Joey Wahler (Host): It remains very common, so we're discussing lung cancer and screening for it. Our guest, Dr. Richard Leone. He's a thoracic surgeon for Skagit Regional Health. This is Be Well with Skagit Regional Health. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Leone. Welcome.

Richard Leone, MD, PhD, FACS: Good morning, Joey. Thanks for having me on today.

Host: Now, great to have you aboard. Appreciate the time. So first, how serious a problem does lung cancer continue to be in the U.S.?

Richard Leone, MD, PhD, FACS: You know, lung cancer is a big problem. It's actually the leading cause of cancer death throughout the world, and it's got the highest rate of cancer death among both men and women throughout the whole world.

Host: And that's been the case for a while, right?

Richard Leone, MD, PhD, FACS: Yes, it has. We've come up with new treatments for lung cancer, but unfortunately there are still a whole lot of people dying from it. It's a very serious disease.

Host: And so who's most at risk for lung cancer and how often should they be screened?

Richard Leone, MD, PhD, FACS: Well, the biggest risk factor for lung cancer is smoking. In the absence of smoking, lung cancer would be very rare. It can happen from other exposures, but lung cancer is really directly caused by smoking. About 85 percent of lung cancer cases can be directly attributed to smoking, and then some exposures to other things like chemicals, dust, other noxious agents, cancer causing agents, can contribute, but it's really about smoking.

Host: So, obviously, despite the increase in public warnings over the years and warnings from professionals like yourself, too many people, unfortunately, it seems, are not heeding those warnings, right?

Richard Leone, MD, PhD, FACS: That is correct. Smoking has decreased, and the incidence of lung cancer is going down, but it's still quite serious. But there is progress. So now we have lung cancer screening available, which is important because most cases of lung cancer are not diagnosed until they've progressed very far. Lung cancer, unfortunately, does not have a lot of symptoms in patients until it's very advanced, and if we can find lung cancer early, it's very treatable and often curable.

Host: Absolutely. And so, speaking of which, you led me beautifully into my next question, what does that lung cancer screening involve?

Richard Leone, MD, PhD, FACS: Screening for lung cancer these days involves a low dose, a low radiation dose, CAT scan or CT scan. It's a very quick procedure that takes about three minutes to do, where the patient the hospital and has a CAT scan done that does not require any IVs or any intervention at all, other than laying down on the CAT scanner, takes about three minutes, and it gives us a high resolution view of the lungs. And the thing about screening CT scans are they're very low radiation, as opposed to other CT scans, which can have high amounts of radiation, a screening CT scan is very low radiation dose.

Host: And so, for those considered high risk, which you mentioned earlier, are for the most part smokers; when should the average person start having these screenings done and how often should they be done?

Richard Leone, MD, PhD, FACS: So this has been looked at, and we now have standard recommendations that come from the federal government and also from the World Health Organization. The criteria these days for screening include whether you're a smoker, currently, or a former smoker, and you're between 55 and 74 years old.

And then some other requirements include, did you smoke one pack a day for 30 years or more, or two packs a day for 15 years or more. So those are the two most important criteria. And then another thing is, if it's been more than a year since you've had a CAT scan, then it also makes sense to get another screening CT scan because cancers can show up in less than a year. So those are the main criteria.

Host: And so, if there's a possibility of lung cancer, how do you and yours go about diagnosing it?

Richard Leone, MD, PhD, FACS: If we find a nodule that looks worrisome on the CT scan, we then go to a more specific diagnosis modality called a biopsy. And so a biopsy is where we go in and take a little piece of lung to determine if there's cancer or if there are other problems there.

Host: And once there's a lung cancer diagnosis, what's the next step from there?

Richard Leone, MD, PhD, FACS: Once a diagnosis is made, then we determine how far advanced it is. And let me speak for a minute about diagnosis of lung cancer, because the biopsy methods that we use have changed quite a bit over the past couple of years. Traditionally, people with a lung nodule have undergone a biopsy done on the CT scanner by a radiologist where they place a needle into the lung.

