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Prakash Chandran: Lung biopsy is a procedure performed to remove tissue or cells to determine if lung disease or cancer is present. As technology has improved, so have treatments for lung cancer, namely these biopsies. We're going to talk about it today with Dr. David Sternberg, a cardiothoracic surgeon with the Karmanos Cancer Institute in Detroit, Michigan, as well as the McLaren Oakland Hospital.

This is McLaren's In Good Health, the podcast from McLaren. My name is Prakash Chandran. So Dr. Sternberg, really great to have you here today. Thank you so much for your time. You know, when considering all different types of cancers, how common is a lung cancer diagnosis?

David Sternberg, MD: Well, thank you very much for having me first, Prakash. Lung cancer is the most common cause of cancer death in the United States. As you may know, the most common cause of death in the United States is still heart disease, but the second most common cause of death is cancer. And the most common cause of cancer death is from lung. As a matter of fact, lung is such a common cause of cancer death, that if you were to tally up all of the Americans who died of breast cancer and colon cancer and prostate cancer and add them up, lung cancer would still be a more common cause of cancer death. So it's a significant public health problem. For example, last year and as many years before, about 155,000 Americans will actually succumb to lung cancer. So it's still a great, very significant public health crisis that even during the pandemic killed more Americans than coronavirus did.

Prakash Chandran: Wow. That is incredible. I actually had no idea. This may be a difficult question to answer, but why do you think that is? Why does lung cancer contribute to so much death in this country?

David Sternberg, MD: Well, certainly I think the number one answer's always going to be because of smoking. Smoking is a significant cause and the primary cause of lung cancer in approximately 85% to 90% of the lung cancer diagnosis that are made. There are some other reasons for people to get lung cancer, minor reasons. But cigarette use is still the number one cause of cancer death. And even though it typically does take a long time for cancer to develop in people who use cigarettes, it's still a major driving force of not just one cancer formation, but also lung cancer death. To answer why it is such a common cause of death, as opposed to why breast cancer and prostate cancer do not, for example, kill as many Americans as lung, I believe that just simply has a lot to do with how many mutations are caused by cigarette smoke in lung cancer itself.

Prakash Chandran: Yeah. So that actually leads me to my next question around lung cancer screening. Can you just talk at least at a high level around who should be getting screened and when they should begin?

David Sternberg, MD: Well, screening is a fantastic subject. And I really appreciate you bringing that up because it's a that's topic near and dear to my heart. If you're talking about mitigating the risk of dying from lung cancer, then you really have to talk about that. Back in the 1950s, after mammography was sort of determined to be helpful in preventing cancer death in women from breast cancer, there was a tremendous push. But in the 1950s, all they really had were x-rays and sometimes they also had sputum analysis. The technology just really didn't exist back then to screen patients in a really meaningful way to see if they had lung cancer. And for about 60 years, the US government funded multiple large scale trials, but it wasn't really until 2010 that we came up with a real protocol and process to really screen patients in a comprehensive way. So the US government really signed on and Medicare started to pay for lung cancer screening CT scans in around 2013. And right after, we started to screen patients and the criteria we typically use are patients who have smoked 30-pack years or 1 pack a day for about 30 years over the last 15 years or currently smoking, who were over the age of now 50, those would be the criteria that we would use. And what the government determined is that if we apply those criteria and we start screening that population, people with more than 30 pack years who are over 50 years old, that we could significantly reduce their chance of dying from lung cancer by at least 20%, at which point the government stopped the trial because so many lives are already being saved.

Prakash Chandran: Wow. That's incredible. Now, if for example, I have people in my life that certainly meet the criteria for those 30-pack years, but they're not 50 yet. What is your recommendation for people that might want to get screened younger?

