Melanie Cole MS (Host): Welcome to the podcast series from the Specialists at Penn Medicine. I'm Melanie Cole and today we're highlighting Princeton Thoracic Surgery. Joining me is Dr. Leonid Emerel. He's a Thoracic Surgeon at Penn Medicine. Dr. Emerel, I'm so glad that you're joining us today, and we know there are several types of lung cancer, but the most common of these are non-small cell lung cancer and small cell lung cancer.

Tell us a little bit about what distinguishes one from the other from the perspective of pathophysiology and how does the diagnoses of one or the other alter your approach to management?

Leonid Emerel, MD: Good morning. Thank you very much for having me. You are correct. Non-small cell and small cell lung cancer, is essentially the great majority of the pathology that we see as thoracic surgeons. In general, non-small cell lung cancer is the more common and the most treatable of the two. Small cell and non-small cell lung cancer are differentiated based on pathology.

 So it would take a biopsy and a pathologic diagnosis to confirm. But in general, small cell lung cancer tends to be highly associated with a long history of smoking and tends, although not in every single patient's case, to have a poor prognosis and is usually not treated with surgery, but rather a combination of therapy that includes systemic therapy such as chemotherapy, radiation, and even some immunotherapy. Non-small cell lung cancer, which is further subdivided into adenocarcinoma and squamous cell carcinoma, depending on its origin, whether an adenocarcinoma is coming from glands within the lung and squamous cell carcinoma, usually within the lining of the inside of the windpipes; tends to be the most treatable and tends to be the one that if caught early, is best treated with surgery.

Host: Well, thank you for that overview. So now can you tell us a little bit about what happens when a patient is diagnosed with one of these lung cancers at Penn Medicine in Princeton? Who's involved at the early stage, what are the steps that can be very dizzy and confusing? Tell us a little bit about how the process works.

Leonid Emerel, MD: Here at Penn Medicine, Princeton, we have a multidisciplinary cancer clinic in the Medical Arts Pavillion on the fifth floor where I work with medical oncologists, radiation oncologists, social workers, dieticians in an effort to provide multidisciplinary care for our patients. So sometimes the patient may be referred to a medical oncologist. Sometimes the patient may be referred to me as a thoracic surgeon, and we work together to evaluate each patient's unique circumstances, their medical and social history, and to provide the appropriate tests for what is called staging of their cancer to allow them to discern and diagnose and differentiate what would be the best treatment option for each individual patient and their family.

Host: Well, a multidisciplinary approach is certainly comprehensive and so important for these patients. Now, while this is so stressful, Dr. Emerel, there are a lot of choices that have to be made, doctors to see, appointments to make and administrative frustrations, and insurance and I mean, there's just so much. I'd like you to speak about nurse navigators, APPs, support staff, as we talk about that multidisciplinary approach, and we think of pulmonologists and oncologists and all these doctors, but the support staff are really who help guide the patient through this world that you're in.

Leonid Emerel, MD: Unique to Penn Medicine and our multidisciplinary cancer clinic, we have a strong system of nurse practitioners, physician assistants, and nurse navigators, including my practice that allows us to essentially facilitate all the care that the patient needs. We don't give numbers for patients to call and make appointments, to the situation where at the end of our clinic visits, we provide the information and scheduling, so the patient does not have to take care of anything themselves. We provide the insurance authorization, all the paperwork, all the scheduling, so the patient has a date and time to what test they need, and essentially all the patient and their family has to do is show up and get the test done.

So we organize things so that people have visits that don't require multiple trips to the hospital. If patients can get better procedures and imaging studies at a even cheaper price using non Penn medicine facilities; we certainly encourage that when able to, based on insurance and different unique circumstances. And in general, we try to limit all that confusion and concern so that the focus continues to stay on the patient and their wants and needs, in an effort to provide better longitudinal care.

Host: Well speak about the diagnosis of metastatic or recurrent lung cancer and how are the different approaches to treatment and different processes and interactions compared to patients being treated for the first time when somebody has metastatic? Again, that is a confusing and more scary situation. Tell us what's different as you approach patients that way.

Leonid Emerel, MD: As a surgeon, of course we try to catch cancer early and allow there to be a surgical opportunity to provide the best chance of cure. But in cases where there is cancer that is either spread to the lymph nodes or certainly other parts of the body, that's where the multidisciplinary care is so important.

