Joey Wahler (Host): It's the second most common cancer in the United States and the leading cause of cancer deaths. So, we're discussing lung cancer. Our guest is Dr. Garrett Sherwood. He's a medical oncologist specializing in lung cancer and thoracic malignancies. This is Meaningful Medicine, 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. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Garrett Sherwood, MD: Hi, Joey. Thanks for having me.

Host: Great to have you aboard. We appreciate the time. By the way, only skin cancer is more prevalent than lung cancer in the US. And so, first, what is lung cancer? What happens when cancer hits our lungs, and what are the most common types of it?

Garrett Sherwood, MD: Thanks for that. Lung cancer is incredibly common, like you said. There's multiple different environmental exposures that can transform the DNA or the code of a normal lung cancer cell into a cell that grows out of control. And at that point, a cell has transformed from a normal cell into what we consider a cancer cell. Those cells grow in groups that we call tumors, and then over time try to spread through the blood or the lymph system to other parts of the body.

Lung cancer comes in two primary types. The most common type is called non-small cell lung cancer. It's also the more treatable of the two types. The second type is called small cell lung cancer. The primary difference is in the aggressive nature of the latter of these two. Small cell lung cancer often spreads through the body very quickly; and thus, it's very hard to find at an earlier stage like we find many other cancers at.

Host: Gotcha. So as you well know, Doctor, one of the biggest misconceptions is that only smokers get lung cancer, but that's not true, right?

Garrett Sherwood, MD: Absolutely. I'm glad you brought that up. Anyone with lungs can get lung cancer. It's true that we've spent in the medical profession quite a bit of time and effort identifying the patients that are at risk of lung cancer and making sure patients are aware of the link between smoking and lung cancer, but that's been somewhat of a detriment in modern times of not emphasizing enough that anybody can get lung cancer. There's multiple environmental factors that can predispose people to lung cancer. Radon and asbestos exposure have been well described, but there's also genetic or hereditary factors lung cancer can occur in patients without any significant environmental, exposures, without a smoking history. And sometimes these lung cancers run in families just the way breast cancers and others do.

Host: Understood. So, people often assume as well that lung cancer always comes with obvious symptoms like a persistent cough, for instance. But what are the early signs people might overlook or dismiss from your experience?

Garrett Sherwood, MD: Well, that's one of the problems with finding lung cancer as early as we want. We have a much more lung tissue than we do have tumor in the lungs, even in somebody with an early-stage lung cancer. So, early-stage lung cancer is often clinically silent, and that's why we need to do a better job of emphasizing screening for those that are at risk and following up on incidental nodules in those that have scans done that detect tiny spots in the lungs that we call nodules.

But like you mentioned, persistent cough is one important symptom that should trigger a patient to be concerned about lung cancer. If that cough comes with weight loss, if that cough comes with blood mixed in with the sputum, or if that cough comes with persistent hoarseness, those would be other clinical signs that I would strongly encourage patients to advocate for themselves for, to ask their doctor, "Do you think this is something more than bronchitis or pneumonia? Should I be worried about something like lung cancer? And do I need to do an additional test beyond just a chest X-ray, like a CT scan, in order to help rule out whether cancer could be there?"

Host: Gotcha. So, there's still a stigma around lung cancer, right? That can affect how patients seek care. So, how does that impact patient outcomes, and what do you want people joining us to understand about that stigma?

Garrett Sherwood, MD: Yeah. Unfortunately, that's absolutely true. And I think what a lot of people don't realize is that the patients that are getting lung cancer that are coming to my clinic today started smoking in the 1960s and 1970s. The vast majority of those patients have quit smoking. And at that time, many doctors were smoking. And I think we tend to take the lens of what we know today and apply it to the decisions that people made in the past. And so, it's important that we recognize that any cancer patient, whether they have lung cancer or any other type, all of those patients deserve our compassion, and they all deserve the best the medical profession can deliver to them.

Host: Yeah. Oftentimes when it comes to skin cancer as well, you can get it later in life from exposure that happened when you were just a kid, right?

Garrett Sherwood, MD: Absolutely, yes. And again, the majority of people diagnosed with lung cancer today have quit smoking, years and years ago.

Host: Of course. We should point out, right, Doc, that that doesn't mean you shouldn't quit in order to avoid cancer and, of course, to be healthier in many other ways as well. But I guess what we're saying is if you were a smoker and you've quit and you've quit for a while, you don't really know whether or not you're going to still get cancer, right? It's really pretty arbitrary, isn't it?

Garrett Sherwood, MD: Absolutely. And we've tried to simplify the screening guidelines to make sure that patients that are eligible for screening are able to go to their primary care provider and encourage them to consider a low-dose CT screening study. These screening studies are for patients ages 50 to 80, and for anyone that has smoked 20 pack years, meaning an average one pack a day for 20 years, regardless of whether they've quit or not.

Host: Speaking of which, you led me beautifully there into my next question when we talk about screening. It can save lives literally, right? But many people don't realize they qualify for it. So, who should be getting screened here for lung cancer, and what does that process actually look like?

Garrett Sherwood, MD: Screening absolutely can save lives. We know that less than 10% of patients that are eligible for lung cancer screening get screened, which is unfortunate, and that is a major contributor to why the success rates for lung cancer treatment often fall far below that that we see for things like breast and colon cancers, where 60% and 70% of patients that are eligible get screened.

Screening is very simple. It's a CT scan. But we intentionally use a low dose of radiation so as not to expose the patients to too much radiation. It should begin at age 50. And again, these are in patients that have smoked for at least 20 pack years, regardless of whether they have quit smoking or not. The screening's designed to be annual, meaning that each year you should have a follow-up CT scan to either follow up on any spots that we call nodules that were seen on the prior scan, and to rule out the presence of any new nodules.