David Sternberg, MD: Yeah. So, that's a really good question because I just finished meeting somebody who was several years younger than 50 years old that unfortunately had been smoking since an early age and had developed lung cancer. You know, the US government has to choose a number and certainly they don't want us screening 25-year-olds because obviously we don't want to be screening patients who have an incredibly low likelihood of getting cancer because not only is it not beneficial, but that can be harmful. But the cutoff from the government is 50. But very often when we meet patients who are younger, if they have specific risk factors or family history, we will still screen them when they're younger. So, it's not the official government line, but it is commonly done and, in many situations, has saved quite a number of lives.

Prakash Chandran: Yeah, well, that makes a lot of sense. You know, one of the things that I had been seeing in the news recently is that the actual deaths from lung cancer have been decreasing over time. Is that something that you can speak to?

David Sternberg, MD: Sure. So the thing that's been dropping over the past 10 years has been death from lung cancer. Lung cancer in the past used to be one of those tough cancers. And even as recently as 10, 12 years ago, survival from really all four stages of lung cancer collapsed; in five years, was typically only about 15%, which meant only about 15% of our lung cancer patients would be alive five years after their diagnosis. But I'm happy to say that it's already gotten significantly better over the past 10 years. And it's really soaring past 25, 26% and the reason for that is the combination of lung cancer screening and also early lung cancer biopsies, and the combination of screening and early lung cancer biopsies are allowing us to catch lung cancer at an early stage and really catching it in early stages, everything in lung cancer, because if you can catch it at a really early stage, like a stage I, your survival can be as high as 90%, which is fantastic. But unfortunately, if you don't get screened and you don't catch it at an early stage and you catch it at stage IV, well, then your survival can be unfortunately, really significantly lower, more in the 10% range. So it's so important to get screened and so important to get early lung biopsies hopefully and preferably minimally invasive if there's anything abnormal seen, because you can take a disease that can be quite serious, quite brutal, quite hard on both the patient and their family and you can turn it into something that is much easier to deal with.

Prakash Chandran: Yeah. So there's definitely an importance placed on getting that screening done as soon as possible. Let's talk about the screening itself. What exactly are you looking for during a screening?

David Sternberg, MD: Well, the first and foremost thing that we're looking for in lung cancer screening is the presence of lung cancer. But when you do a lung cancer screen, you do get a pretty good look at somebody's chest and their anatomy. So you can see other things that are wrong and we have, for example, seen lots of evidence of hardening of the arteries is commonly seen, hardening of the coronary arteries. And sometimes when you show the patients, their lung cancer screen, it's actually a good time to talk to them, especially if they're still smoking, because you can say, "Look, I know you've still been smoking and I'm really happy to tell you today that you don't have lung cancer, nor do you have any nodules that are even concerning for lung cancer. But did you know that your coronary arteries, which are the arteries that leads to your heart, are in the process of hardening? Did you know that you're developing an aneurysm? Did you know that the valves around your heart are hardening? Did you know that you have a large hernia and that your stomach has moved up into your chest?" These are some of the things that we find actually quite frequently. And when patients actually hear this information, they're quite surprised because very often patients feel fine. We're typically only screening patients that are otherwise healthy. So, in those situations, patients are often shocked to learn that even though they may not be sick yet, they've already started to do quite a bit of damage to their bodies and this helps us and often motivates patients to quit smoking right away.

Prakash Chandran: Wow. So multiple benefits from that screening. So you mentioned obviously the primary thing that you're looking for is lung cancer, which I'm assuming gets represented by some sort of lesion or nodule. And when there is that nodule of concern, then you remove it for a biopsy. And obviously, we're talking about advancements in lung biopsies. So outside of the presence of cancer, what can be determined from a biopsy of one of those nodules?

David Sternberg, MD: That's an excellent question. But just to harp on one point you made before, one other thing that I love to show patients if they don't have lung nodules, I love to show them the actual emphysema process, because you can actually see the holes in your lung forming. So for a lot of smokers, it's a really great chance to say, "Hey, you don't have lung cancer, but look at the holes in your lung. Do you see that? I mean, do you see the actual holes forming? Are you short of breath? Because it's going to get worse and these holes they're there and they're going to get bigger." So for a lot of patients, it's a real significant, realization when they look at these scans and they see that it's real. It really helps us help lots of people quit cigarette smoking.

