Jaime Lewis (Host): According to the Lung Cancer Research Foundation, lung cancer is the leading cause of cancer death worldwide. In fact, 1 in 16 people will be diagnosed with lung cancer in their lifetime. But there is hope. New lung cancer diagnoses are steadily declining, as are mortality rates. Here for a panel discussion on lung cancer screening and treatment options are Dr. Sam Kosseifi, lead Pulmonologist at Holy Cross Health in Fort Lauderdale, and Thoracic Surgeon, Dr. Erik Sylvin, also at Holy Cross Health in Fort Lauderdale. They'll talk about common misconceptions about lung cancer, guidelines for screening, and advancements in technology for lung cancer treatment. This is Thrive with Holy Cross Health, a production of Holy Cross Health.

I'm Jaime Lewis. Dr.  Kosseifi and Dr.  Sylvin, thank you for being here.

Erik Sylvin, MD: Thanks for having me.

Sam Kosseifi, MD: Thank you, Jaime, for having us. It's a great pleasure to be part of the podcast.

Host: Well, let's start with you, Dr. Kosseifi. What are the symptoms of lung cancer that individuals and practitioners should be aware of for early detection?

Sam Kosseifi, MD: Well, Jaime, at its early stages, patients with lung cancer usually are asymptomatic, so you don't have any symptoms early on. But later on, sometimes you can start having some cough, some shortness of breath, some nonspecific pains. But in its early stages, patients can be completely asymptomatic.

Host: Dr. Sylvin, moving to you, what are the most common surgical options available for treating lung cancer and how do they differ from one another?

Erik Sylvin, MD: There's a variety of surgical options. The most common operation that we would perform is something called a pulmonary lobectomy, and that's taking out a lobe of the lung. Your right lung has three lobes, the upper, the middle, and the lower, and the left lung has an upper and a lower. So that's the most common operation is a lobectomy, but it all depends on a lot of other factors such as the size of the tumor and if there's any other lymph node involvement. So there's other options that we do have now, something called a wedge resection or even a segmentectomy where we don't have to take the entire lobe of the lung. If it's a smaller tumor, we're sometimes able to just kind of, as I joke, give it a haircut, just kind of take off just that tumor, where the tumor is and a healthy part of the lung surrounding it.

Host: Dr. Kosseifi, I'm thinking about common misconceptions that we have about lung cancer, who gets it, what kind of lifestyle behaviors that lead to it. What are some of those common misconceptions from your perspective about lung cancer and its treatment that should be addressed?

Sam Kosseifi, MD: This is really an important question here. For me, the most common misconception is basically, providers not being aware of an effective screening tool for lung cancer. As you know, lung cancer remains the leading cause of all cancer death worldwide. It's the number one killer, and we have an effective screening method to detect it at an early stage, but some providers still don't know or they don't implement, or they don't screen, or allow their patient to get into a screening program to pick it up early. I feel like this is an important misconception here. We do have an effective low dose CT lung screening for lung cancer, so it's important to recognize that and screen high risk patients for lung cancer. That's the only way we can fight this disease.

Jaime Lewis (Host): Dr. Sylvin, thinking of those high risk patients, what are the key factors that determine whether a patient with lung cancer is a candidate for surgery?

Erik Sylvin, MD: It is a long list. Having a multidisciplinary group, lot of physicians getting together to try to figure that out is key. And there's so many things to look at, but we'll look at the patient's overall physiologic condition just because someone may be let's say, 80 or 85 years old, well that doesn't, age itself doesn't automatically preclude someone from having surgery.

So we'll look at their level of fitness. Can they walk up a flight of stairs? Are there active, daily activities? Can they do a load of laundry without being really short of breath? Other comorbidities, do they have heart disease, do they have peripheral vascular disease, people smoking, so on.

So we have to look at the patient as a whole, we have to look at all the other medical problems that they may or may not have. We have to look at their support network, do they have people at home to help take care of them, and then also, are there other options if we think or feel that the patient may not do well with surgery? Meaning that it may impact their life or their lifestyle. For example, maybe they will be on oxygen for the rest of their life after taking out part of their lung, that's something to consider and maybe that patient really doesn't want that. So it's an easy question but a complicated answer in that we really have to look at the patient as a whole, look at everything, we take into account a lot of factors to come to that decision.

Host: Speaking of complicated factors, I want to talk a little bit with Dr. Kosseifi about low dose computed tomography, which is sometimes called LDCT. How effective is LDCT in detecting early stage lung cancer and who should consider this screening method?

Sam Kosseifi, MD: Low dose CT lung screening is very effective and it can reduce death from cancer, lung cancer by 20%. So it's an effective way to reduce the mortality of lung cancer by 20%. It's a very simple, procedure. It's a screening tool. It's among the routine screening modalities.

I mean, it probably is the easiest, and it takes less than five minutes to perform. You don't need any preparations. There's no needles involved, and all what you need to do is just hold your breath for six seconds. It's not a tube, it's a donut, it's very simple, very easy, and you don't need any prep or anything like that, it's effective, 20 percent reduction in mortality, that's a huge number.