Host: Before we go any further, let me ask you to just touch a little bit more on what you mentioned a moment ago, that only a fraction of people go for cancer screenings and it pales in comparison to some of the other major cancers. Why do you think that is?

Garrett Sherwood, MD: I think there's multiple factors. I think unfortunately, some of the bias towards lung cancer patients still exists within the healthcare system, and you have providers that aren't as apt to push a patient to get a lung cancer screening study. The guidelines have actually been out since 2013. So, these aren't necessarily new. And despite these being close to 15 years old, we've not seen a dramatic increase or uptake in screening really in any part across the country.

I think, as you mentioned, lung cancer patients are also a little bit less likely to advocate for themselves. And so, even those that may identify that they could benefit from a screening are less likely to go to a primary care provider or their doctor's office and say, "Hey, I think I qualify for screening. Will you screen me?"

And then, lastly, I think the lung cancer community can do a better job of publicizing the need for lung cancer screening. You know, we're all well aware of, you know, Breast Cancer Awareness Month and the pink ribbons that you see people proudly wearing. We don't really have that sense of pride or ownership in the lung cancer, you know, patient community and their support givers.

Host: I can't help but ask then, Doctor, how frustrating is that for someone like you that's trying to fight this and is to some degree, as the saying goes, pushing the boulder uphill? You want the word to get out. Obviously, conversations like this certainly help, but it would be so much easier for providers and mainly patients easier and better if they would just heed these warnings, right?

Garrett Sherwood, MD: It would. Unfortunately, there's multiple different obstacles within the system that make this challenging. And so, I think for a system that's serious about tackling this problem, you have to engage all of the various different stakeholders that touch these patients. It starts with the patients themselves and their family, their community.

I'm hoping that this podcast will reach not necessarily just the lung cancer patients. You know, many of my patients are in their 70s and 80s, but their children, their friends, their families who can then, you know, turn to someone that they recognize might be eligible for screening. We need to do a better job engaging with the primary care providers and understanding what are their obstacles and what are their barriers to getting patients screened. Many of these doctors and APPs are overworked, and they're practicing in communities where they don't have access to as many resources as they would like. And that certainly limits their ability to screen everybody as much as they would like.

And then, health systems need to do a better job of following up on abnormal findings. We know that many patients that ultimately get diagnosed with lung cancer have a spot or a nodule that was seen on a prior scan that was done for a different reason, but these number in the tens of thousands in our community every year.

Almost 50% of patients that have a CAT scan done of their chest for any reason will have a lung nodule. And so, it's incredibly challenging to pick out the needles in the haystack, so to speak, of which of these nodules are concerning and may be a precursor to what ultimately becomes a lung cancer.

Host: And it takes a village, as they say, and very well said by you indeed. Couple of other questions for you. Lung cancer treatment has evolved rapidly in recent years. That's part of the real good news, of course. So, what are some of the biggest advances that are changing survival and quality of life for these patients?

Garrett Sherwood, MD: Yeah. Thankfully, that's been the number one thing that I think has contributed to some of the improved statistics about how our patients are doing with lung cancer. I can't tell you the number of times I've had a patient come to my clinic with the understanding that they have a lung cancer that is advanced and has started to spread, but they also come in with the belief that there's nothing that can be done for them, and that couldn't be further from the truth.

We have seen the advent of a group of treatments that we call immune therapies. These are medications that work with the patient's own immune system to help get the immune system to attack and eradicate the cancer. And when these treatments work, they can work incredibly well to the point where patients that show up to clinic with metastatic or stage IV cancers can go into remission. And I have a growing group of patients that have not only gone into remission on these treatments but have been able to stop their treatment and remain in remission for years and years, even after the end of their course of treatment.

Host: And speaking of which, for years there was a belief that lung cancer was always a death sentence, right? But those survival rates have now changed. So off what you just said, any numbers you can give us that illustrate just how much the picture has gotten brighter here?

Garrett Sherwood, MD: Yeah, absolutely. The numbers aren't as good as we want them to be, but like you said, they're improving. With access to the latest drugs, we can now quote people about a one in four chance that even with a metastatic cancer, again, a cancer that we would previously considered to be incurable and one with almost no chance of surviving five years, about 20% of those patients are living five years today.

Host: And then, in summary here, Doctor, what gives you the most hope on a daily basis when you're treating these lung cancer patients? What's most rewarding about what you do?

Garrett Sherwood, MD: The most rewarding thing is the sense of gratitude that patients get and demonstrate when they get into my clinic. I think many of these patients feel like they've battled the healthcare system, and it's been an uphill climb to get to an oncologist's office to get to that final diagnosis. But we're doing a better job of creating streamlined systems that allow every patient to get evaluated quickly and efficiently, and we're giving more patients the chance to have these dramatic outcomes by getting patients started on treatment before the symptoms of the disease progress to the point where they're no longer treatable.

Host: Sort of wrap things up here. You're saying that the treatment options are getting better all the time, but it all starts with that screening, doesn't it?

Garrett Sherwood, MD: Absolutely, yes. The number one thing we can do to improve the cure rate for lung cancer is to make sure that the patients that are eligible to be screened get screened, and those that have an incidental finding get that followed up on.

Host: Well, folks, we trust you are now more familiar with lung cancer and the importance of screening. Doctor, keep up all your good work, and thanks so much again.

Garrett Sherwood, MD: Thanks so much for having me.

Host: Absolutely. And to find a physician, please do visit novanthealth.org. For more health and wellness information from our experts, please visit healthyheadlines.org. If you found this podcast helpful, please do share it on your social media. Thanks so much again for being part of Meaningful Medicine, a Novant Health podcast.