, a great part of patients that have smaller cancers, less than two centimeters, which is just under an inch, can have surgeries that will significantly spare lungs and allow for better quality of life to patients and also allow us to perform surgery in more borderline patients, perhaps patients that we could not do surgery a few years ago.

Melanie Cole, MS: What an exciting time in your field. And these advancements you've just described really are amazing. So, Dr. Weksler, what does it mean to be a Center of Excellence in Lung and Pleural Cancer care? It's not something every hospital or medical center can claim. Tell us a little bit about the primary mission or the overarching goal of this cancer center and the center of excellence.

Dr. Benny Weksler: The goal is always optimal patient care. And optimal patient care in our group can be going all in or going as far as the patient would like to go, but always keeping the patient as the center of everything we do. That I think would be the number one thing.

The number two thing is a multidisciplinary approach to our cancer patients. And what I mean by that is that the vast majority of new lung cancers, we discuss them in our group. That includes pulmonologists, medical-oncologists, radiation-oncologist, and surgeons, and last but not the least, our pathologist. And we review all the information. And then together, we come up with a best strategy for treatment. It used to be that if you go to a surgeon, you would get surgery. If you go to a medical-oncologist, you'll get chemotherapy, and if you go to a radiation-oncologist, you'll get radiation therapy. This is not something that we do here. We try to discuss each patient and come to a consensus on what is the best treatment, what is the treatment that will provide the most comfort, what is the treatment that is most likely to provide a longer and more productive life for each one of our cancer patients?

Melanie Cole, MS: Dr. Weksler, where have advancements in screening such as low-dose CT scan, where have you seen these having the best outcomes for your patients? Tell us a little bit about how that fits into the picture and how that's really helped to advance the field, but also based on those, how you help with things like smoking cessation in your surgical patients or just in high-risk patients.

Dr. Benny Weksler: So, two-part question. So, let's start with the screening. So, this is an incredibly important part of what we do today, and many patients now come to me from our screening program. Our screening program is very large. I think it's the largest one in Western Pennsylvania, and it has one more thing that's important. All of our findings that suggest cancer are discussed in our multidisciplinary conference. So, every time a radiologist believes that there is the possibility of a suspicious nodule on the chest CT, the screening chest CT. This patient is discussed with multiple professionals to make sure that there are no unnecessary surgeries, that we don't overtreat patients, and this is very important.

The factor that perhaps is a problem in a way in screening of lung cancer or some of the problems is, one, I think there are still physicians that don't refer to lung cancer screening, having a nihilistic outlook of the disease. And to those, I say that if you send patients to have mammograms and screening colonoscopies, the reduction in mortality from lung cancer screening is exactly the same, 20% of reduction in mortality for mammograms or screening colonoscopy. So, this is effective, and I think there should be no physician reluctant in sending his or her patients to have screening.

The second thing is really patient fear of the screening. Many of these patients carry with them the stigma of smoking. And society has kind of looked at lung cancer as a lifestyle option disease, forgetting that smoking is a vice and patients are addicted to the nicotine, and many can't stop taking it. And patients are afraid because they know that the risk of lung cancer is higher in smokers and the screening may review that they have a disease that many see as not curable. Again, to those patients, I say it is curable if we're able to detect it early in our screening. So, I would strongly encourage, one, physicians to order the test and, two, patients to take it for the sake of early detection and decreased mortality.

All of our patients that still smoke, and that's still about 30% of our lung cancer patients or patients that are going to be submitted to lung resection are still smoking. And there is a big controversy, believe it or not, if it's worth making an effort to insist that they stop smoking before surgery, since many investigators feel that it takes eight to 12 weeks before the effect of smoking cessation are noted during surgery. We don't feel it like that, and we make a big, big push for our patients to stop smoking before surgery. I think it's the best opportunity for them to make a significant change in their lives that will affect them for years and years to come. So, we aggressively try to make them stop smoking. We aggressively try to prescribe medications and patches and try to do all the best techniques to see if our surgical patients stop smoking. And definitely in high-risk patients, I think this is more rewarding, because it may allow us to do surgery in patients that otherwise could not be submitted to surgery.

Melanie Cole, MS: Well, thank you for that. So, Dr. Weksler, tell us a little bit about how robotic surgery has really come into play. You mentioned at the beginning as you were talking about the changes in your career that you've seen. How has robotics surgery really entered pretty strongly? And speak about how that is as far as technique learning experience of the physician and patient outcomes.

