Dr Rania Habib (Host): When you think of lung cancer, your mind likely runs to a patient who has smoked cigarettes for his or her entire life. It's a cancer that something comes with a different stigma. This is Flourish, a podcast brought to you by PRISMA health. I'm your host, Dr. Rania Habib. Joining me today is Dr. Rohan Arya, an Interventional Pulmonologist with PRISMA Health Pulmonology and Associate Professor at University of South Carolina School of Medicine. And he is here to share with you what you should know about lung cancer. Welcome Dr. Arya. And thank you for sharing your knowledge with us today.

Rohan Arya, MD: Thank you, Dr. Habib, for letting me be a part of this.

Host: To begin, is lung cancer still common even though smoking has decreased? And why?

Rohan Arya, MD: So lung cancer is still one of the most common cancers worldwide. And this is true if you look at the literature which is as current as June of this year. Most of the information we have is from developing or first world and second world countries. And cigarette smoking is still the biggest reason. Even though smoking has decreased, when you look at who has stopped smoking, is it the younger group that now does no longer smoke. Is it the older people, patients who have smoked their whole life and now stopped smoking once they're later in life.

 The risk for cancer does not completely go away because you stopped smoking.

So identifying one specific reason why it is still very common despite the actual smoking, in population has gone down is difficult.

Host: We have seen a dramatic rise in vaping in young adults and teenagers. Can vaping lead to lung cancer?

Rohan Arya, MD: The simple answer is we don't really have enough information to determine how much of a risk it will have in terms of developing lung cancer. What we do know is the vape products don't seem to contain the tar, carbon monoxide, and some of the other products of combustion that you find in cigarette smoke.

But it does have a lot of other chemicals which may potentially lead to cancer, but we don't know as of now. We do know that some of these chemicals do cause very high levels of inflammation in the lung. And I guess we need to see in the long term, does this ongoing inflammation lead to cancerous changes?

Host: I'm sure you get this question all the time, but is vaping or cigar smoking considered safer than cigarette smoking?

Rohan Arya, MD: I think, we should look at it differently. Cigar and pipe smoking both can increase the risk of lung cancer when you compare it to people who don't smoke anything at all. Based on all the research that has been done so far, the more cigarettes or pipes that one smokes, and the longer that they smoke these things throughout their life, there is still a greater risk of developing lung cancer. These things can also cause cancer of the mouth, the throat, the food pipe.

Host: What is your opinion about shisha or hookah? Because obviously that's becoming extremely popular worldwide.

Rohan Arya, MD: A lot of times it's going to depend on what's in there. Some shisha may have actual tobacco products, some may not. I know sometimes the apparatus is used for marijuana. So I think the risk for lung cancer and any other diseases from using the shisha apparatus itself depends on what you're putting in there, what you're burning and what you're inhaling. So if it is tobacco, then it should be similar to the risk of smoking if you use it as much as other people who smoke cigarettes.

Host: Okay. That makes perfect sense. Now, can secondhand smoke increase your risk of lung cancer?

Rohan Arya, MD: The simple answer would be yes, but I guess we can start by defining second hand smoke. It's either the smoke you inhale from the lit cigarette that's kind of smoldering away or the smoke that the smoker exhales after taking a draw from the cigarette. Both of those expose people to the carcinogens and the chemicals in the cigarettes that cause cancer, though the risk of cancer depends on how much exposure you have.

So the more intense, for example, sitting in a closed room all day with someone who's smoking away, that's a pretty intense amount of exposure you've had and the duration, how long each exposure is and throughout life, how much of the exposure you're getting. All of that will add to how likely you are going to be to get lung cancer from second hand smoke.

Host: So it's more about duration and quantity of how much tobacco you're actually inhaling as the passerby.

Rohan Arya, MD: Yes. These are the intensity and duration.

Host: Now, what is third hand smoke? Could you define it for us and explain how that is dangerous?

 Mm

hmm

Rohan Arya, MD: Sure. So, third hand smoke refers to the leftover chemicals and compounds, that are in the room after the smoking activity has been done. And, for example, people have cleared out of the room. So, if someone is smoking in a room, at the time they're smoking, the lit cigarette, and the smoker who exhales the smoke exposes you to secondhand.

But when you leave the room, those particles then land on surfaces. Whether it's the floor, whatever surface you have available in that room. Walls, counters, all of these things. And they don't necessarily degenerate and go away. They will stay there. So when people come in at a later date and start touching these surfaces, now their skin is exposed to all those chemicals.

And the skin can pretty easily absorb them. And although we don't know if that will lead to an increased risk in cancer, we do know that you can get health issues with these things.

Host: Now, for those who have smoked for a long time, can quitting still be beneficial?