But to answer your question that you just posed in terms of getting a lung biopsy, we actually will nowadays try first to biopsy these nodules in an incredibly noninvasive way. You see, the trick in diagnosing these things is to try to do it in a way that doesn't upend somebody's life. We can't open everybody's chest and remove part of the lung just to find out what a nodule is, because we don't want to hurt people and we don't want to operate on people who don't have cancer. So what we tend to do is we tend to use a robotic scope. People are comfortable with the ideas of endoscopy, upper endoscopy, colonoscopy. We have a special one that we actually use in the lung, which is obviously separate from the other ones that are used in the intestinal system. And we actually will drive that all the way down into their lungs. It's hooked with a robotic computerized navigational system and also an ultrasound. And we'll drive all the way out to the nodule and we'll stick a needle in it and we'll suck out some of those cells and try to determine if there are any cancerous cells.

Prakash Chandran: Wow. So is this a new type of technology, this robotic minimally invasive procedure of actually accessing the nodule?

David Sternberg, MD: It is and like a lot of innovations in lung cancer or lung cancer surgery, it's relatively recent. The technology has been on the market, I would say, for about five years, but it's really been taking off over the past couple. There are several older forms of technology, several predecessor forms, that have been around for a little bit longer. It wasn't a brand new technology that came out of nowhere. We tend to build layer upon layer of technological advancement. So we had a previous form but the new robotic bronchoscopy system that we acquired and operationalized at McLaren Oakland in January, has been on the market for a few years now.

Prakash Chandran: So I'm assuming one of the obvious benefits to the patient is they don't need their chest opened in order to actually access the nodule, as you stated, but are there other benefits that the patient can enjoy when using this new type of technology to get the biopsy?

David Sternberg, MD: Well, it's not exactly health food, so it's not going to help them lose weight nor it's not like it's going to help them regrow hair that they may have lost. But we are able to go down there and we are able to go really into inner reaches and really all over their lungs and get really a good sample and find out what's going on there. And while we're there, we can also look at their lymph node. So if it is God forbid a cancer, we can also stage them so we can have their diagnosis and staging done with one visit. We do it under general anesthesia, so the patients are totally asleep for it, which is nice. And the reason for that is because it's uncomfortable just to have anything driven into your lungs. But it's significantly less painful than an older technology, namely that of a needle biopsy through your chest wall, where a needle had to get inserted in between your ribs, past the nerves. And a lot of patients found that relatively uncomfortable. With robotic technology, there's a lower chance of collapsing someone's lung. There's a lower chance of seeding cancer into the lining of the chest. It's just less painful and generally tolerated better. Most patients will go home with a sore throat and they'll have a sore throat for a couple days.

Prakash Chandran: So some people might be listening to this and they're a little apprehensive about a robot doing this procedure. Can you talk at a high level around how this robotic technology works and if you're still in control of the robot?

David Sternberg, MD: Oh, yeah. The robot is basically controlling a very long tube. And I can totally understand why everybody would feel that way because robots don't have a conscience and they don't have anxiety. And who would want someone taking care of them who didn't feel concerned for their health and wellbeing, didn't feel anxiety for their children. You know, of course, nobody would want somebody like that making major decisions about their health. But the robot is basically something that allows me to get into a space I otherwise couldn't get into. You see, I'm very fond of my hands. I've had them since I was born. I take good care of them, but they can't fit into somebody's mouth and down their throat. And if I tried to do that, I'm pretty sure I'd be arrested right away. So we have to find some comfortable and minimally invasive way to go down into their lungs without requiring a lot of dental work. So the robot allows us to take a small narrow tube. It's just a few millimeters. It's really just not even a centimeter, a fraction of an inch and just gently kind of drive it, and it's very flexible. And the robot actually controls all the angles that it bends so we can actually bend it and curve around corners, so we can really just drive it in a minimally traumatic fashion, making multiple turns to the right, to the left, to the right, to the left, all the way down. And that enables us to do this with a significantly lower amount of trauma. And ultimately, when you biopsy someone to see if they have a problem, the one thing you really don't want to do is hurt them. You don't want to traumatize them. If they have cancer, we obviously want to treat it right away, but if they don't have cancer, we also don't want to hurt them or traumatize them. We want them to go back to their normal lives, you know, happy with the realization that they don't have a cancerous process. So it's real important for us not to hurt people, injure them, or even make them terribly uncomfortable during this process.