So, in terms of who qualifies for it, I mean, if you're an active smoker, or you quit smoking, within 15 years, and you have a 20 pack year history of smoking. Pack year is a way to measure how much you smoke, so basically it's determined by how many packs of cigarettes you smoke, and multiply it by years, so, basically, if you smoke one pack per day for one year. This would be like one pack year. So if you smoke one pack per day for 20 years, it would be like a 20 pack year, smoking history. And if you're between the age of 50 and 80, and you're asymptomatic, then you qualify for low dose CT screening.

Host: Amazing. So glad that we have that at our disposal. Dr. Sylvin, what can a patient do to best prepare for lung surgery and recovery and doing it well?

Erik Sylvin, MD: That's an easy answer because if a patient is smoking, the first thing to do is to stop smoking. We have data to suggest that if a patient's able to stop smoking as little as two weeks before surgery, the chances of having a bad outcome dramatically drop, and getting them through surgery with less complications, is more likely.

The other thing that I tell patients is to keep exercising and to get their aerobic capacity up. So, if a patient is inactive and doesn't have a contraindication to exercising, I tell them to at least just walk around the neighborhood anywhere they can for about 30 minutes a day for 3 to 4 times a week.

And if they can go do further, go further than, we can do that, then I encourage them to do so. Another thing that we do do is here at Holy Cross, we have a pulmonary rehabilitation center it's also known as, if we can get, sometimes we'll get patients into that rehab actually before surgery and it's kind of known as prehab.

If we can get them in to exercise them to get their hearts and their lungs in better condition. If a patient goes into surgery more fit, I always say stronger in, stronger out. If they could go in know, a better aerobic capacity, then the chances again of having a complication drops dramatically, and the chances of them getting out of the hospital sooner increases.

Host: Yeah. Another reason to get and stay active. Dr. Kosseifi, in what ways has technology like the ION improved the accuracy of safety of lung biopsies?

Sam Kosseifi, MD: So basically, lung cancer can grow in any part of the lungs, so you need to have a technology that will allow you to reach to a different areas of the lungs. This way you can take the biopsy and make the diagnosis. On the other side, you also need the technology that is safe also with less complication rate and that allows you to make the diagnosis and the staging at the same time.

And all those features, are part of our ION robotic bronchoscopy. And we recently integrated the cone beam into our ION system for higher precision. So it's a computer based technology, that will allow us to navigate and reach into the smaller tubes into the lungs and with high precision, high diagnostic yield.

 The catheter is ultra thin and integrated into a vision probe. It allow us to navigate easily and it will lock itself on the spot on the target. So it gives us higher precision rate and very few post op complications. You know, it's an outpatient procedure that will help us to detect cancer early and stage at the same time.

Host: And speaking of robotics, actually, Dr. Sylvin, how has robotic assisted surgery improved the accuracy and safety of lung surgery?

Erik Sylvin, MD: Yeah, it's really, really revolutionized the field. Using the robot, we're able to attack, basically do the operation from a different point of view, a different visual perspective. Advantages of the robot is one, that the camera that we use is 10 times the magnification of the human eye. So we can see things that we can't see with our eye when we're doing a traditional open operation. Another facet and benefit of the robot is that it gives us, our humans basically only have about five degrees of freedom with their wrists. But with the robot, it gives seven degrees of freedom, meaning that we could twist and turn and get into crevices and see things that we normally wouldn't see or be able to do with our hands.

So, being able to see where to essentially cut or burn or get into those anatomic planes, it's just unparalleled. There's not another instrument out there that we're able to do that. Also, you know, the human beings, no matter how steady their hands are, we do have a little bit of a tremor, and the robot eliminates that.

So, that's, you know, a key advantage. And then finally, which I think this is a, you know, an area of controversy in the thoracic literature and among thoracic surgeons, but when we do a lung cancer operation, the operation is basically twofold. It's to get the tumor out. But another part of the operation is to dissect or take out various lymph nodes.

Lymph nodes live in the chest and certain anatomic areas and we go and we dissect those lymph nodes out. And the reason being, is that lung cancer, when does spread, it often spreads to the lymph nodes, in a somewhat predictable pattern, although every patient is different. By taking those lymph nodes out, we're able to look at them under a microscope and see has cancer spread.

Based on that, we can give the patient, assign the patient a stage, and based on that stage we can give better treatment. So the lymph node harvest from a robotic operation is way superior to doing that as what it was as an open operation. So it's not clear if that improves survival yet but there is some early literature to suggest that it may and I'm a big believer in that.

So, just the sheer number of lymph nodes that we're able to get during a robotic operation is a lot higher than previous. Also, traditionally through an open operation, we would have to make a bit incision and essentially go in and spread the patient's ribs, which could be quite painful.

 So, the amount of pain that a patient experiences after robotic lung surgery is far, far less than what it was previously. And also the blood loss is different. We're really not cutting through any muscle or dividing any muscle but we're sneaking through the rib spaces. So, the patient's getting out of the hospital quicker, we're seeing on more routine basis now.