Rohan Arya, MD: If you can stop smoking, there's always going to be benefits to that. Whether it's cardiovascular health, general lung health, oral health, so your mouth and teeth and gums. When you talk about risk for cancer specifically, with time, when you stop smoking, your risk for cancer does start to go down. It'll never go back to the risk that a non-smoker has, but the longer you stay smoke free, the closer it gets to simply age-related risk factors.

Host: So what are some helpful tips that you can give our listeners for quitting?

Rohan Arya, MD: So with regard to quitting, a lot of times we tend to just tell our patients, quit, it's not good for you, that doesn't help. Smoking is very addictive and they're dependent. A lot of things in their life are kind of intertwined with smoking. So it's habitual, it's associated with many things in life, emotions. So it's hard to just yank that out of your life and expect it to happen. What I try to have people do is change your lifestyle. So things that you associate with smoking. If it's Friday night happy hour, maybe avoid those for a bit so that you're not tempted to smoke. Change where and how you smoke.

I make my patients go and smoke by their mailbox. Whether it's raining, thunderstorm, snow, hurricane, civil war, they will go to their mailbox and smoke there. And so every time they need to go there, they think twice. Do I really want to go? It looks like lightning. Maybe I'll stay in the house. I tell them not to smoke in their car. Get out of the car and park somewhere safely and try that. This way they end up breaking those habits. Getting up in the morning having that first cup of coffee with the cigarette. I tell them, change it up. Have something different in the morning so that you break that connection. So that's one way. Adding to that, supplementing it with nicotine replacement products. The chewing gum, the lozenges, the patches, all of these do help.

Host: That is fantastic. Now, which method have you found, in terms of the nicotine replacements, has been most successful in your hands with your patients?

Rohan Arya, MD: I think everyone has been different. There are some people who will not use the gum because of poor teeth. Chewing the gum is a nightmare for them. Other people prefer the gum because they feel like the chewing helps that oral fixation with the cigarette. Some people do well with the patch. So, I think everyone is different.

Key thing is going through each of the options, making sure whoever you're dealing with can bring that into their lifestyle without making it overly complicated.

Host: Besides smoking, what puts you at a greater risk for lung cancer?

Rohan Arya, MD: There are other exposures like, for example, radon. When you look at this documentation that high exposure to radon may increase the risk of lung cancer. There is chronic medications. So people who are on immune therapy or immune suppressing therapy, can be at risk for lung cancer. For example, HIV patients. So there's also a relationship to asbestos exposure and lung cancer. Generally speaking cigarettes are the number one cause of lung cancer.

Host: When we look at lung cancer in the population, is it more prevalent in men or women or certain ethnic groups?

Rohan Arya, MD: While there is some evidence that race may affect the risk of getting lung cancer, the more important factors are always going to be how much the individual has smoked, how long they've smoked, are there any other exposures that may work kind of synergistically with smoking? For example, we talked about asbestos, radon, any kind of medications they're on, diet, exercise, underlying disease like COPD.

All of these may impart some additional risk factors, but the big one is mostly smoking. There's a small population of women who may be prone to getting one form of lung cancer that may not be associated with smoking. But generally speaking, it's going to be the cigarette smoke exposure.

Host: And in that small population of women what variety of lung cancer are they getting in those non-smokers?

Rohan Arya, MD: In this population, we see adenocarcinoma. It's a non small cell lung cancer.

Host: Could you share with us some signs of lung cancer?

Rohan Arya, MD: Generally speaking, lung cancer is a very silent disease. Starts off small and it continues to grow throughout the lungs. And the first signs tend to be when it's causing problems, so a new cough. Or if someone is a smoker, they tend to have a smoker's cough, they may have a change in how the cough sounds like, or how the cough is, generally speaking.

If the cancer starts to affect other structures, if it affects the outside lining of the lung, you can have chest wall pain. If it affects blood vessels, you can cough up blood. If it affects certain nerves in the upper parts of the lungs, it can affect your voice. So, the symptoms vary from absolutely no symptoms until it's very late, to a whole spectrum of maybe shortness of breath, some cough, voice change, chest pain, coughing up blood. It's all over the place, because if it affects the bones, you'll have bone pain. There are certain symptoms which we call constitutional symptoms or B symptoms, which include, weight loss, unexplained. So it's not like they're trying to lose weight, it just keeps going no matter what happens. Loss of appetite, where they're no longer hungry, their food no longer appeals to them and they don't eat much.

Hormone imbalances, imbalances, electrolyte abnormalities, night sweats where they soak their clothes and sheets and have to change them, so not just, I'm sweating because it's hot, they're soaking their clothes. Fevers and even various neurological problems.

Host: Now, we know that success rate in lung cancer treatment typically goes up when we catch it early. Is there a screening for lung cancer, and if so, what does it involve, and is it covered by insurance?

