Melanie Cole, MS (Host): Welcome to AHN MedTalks, 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 today, we're highlighting From Referral to Resection: A Practical Framework for Evaluating and Treating Thoracic Surgery Patients. Joining me is Dr. Mathew Van Deusen. He's a thoracic surgeon with AHN Cardiovascular Institute.

Dr. Van Deusen, thank you so much for joining us today. Before we get into referral to resection, what's the scope of the issues we're discussing here today? What are some of the most common reasons for referral to thoracic surgery?

Mathew Van Deusen, MD: Well, thank you for having me on. That's a great question to start with. We see a lot of patients with lung cancer. Lung cancer is a very common disease process in the United States. It's actually a leading cause of death in the United States. We see the majority of our patients come from either screening in the public entity. We see patients from screening processes. We see people that are referred with nodules that are found incidentally. And we see patients that are presenting with symptoms from their underlying lung disease.

Melanie Cole, MS: Thank you for that. So when we think of a referral for a potential thoracic surgery patient, give us a little bit of your step-by-step framework for evaluation. What information do you get? What information do you wish was consistently included in the referral from wherever it came from?

Mathew Van Deusen, MD: i think, again, going back to how people present, it's important to understand that some of these people are pre-screened in the community, and that's a great way that they are brought to our attention. These are patients that have a heavy smoking history, are of a certain age range, and have either continued to smoke or quit smoking fairly recently. These people are screened with a low-dose CT scan. Those people are benefited by the low-dose CT scan screening in the sense that it can find these lesions earlier and then lead to the referral.

That referral is usually through a screening program or a multidisciplinary review of patients that present with abnormal CT scans. And then, these patients are discussed in that format between the lung surgeons, the medical cancer doctors, radiation cancer doctors, pulmonary doctors, and a plan is made. And so once that plan for referral has been made, patients are then sent to attention of either the thoracic surgeon or the pulmonologist.

We're happy to see patients at an early stage. I think that that can be very beneficial. And I think that some physicians in the community are a little bit hesitant to send people directly, but I don't think that that's really any kind of a problem for us. We're very comfortable managing these patients that have been identified from sort of start to finish. And I think that's an important point to make.

Melanie Cole, MS: I agree with you. I think it is an important point to make. So along those lines, what are some of the most common delays or pitfalls you see in that pre-op workup? And how can referring physicians, community physicians streamline this pathway as we think of imaging and biopsies, the path that patients go through?

Mathew Van Deusen, MD: Sure. I think that our system is designed to get these people in a timely fashion. So, the referring physicians are able to reach out to the surgeons in the group. They're able to reach out to the pulmonologists in the group and make those referrals. Once that referral's been made, our nursing staff and our nurse navigator staff are heavily involved in the process of tracking these people down, coordinating their upcoming visits, and getting them into the system in a quick fashion.

Melanie Cole, MS: When we think about the screening that you touched on before and the low-dose CT scan that so many patients become eligible for one reason or another, when we think, Dr. Van Deusen, about identifying the right patients, acting on those findings, what does high-quality followup look like once the screen is positive? And again, this kind of goes back to the pathway that patients are going to follow to see you. What does that followup look like for the patient?

Mathew Van Deusen, MD: Screening CT scan is designed to capture patients that are at high risk. And so, those are patients in the age range of 50 to 80. Those are patients that have a heavy smoking history, typically 20-pack year history, meaning one pack per day for a period of twenty years. And as I said before, had quit in the last fifteen years.

Once those patients are screened and that abnormal CT scan is identified by the radiology report, it's brought to the attention of the multidisciplinary committee for review. Depending on the findings, the recommendations from the committee can be varied. It may be simple, straightforward repeat imaging followup in a short interval time period, or it may be recommending that an initial followup with either pulmonary or thoracic surgery for further investigation. So, the patients are identified in that fashion and then forwarded on. So, the nurse navigator program, the lung cancer screening program is heavily involved in the followup of these patients, and making sure that they are moving on to their next phase of their care.

So when a patient is referred to our attention, it can be a variable presentation. They may or may not have a diagnosis. When we meet with the patient from the beginning, I think it's important that that patient has a good understanding of why they're here, how they arrived, and what these pertinent CT scan findings are.

Once that's been discussed with the patient, then it becomes a discussion of how do we move forward with, number one, obtaining a diagnosis; number two, going through the staging process. Staging is an important tool for us. There is a number of radiographic studies that can be utilized. There are a number of interventional procedures that can be done to determine what the diagnosis and stage of the patient is. And this is important to the patient because staging is really what determines the overall treatment paradigm for each individual patient.