 We allow the patient to see all different types of doctors that provide cancer care, such as medical oncologists and radiation doctors, in an effort to best treat their cancer. We send all cancer biopsies and diagnoses for genetic testing, which allow us and the disciplinary clinic to essentially provide personalized cancer care, allowing each individual's diagnosis to understand better from a genetic standpoint, and that allows them to tailor a most appropriate treatment plan.

 There's therapies such as chemotherapy, therapies such as immunotherapy, which boosts your immune system to fight the cancer. And even more recent up-to-date therapies called targeted therapies, which allow medicines to treat certain mutations that lead to the development of cancer, which is what may not be applicable to every patient, and that's where the genetic testing comes in.

As the surgeon, my role is to provide the best recommendations possible for each individual's care. Whether that is to obtain biopsies in the form of bronchoscopy or surgical procedures, to biopsy lymph glands in different parts of the lung, or to more definitive care, which revolves around minimally invasive approaches to surgical resection for the best outcomes and the best postoperative course.

Host: Dr. Emerel,I'd like you to speak about what's really exciting in your field right now, and you practice some rather sophisticated surgeries. I'd like you to tell us about these, what they mean for your patient, and anything else that's really exciting in your field right now.

Leonid Emerel, MD: To keep it brief, my practice is all in comprehensive with regards to thoracic surgery care and a focus on surgical oncology. I provide care from diagnosis to treatment in the form of bronchoscopy and more advanced procedures called endobronchial ultrasounds, which allow us to perform non incision based biopsy of lymph glands within the chest for both staging and diagnosis.

I perform minimally invasive surgery, usually with the form of surgical robotics for both diagnosis and definitive cancer care in the form of surgical resection of lung cancer, which may entail either a diagnostic small resection, up to the form of something called a segmentectomy, which is a partial resection of a portion of the lung, all the way up to what is essentially the gold standard of care, which is lobectomy, and the resection of lung tumors, as well as removal of lymph glands, and all the appropriate, necessary portions of a good cancer operation. A lot of my practice is geared toward minimally invasive surgery, which implies the use of small incisions rather than a big incision, that requires any form of rib spreading. And that has been shown in multiple medical trials to decrease the postoperative pain, shorten the length of stay in the hospital and provide equivalent cancer outcomes.

That ability supported by our system here at Penn Medicine allows me to provide that for the patients and be able to tailor each individual's patient operation to maximize and optimize their postoperative care and results.

Host: It is very personalized medicine. This is so interesting, Dr. Emerel, and what you do is so important. As we wrap up, I'd like you to speak to pulmonologists, cancer specialists, primary care providers in your community. What would you most want them to know about Princeton medicine physicians, thoracic surgery, lung cancer screening, because they are definitely involved in that. So speak to them right now.

Leonid Emerel, MD: I would like to tell them that our practice here and it's me as well as my partner Dr. Jack Heim, who's been in this community for many years, including the old hospital at Weatherspoon Street. I would tell them that our practice is incredibly reachable. My number is available to any provider that has worked with me.

Our practice gets patients in to see them usually within three days of their initial consultation. And as mentioned before, my nurses and schedulers, essentially remove all the scheduling and paperwork as it pertains to their cancer treatment and care. We do all the scheduling, we do the authorizations.

We really allow the patient to leave that day with a plan and set times for different tests and procedures. So that a lot of the responsibility falls on us and not the patient because it can be very overwhelming. I think our practice has fantastic outcomes and really provides a humanistic approach to patient care, and really is patient centered.

I think the feedback speaks for itself and I would be available anytime for any of the providers to talk directly, and my number is readily available between my colleagues and essentially any provider I work with. With regards to cancer screening, I think the community as a whole has done an amazing job of increasing lung cancer screening in the form of the lung cancer screening CAT scans.

 More people now who meet criteria are getting the scans, and I think that's led to a lot of more diagnosis of early stage lung cancers, which are the most treatable and have the best outcomes.

Host: Thank you so much Dr. Emerel for joining us today and sharing your incredible expertise today with other providers. And to refer your patient to Dr. Emerel, you can call him direct to his nursing staff and scheduler at 609-853-7200.

Or if there's a provider that needs to reach Dr. Emerel directly, you can call him on his cell to discuss patient recommendations and referrals at 732-241-6319. That concludes this episode from the specialists at Penn Medicine. I'm Melanie Cole.