Rohan Arya, MD: There is lung cancer screening, and this is for the most part done across the country. Here at PRISMA Health, we've set up our lung cancer screening program, which our lung team here manages. If you are an individual between the age of 50 and 77, you've smoked a certain amount in your life, that certain amount is 20 pack years, which is approximately one packet per day for 20 years, or any combination of packs and years that makes that. If you fit in those two, in that group of people, you would be considered at risk for lung cancer. And so these patients would be enrolled through a program where we talk about the risks and benefits of screening. The potential to find normal things and abnormal things on the CAT scan, which may lead to additional testing.

Radiation exposure, although it's minimal, we still have to disclose that. And if they're okay with going through this process, we also need to talk about smoking cessation, how to help them stop smoking, and then enroll in the program. Essentially, once a year, they will get a low dose CAT scan of the chest, looking for any possible signs of lung cancer.

Based on the findings, we either continue going once a year, or if more concerning findings are found, then we can adjust how much quicker we need to screen them. The screening criteria is called Lung RADs, and they have four categories, 1, 2, 3, and 4. So usually 1 means no abnormal findings, 2 means there may be some spots or nodules there which are not concerning, 3 and 4 generally have more concerning findings and you should follow up with a closer time interval or maybe even biopsy. And insurance companies do pay for these screenings.

Host: That's fantastic. Because you're really doing a service for that patient to have them followed by this multidisciplinary team. And the fact that the patients can get it covered, sounds like it's a win-win for these patients. Now is lung cancer curable? And if so, how is it treated?

Rohan Arya, MD: The treatment of lung cancer depends on the type of lung cancer it is, the stage, whether the patient is actually strong enough to tolerate the surgery or treatment, and you put all these things together and we here discuss them in a multidisciplinary group as well, go over all their findings and come to a conclusion as to how we will treat these. Early stage, stage ones, two and even three a, based on where this cancer is, whether they can tolerate surgery; can have surgery, which is considered the best option. I say that with an asterisk because studies show that, specific radiation like, focal radiation therapy can be equivalent to surgery.

But generally if they're a good surgical candidate, the cancer can be taken out and it hasn't spread anywhere. The ideal treatment would be surgery. Anything else would be a combination of chemotherapy and radiation. And nowadays we have even more advanced medications, to enhance the immune system and help the immune system fight the cancer.

Host: That is wonderful. People with lung cancer are often inflicted with a stigma that is connected to that disease. What can we do to overcome that?

Rohan Arya, MD: It's a complex issue and depending on the population you're dealing with, it's very different. A lot of things come into play. The socioeconomic status, the cultural group that you're referring to, who's treating them, you know, ethnicity, there's so much that is involved in this.

It's difficult to determine what specifically we can do to overcome that. I think you have to realize that each individual has to be treated differently. There is some literature, actually it's got a bit of literature looking at, especially in the African American population, the fear of doctors and the lack of trust. I haven't seen anything out there that will tell you specifically how to handle these situations. The best approach as always is to treat your patient individually based on what they have going on in their life and addressing that issue.

Host: Now, unlike other cancers, let's say breast cancer, prostate cancer, because the number one cause of lung cancer is smoking, society often says, well, hey, you caused this cancer yourself. How can we break that cycle to help society understand that, yes, tobacco is a risk factor, but there are other elements involved?

Rohan Arya, MD: That's a tough one. So education is probably going to be the number one approach. Educating against, first of all, tobacco use. Next would be, actually, you have to be compassionate. I mean, people are not smoking because they have nothing better to do. It's actually addictive. This plays a role where you have to look at this from the eyes of an addiction specialist. How do you treat your patient so that they can move away from smoking?

How can those close to them, rather than point fingers at them and say, Hey, you're smoking, help them change their lifestyle and kind of get the cigarette smoking habit out of it. So it's, multifactorial again. I wish I had a pretty straightforward answer, but it comes down to education with those around you supporting you to help make changes in your lifestyle that are sustainable is probably the best approach.

Host: I love that. Thank you so much for your expertise, Dr. Arya. Are there any key take home points that you would like to leave with our listeners today?

Rohan Arya, MD: I think, in the long run, if you know people who are smoking and they would like to stop, sometimes helping them across the finish line is a lot easier than trying to punish them for doing it. Their physicians can help. There are nicotine replacement products. Even other medications available. Talk to your primary care. Talk to your lung doctor. Talk to your psychiatrist. Whoever is involved in your healthcare to help you make that step to stop smoking.

Host: Absolutely. Compassion is absolutely key. I love that. For more information and to listen to additional episodes of Flourish, please visit prismahealth.org/flourish. This has been Flourish, a podcast brought to you by PRISMA Health. I'm your host, Dr. Rania Habib. Stay well.