The second part of the conversation that I typically have with the patients involves a general assessment of their overall health and specifically their cardiopulmonary health, so that decisions regarding surgical intervention can be made in making sure that those patients are treated in the safest and most likely successful way regarding their particular presentation.

Melanie Cole, MS: We'll get into some of the treatment specifics. But before we do, Dr. Van Deusen, for complex patients and non-complex patients, speak a little bit about an effective multidisciplinary model. What does that look like in practice? Who needs to be at the table, and how do you handle uncertainty, maybe even disagreements in care while keeping care moving? Who's in charge of the patient's care? Speak about the importance of that multidisciplinary approach.

Mathew Van Deusen, MD: Well, certainly for complex patients, I think that that multidisciplinary care committee is critical. That can be accomplished in multiple ways in modern era. Number one, we do have these regular meetings on a weekly basis that allow the larger group to review lung cancer screening studies as well as these complex patients. Typically, it involves the medical-oncologists, the radiation-oncologists, a radiologist, pulmonologist, interventional pulmonologists, pathologists, and thoracic surgeons, as well as nurse navigators to, again, control the flow of the patient moving forward. Complex patients, I think, are routinely discussed in this fashion.

In addition to that, we're all very comfortable interacting with one another in regard to a specific patient. So even patients that are maybe presented at a multidisciplinary committee, further discussion is often taking place between the treating medical-oncologist, the treating radiation-oncologist, and the thoracic surgeon so that multidisciplinary approach is utilized throughout that patient's care. We try to follow the NCCN guidelines as much as possible in regard to how a patient should be evaluated and managed in the current era.

Melanie Cole, MS: Well, then now let's talk about staging and treatment strategy, Dr. Van Deusen, how does that drive your overall strategy? How do you decide? Because you have more tools in your armamentarium today when we think of minimally invasive and robotic approaches. When you're counseling and working with patients and working with the referring physicians, tell us a little bit about that process.

Mathew Van Deusen, MD: Well, so I think the idea is that we want to provide more or less one-stop shopping so that patients can get all of their testing, or at least all of their testing can be coordinated by members of this group. And so, in regard to staging, there's the radiologic aspect of that. That includes CT scans and PET scans and potentially site-specific imaging like an MRI of the brain.

Invasive modalities that can be performed by the pulmonologists, the interventional pulmonologists, and the thoracic surgeons typically involve diagnostic bronchoscopy type of procedures, as well as endobronchial ultrasound type of procedures to assess lymph nodes around the windpipe and around the hilum, the root of the lung. And those are the main modalities that we're using to, in a minimally invasive fashion, assess for local spread of disease from the lung lesion into the hilar and mediastinal lymph nodes

Melanie Cole, MS: Dr. Van Deusen, this is such an interesting topic, and there's so many points that we could cover. But as we think of the field of thoracic surgery, where do you see it going in the next five to 10 years? Where do you see AI enter into the field of staging and planning surgery? What's exciting in your field right now?

Mathew Van Deusen, MD: I think the generalized move to minimally invasive techniques has been an ongoing strategy in thoracic surgery for some time. And I think that that can only continue. You mentioned artificial intelligence. Certainly, there are blossoming programs from a radiologic standpoint that can give a calculation of the expected risk of a nodule being of a malignant nature. And those programs can be incorporated into the regular flow of the screening program and of a multidisciplinary committee, allowing additional information to be gained and recommendations to be made based on the score of the particular lesion in question.

I think, in addition to that, obviously the revolution in systemic therapy that has come about over the last five to ten years in regard to targeted therapies and the role of immunotherapy in treating patients with larger tumors, later-stage disease tumors, meaning either larger tumors with lymph nodes around the lung or lymph nodes around the mediastinum. Those interventions, those innovations in medical therapy are a huge part of the future care for lung cancer patients.

Melanie Cole, MS: This is a great topic. As we wrap up, do you have any final thoughts or key takeaways for referring physicians when we think of that practical framework for evaluating and treating thoracic surgery patients?

Mathew Van Deusen, MD: I would like to have the referring physicians in the community to have an understanding that we're an accessible group. We want to be involved early in the patient care paradigm. We may be recommending further referrals to the pulmonologist or interventional pulmonologist for assistance with diagnosis and staging.

We sometimes are doing that on our own. We want to get the patients in a timely fashion. We want to make sure that there is an understanding that we are comfortable and capable of going through the diagnosis, the staging aspect, the preoperative evaluation process. And then, obviously, moving forward with appropriate types of treatment, whether that be minimally invasive surgical techniques or combined medical therapy, radiation therapy in certain situations, and so on.

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