Prakash Chandran: Yeah, I'm glad you covered that. And one of the things that you mentioned is obviously trying to treat it right away if you do identify that there is cancer there. Can this advancement in robotic technology actually administer treatment as well?

David Sternberg, MD: Well, that's something that we're looking at. It's a relatively new technology, but since we're able to track all the way down into the lung, there is the idea that perhaps we could even deliver chemotherapy or perhaps forms of energy therapy to fry, kill the cancer, or inject it with a chemotherapeutic agent. That's something that's being looked at very aggressively right now. It hasn't yet been finally cleared and we haven't really proven in studies that it's better than having it removed or better than having a treated with radiation. So it's too early to say, but it's something that's being investigated. But, you know, whenever a new technology comes out, it generally takes years for us to know whether or not the technology is, first, not harmful and then, second, actually beneficial or better than anything else out there.

Prakash Chandran: So just as we close here, one question I always like to ask is, you know, you've been a cardiothoracic surgeon for awhile. You have a lot of experience working with a lot of different types of patients. What is one thing that you just know to be true, that you wish more patients knew?

David Sternberg, MD: The most common thing that I see both from the communities, even around the hospital is that smoking is still very common despite the fact that we have now prevented billboards from targeting children and we've raised taxes on it, and we've done everything to raise awareness. And I think there is now universal acknowledgement that cigarettes cause cancer and cause cancer death, but still smoking is incredibly common. And that hasn't stopped and I think part of the reason why is because people don't necessarily see the consequences coming anytime soon, or if they see the consequences ever coming at all, they just don't think they'll be that bad. So if there's one thing I wish I could tell people when I see them smoking cigarettes is that there is a better way to deal with their, you know, nicotine addiction. I know smoking is a fantastic way to control stress, but there's a better way to deal with it than using cigarettes, because the consequences will be there. And, you know, like eating in a restaurant, the bill does come due, you know, after the meal. And when you do smoke cigarettes and you smoke them for a sustained and long period of time, it just doesn't damage your lungs, it damages your heart, it damages your blood vessels, it damages so many different systems in your body, causes so many different problems. So that's the one thing I wish people really knew is that the smoking is not just bad, it's worse than you ever imagined and it happens to everybody who smokes. Everybody who smokes will have significant damage to their body done.

Prakash Chandran: You know, I've done over 500 of these conversations across medicine. And I would say 80% of the conversations have some flavor of yes and don't smoke, right, regardless of what we're talking about, because as you said, it affects so many systems in the body. And I think that, to your point, people want that instant gratification and they don't see the bill that's coming due years down the road and it affects everyone. So I think that is perfect advice to end on. Thank you so much for your time today, Dr. Sternberg.

David Sternberg, MD: Oh, you're welcome. Thank you so much for having me.

Prakash Chandran: That was Dr. David Sternberg, a cardiothoracic surgeon with Karmanos Cancer Institute in Detroit, Michigan, as well as the McLaren Oakland Hospital. Thanks for checking out this episode of the McLaren's In Good Health. to learn more about Dr. Sternberg or to submit a question, you can visit mclaren.org/dr.sternberg. And that is D-R-S-T-E-R-N-B-E-R-G. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been once again another episode of McLaren's in good Health. My name is Prakash Chandran. Thank you so much, and we'll talk next time.