Dr. Benny Weksler: So, robotic surgery for lung has been around since about 2005 perhaps. I started doing it in 2008. So, I'm a relatively early adopter. And there is no question, and many studies now show that robotic surgery is highly beneficial for patients, both in outcomes, meaning less complications, early return to work, less pain, but also in some other areas that perhaps we don't think too much as patients, but we clinicians think, for example, robotic surgery allows us to remove more lymph nodes, which means that we can detect more patient that may require more treatment after surgery. It also allows us to do more complicated surgeries that until recently the only way to do them would be with open surgery. So, for example, now we can do highly complex surgeries, preserving lung, preserving airway, doing robotic surgery instead of opening. So, I feel that robotic surgery really revolutionized the field.

The other thing is that something rarely talked about is surgeon durability, right? Meaning how long does a career of a surgeon spans? Today, we know that we're going to be facing a shortage in surgeons, in particular cardiothoracic surgeons. And the robot is so much easier on the body than traditional surgery. And I feel that surgeons will be able to prolong their productive career and perhaps that will mitigate some of the shortage issues that I think are looming on the horizon.

Melanie Cole, MS: This is such a fascinating conversation, Dr. Weksler. And as we get ready to wrap up, I'd like you to speak about the AHN Lung and Pleural Cancer Center of Excellence. Tell us a little bit about patient navigators, how these help the patients get through because this is very scary and these are scary cancers for patients. It can be a dizzying world, especially since you mentioned the multidisciplinary team. There's so many doctors involved. Tell us a little bit about the center itself, care close to home, multiple locations so that radiation, chemo, adjuvant therapies are a little bit easier to come by. Speak about all of that in your team.

Dr. Benny Weksler: Yeah, that's an excellent question, and thank you for bringing this up. So, we have cancer-specific navigation, meaning we have nurses that help patients navigating this disease. So often, they'll come to my office, and I'll tell them the diagnosis and it's extremely scary. And now, sometimes they need to go see a radiation-oncologist and they need to see a medical-oncologist. And perhaps they need to get a stress test and they need to get lung function tests and we need to schedule them for surgery. So, all of a sudden we have a patient that is really worried, is really concerned, and perhaps in some ways disoriented that we give him six, seven things to do after he leaves our office, and that's going to be amazingly challenging.

So, in those patients, our nurses give them their cell phone numbers and call them to schedule the test, to orient them where to go, to orient them when to go, and also to make sure that they keep those appointments. Often the person that receive the most communications from our patients is our nurse navigator, and they call her when they're worried about their scan, they call her when they want an earlier appointment to see us. So, the nurse navigator really is a huge facilitator in the whole process.

The other thing that, again, it's great with the nurse navigator, I don't need to look at the patient's address and try to figure out where they're going to have their scans, what is the easiest way for them to get their radiation or their chemotherapy or their biopsies. Our nurse navigator will figure it out/ and since we have multiple sites across Western Pennsylvania, the nurse navigator can get them into the area that's closest to their home so they can get most of their specialized care as close to home as possible. Occasionally, they do need to travel, of course, for surgery to see us in our centers. We operate in three areas in Western Pennsylvania. Then yes, those may not be as close to home, but everything else, including the test, the stress test, lung function tests, Cardiology appointments, Pulmonology appointment can be done closer to home. And our nurse navigators are the ones that figure this out and match patients with the best location, best doctor, so they can have an easy treatment time.

Melanie Cole, MS: You have any final thoughts that you'd like to leave other providers with and when do you feel it's important they refer?

Dr. Benny Weksler: So for primary care providers, I think we can be helpful as soon as a lung nodule is detected. We can help them provide the appropriate follow up. We can discuss with our group as to when and if a biopsy is needed. And I think that as soon as an abnormality is detected on the chest CT, we can be helpful. For pulmonologist, I think we are open to whatever their needs are, and some pulmonologists would prefer to refer to us just like primary care physicians when there is a nodule, you know, let us deal with them. Other pulmonologists would like to manage these patients a little longer and even do some biopsies themself and refer to us for treatment, which is also fine.

I think the important thing for us is we are going to try to deliver the best care possible for their patients in the cancer area, and we are going to make sure that patient is back to their care after we are done. So again, patients can maintain their relationship with their doctor close to home in a more comfortable setting.

Melanie Cole, MS: Thank you so much, Dr. Weksler, for joining us today and sharing your incredible expertise for other providers. To learn more or to refer your patient to Dr. Weksler, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole. Thanks so much for joining us today.