Carl Maronich (Host): Meaningful Medicine is a Novant Health Podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm Carl Maronich. And with me today is Dr. Nathaniel Meier, a critical care pulmonologist with Novant Health. And we'll be talking about lung cancer screenings and biopsy technology. Dr. Meier, welcome to the podcast.

Nathaniel Meier, MD: Hey, thanks for having me.

Host: Glad you are able to be here. And lung cancer is the leading cause of cancer death in the US, representing about one in five of all cancer deaths. Maybe you can talk a bit about the importance of early detection when it comes to lung cancer.

Nathaniel Meier, MD: Yeah. Unfortunately, for lung cancer, the drop in survival is especially steep compared to other more common cancers. And for stage I lung cancer where the disease is very localized, the survival at five years can be between 77% and 92% So, it does respond very well to treatment. Generally, that's radiation or surgery where it's better tolerated than, you know, more complicated systemic treatments for cancer diagnosed at later stages.

Host: So obviously, early detection does save lives. So, let's talk about screening. I understand there are some high-risk patients that are eligible for low-dose CT scans annually. Can you talk about who's eligible for those scans and why it's so important?

Nathaniel Meier, MD: So as far as who qualifies for lung cancer screening, I would say the inclusion criteria are pretty clunky. And so, I would just encourage any patient who's over the age of 50 who has smoked on any consistent basis in their lifetime to talk about whether or not they would qualify for lung cancer screening with their primary care doctor or their pulmonologist.

And it's really important because most lung cancer cases, when they become symptomatic, it's too late. The disease is too advanced to be treatable easily. And so, there's a real opportunity, a real need to try to catch patients early when the disease is treatable.

Host: Certainly a history of smoking raises the risk of lung cancer, we know that. But lung cancer also develops in folks that don't smoke. Can you talk a little bit about that?

Nathaniel Meier, MD: Yeah, I mean, certainly a super strong relationship between smoking and lung cancer, but we think that smoking is really only causal in about 85% of lung cancer cases. And among patients with lung cancer who have never smoked, they're still the fifth leading cause of cancer deaths worldwide. And there are other factors to consider, you know, radon exposure, certain occupational exposures and, you know, air pollution to a lesser extent.

Host: I understand there are people may be going in for some other issue, getting an x-ray, a CT, an unrelated health concern, and they find a spot or a nodule on the lung. If that should happen, can you speak to what would happen next?

Nathaniel Meier, MD: Absolutely. If there's some concern for a nodule or a spot on an x-ray, it should prompt whoever ordered it to get a CT scan of the chest to help us get some better characterization of that spot or nodule. And I think the radiologists here do a really good job of prompting the ordering provider to make sure that happens for those cases.

When we confirm that there's a nodule or a spot on a CT scan of the chest, then our first task is to look back and see if there's any prior imaging that we can find from any other healthcare system, to see if it's been there for more than, say, a couple of years, or if it's even decreased in size over that timeframe, in which case we could assume that it was probably benign or, you know, way less risky for something like lung cancer.

If that's not the case and the nodule's new and we can't identify it on a CT scan from another system before, and there's really any risk factor for lung cancer or cancer that could be metastatic inside the chest, whether that's smoking or a family history of cancer or personal history of cancer, there needs to be some kind of followup for it.

And we've built a lung nodule program here in the Novant coastal market, working with our lung cancer nurse navigators, our clinic, radiology to help identify higher risk patients and need some assurance, they're getting appropriate imaging followup. And then, for the highest risk patients, making sure that we have an opportunity to see them in clinic to talk about options for followup, which may include a biopsy.

Host: I understand recently your hospital added new technology that makes available minimally invasive biopsies for small nodules. Can you talk a little bit about that technology?