All of those things. really contributes better outcomes.

Host: Right. Dr. Kosseifi, given the fact that less than 7 percent of high risk patients are screened for lung cancer and that the five year survival rate for lung cancer is 26%, and it can take patients up to eight months to begin treatment after a suspicious finding, what do you recommend for combating these statistics?

Sam Kosseifi, MD: If you look at our state, state of Florida here, the number is less than 7%. So despite the fact that we feel like we're doing a good job in terms of screening high risk patients, we're still not yet there.

 Probably in state of Florida, between maybe three to five, six percent patients are getting screened for low dose CT. In terms of the five year survival, I think we're doing better jobs than before. Survival rate is up to 29%, from 26%. So that's a good news, but still, it's slow.

I mean, still we can do a better job. In terms of how to combat or how to fight this lung cancer, most importantly is to be able to get the patient on a fast track in terms of when we detect the nodule that's suspicious for cancer, to the time we make the diagnosis, to try to shorten this time, to the least possible. Studies have shown that a delay as short as six weeks from the time of diagnosis to intervention, can basically, reduce survival by 13%. So I think the most important thing is to try to reduce the patient pathway, from the time of detection to the time of diagnosis, to two to three weeks instead of months to make the diagnosis.

So patient comes to our clinic, we move fast. Within two weeks we already have the diagnosis, have the staging. Patient is ready to see Dr. Sylvin or, or, you know, our oncologist at the same time, we already have a round table, tumor board, so we already, have an action plan for him, and that's really what makes a difference, So cutting down the time to make the diagnosis, it's very important, and this is really what's going to make a difference. Time is very critical and it's important to fight against lung cancer.

Host: Dr. Sylvin, we've been talking a lot about different methods for screening, preventing, treating lung cancer. How does a multidisciplinary approach enhance the management of lung cancer patients?

Erik Sylvin, MD: Well again, this has been well studied as well, and we know that patients that are presented in multidisciplinary clinics and discussed, their outcomes tend to be better. Their chances of survival actually increase. Why is that? I mean, it's, basically, it's a think tank.

You're brainstorming with all of your colleagues. You have doctor, physicians disciplined in various subspecialties. I mean, you have radiology, thoracic surgery, interventional pulmonology, oncology, radiation oncology, various social workers, nurses, and so on. So, people that are presented and they're not maybe not straightforward, you can bounce ideas off one another and even though, not every two patients are really the same, there's always a caveat or something that distinguishes one patient from another.

So, perhaps, I would not think of something that perhaps a radiation oncology might suggest something. It's a collegial atmosphere and it just kind of helps everyone think more clearly and, perhaps, one of our medical oncologists might know of new technology or new tests, something that I'm not familiar with.

If he or she suggests that, it reaps dividends in the end.

Host: Right. I can imagine that's only a good thing for the patient and for treatment. So as we wrap up, I just wanted to give you each an opportunity to share. Is there anything else that maybe we didn't talk about today? Some takeaways that you'd like to leave with the audience? Let's start with you, Dr. Kosseifi.

Sam Kosseifi, MD: From my perspective, I advise and encourage people who smoke, to quit smoking, because that's the only way we can decrease or improve outcome and decrease the chance of having lung cancer.

Smoking cessation by itself, has been shown that it can improve survival by 20 percent at seven years. On the other side, I mean, if you are a smoker or you quit smoking within 15 years, you between the age of 50 to 80, come on over, get yourself checked for lung cancer. You know, it's a simple test, and this can save your life. So I really encourage patient to get screened for lung cancer if they are at risk and quit smoking.

Host: That's great. Dr. Sylvin, I'd like to ask you the same. Is there anything you'd like to leave the audience with?

Erik Sylvin, MD: The information about lung screening and the research, and the trials are well developed. The conclusions are kind of almost factual that we know that this will decrease your chance of dying of lung cancer. For whatever reason, especially in the state of Florida, this is underutilized. So, I, advise patients to take it upon themselves to educate themselves if they can. And, you know, it is a misconception that someone may say, I don't feel symptoms or, you know, I stopped smoking 10 years ago, so everything was fine. Well, we know that is not necessarily the truth. So you know, less than 50 percent of people that do get diagnosed with lung cancer are, you know, in advanced stage and less than half we can operate on to try to cure. So early detection in this case is beyond critical.

Host: Right. And it seems like it's the case with everything. Timing is everything. Get to it quickly. Well, doctors, thank you so much for all of your insight, your information and expertise. We really appreciate it.

Sam Kosseifi, MD: Thank you.

Erik Sylvin, MD: Thank you.

Host: Was Dr. Sam Kosseifi, lead Pulmonologist at Holy Cross Health and Thoracic Surgeon, Dr. Erik Sylvin, also at Holy Cross Health in Fort Lauderdale. To learn more about minimally invasive surgery options at Holy Cross Health, visit holy crossrobotics.com. Thank you for listening to Thrive with Holy Cross Health.