Nathaniel Meier, MD: Yeah. So, we're very excited to have the Ion robotic bronchoscopy platform and an integrated portable CT scanner. There's AI that's built into the software for Ion where we're able to take a CT scan of your chest, generate a three-dimensional virtual display of your lungs and airways, navigate out to our target or our pulmonary nodule, using actual shape-sensing of the catheter that we use for bronchoscopy relative to that 3D virtual display. Once we're out at the lesion that we're trying to biopsy, we can use the portable CT scanner that we have to locate the catheter position, the position of the tools we're using, the position of the nodule, both before we biopsy as we do biopsies to make sure we do it safely.

Host: That's amazing technology. And biopsy itself can be a scary word. Is it fair to ask kind of roughly what percentage of small nodules are malignant or cancerous?

Nathaniel Meier, MD: Yeah. And it really varies by size, and there's a lot of imprecision with estimate of cancer risk with each size, unfortunately. So for nodules less than 5 millimeters, that risk is probably less than a percent. For anything from 5-10 millimeters in size, that risk is more like 10-25%. For nodules 10-20 millimeters, it rises to maybe 10-50%. And nodules over 20 millimeters, that's more like 20-68%. And so, like I mentioned, there are wide ranges of the estimate of risk for nodules of each size. And that's why we feel it's important to have an opportunity to meet with us in clinic to talk about, you know, how much you, as a patient, value diagnostic certainty. And then, the risks of different followup strategies, which may include biopsy or imaging.

Host: If the biopsy is negative for cancer, is there still a need to monitor that nodule over time?

Nathaniel Meier, MD: There are a few things that we can pick up with biopsies that are reassuring for the absence of cancer. If we can do a biopsy and pick up the diagnosis of certain benign tumors, such as like a hamartoma or certain infections, then we can really be reassured that this is not cancer.

Barring that, most of the time, best practice would be to follow the nodule with some imaging periodically over a couple of years, or not quite as long if the nodule decreases in size or resolves on its own.

Host: We talked earlier about early detection. I should also ask though, if someone's having other lung issues, what signs should they look for that would prompt them to visit their primary?

Nathaniel Meier, MD: Yeah, I mean there are certain alarming things, of course, that should bring in, I mean, a bloody cough. But also, just a cough that's persisted for more than a couple of months, chest tightness, wheezing, trouble breathing that really limits your activities at all, we're happy to see you and talk about it in our clinic.

Host: And back to the smoking issue, if you're a smoker, definitely if there's any signs, I would guess you want to do something. But as we said earlier, non-smokers can get lung cancer too. So, I would say if you have—I would ask, I guess—if someone's having an issue and they say, "But I've never smoked, so I'm okay," they probably should get checked out.

Nathaniel Meier, MD: Yeah, yeah. Again, for any of those reasons, we'd be happy to see a patient, like, trouble with bloody cough or unintentional weight loss, trouble breathing that limits their activities, chest pain with deep breaths, any of that, we're happy to see them.

Host: Yeah. Doctor, before we let you go, I want to ask what drew you to pulmonology as a specialty as you were going through medical school?

Nathaniel Meier, MD: Yeah. I mean, I spent a lot of time with my grandmother growing up, and she was an English teacher. She really inspired me to read, to learn. She made it fun. And she was a heavy smoker. And like, to the extent, sometimes I remember almost using the smoke in our house as a prop for like pretending to be a firefighter with cousins or NASCAR races in the house or something. But I mean, if you name a smoking complication, she had it. And for such a vibrant woman, it really limited her at the end of her life. And, yeah, I mean, how could you not want to dedicate a part of your practice to helping other families avoid that.

Host: Yeah, absolutely. Well, we're grateful you chose that path. Dr. Nathaniel Meier, critical care pulmonologist with Novant Health. Thanks for being with us today.

Nathaniel Meier, MD: Thanks so much.

Host: For more information, go to novanthealth.org. If you enjoyed this podcast, please share it on your social channels and explore our entire podcast library for topics of interest to you. I'm your host, Carl Maronich. And this is Meaningful Medicine. Thanks for listening.