Sometimes that is still necessary to do, but these days we have more advanced technology that's actually less invasive that we can use to biopsy and determine if someone has a lung cancer. At Skagit Regional Health, we have a new technology called robotic bronchoscopy, and this is where we use a bronchoscope, which is a camera on a long instrument, that we put down the airway with the patient asleep under anesthesia.

And we use the robot to steer out through the tiny airways out to the little nodule in the lung. We can then take a sample with a very low risk of complications, quite a bit lower risk of complications than if we use a needle through the chest to get a biopsy. This is an outpatient procedure that we do routinely here.

It takes about an hour to do. And with it, we can determine if someone does have lung cancer, and we can also determine the stage of the lung cancer, which is important because that dictates what our next steps are to treat the lung cancer.

Host: And so, if there is lung cancer there, what are those next steps?

Richard Leone, MD, PhD, FACS: If lung cancer is early stage, and early stage lung cancer means there's a nodule or a tumor in the lung and it has not spread, beyond the lung into the lymph nodes or other parts of the body. If it is early stage, we then go to surgery to remove part of the lung. And we also have some really, amazing advances in lung surgery in the past couple of years as well.

Host: And what would some of those be?

Richard Leone, MD, PhD, FACS: So the traditional way of doing lung cancer surgery was an operation called a thoracotomy, where we made an incision on the patient's side and then spread the ribs to get exposure to the lung. That's a tried and true method for operating and for dealing with lung cancer, but it's very painful. You can imagine when we have to spread the ribs, that's a big operation and it hurts a lot.

These days, we use, particularly here at Skagit Regional Health, the da Vinci® Surgical Robot for all of our lung cancer surgery. And that allows us to do the same sort of operation, but we don't spread the ribs. We do the operation through small incisions in the side, about 1/2 inch each, and then we go in between the ribs and can do that same operation using the robot.

Interestingly, the robot does not do the operation itself. It's still the surgeon's hands that dictate the motion of the instruments, but the robot allows us to use these little tiny instruments that does not require spreading of the ribs. So the operation itself is faster, it's less invasive, and people oftentimes go home from this surgery in a day or two, as opposed to a week or more they used to be in the hospital when we did these operations open.

Host: Wow. And you make the important distinction there, doctor, that robots in fact have not taken over the room, right? That these are robotic pieces of equipment that still have someone that went to medical school and has performed many surgeries behind them like yourself, right?

Richard Leone, MD, PhD, FACS: That's exactly right. The robot is a surgical instrument that allows us to use our hand motion, whether it be through bronchoscopy or surgery, but the robot is not autonomous. It doesn't do anything on its own. It simply translates our hand motions into much more precise and small motions, through a lot less invasive approach than traditional surgery.

Host: And again, you led me perfectly into my follow-up there because no matter the type of surgery being discussed; it seems robotic surgery has affected just about every branch of medicine, and that preciseness that you just mentioned is often what's mentioned as probably the chief benefit. How does that manifest itself when we're talking about the lungs?

Richard Leone, MD, PhD, FACS: Yes, that is exactly true. The precision allows us to make motions that are difficult to do without the robot. For example, in the lung, when I put the robot camera in, I can see the structures with 10 times magnification and three dimensional vision, in a way, I can't just looking in with my eyes. And then the instruments themselves are very tiny.

And so we can see tiny blood vessels and we can manipulate them and divide them and do the surgery in a way that's very difficult to do or essentially impossible to do without the robot. In thoracic surgery in particular, it has been shown to not only decrease pain and length of stay, but blood loss is quite a bit less as well, because we can simply see those vessels much more easily.

Host: Is all lung cancer treatable?

Richard Leone, MD, PhD, FACS: All lung cancer is treatable, but it's not all curable. So, we've been talking so far about early stage lung cancer, where surgery can be used to try to cure it. If, unfortunately, we don't find the lung cancer until it's advanced, that is, it has spread to the lymph nodes or other areas of the body, we can still treat it these days, and there are new treatments for lung cancer that we didn't have available a few years ago.

There are things like molecular treatments, where we take the biopsy material, and we send it off to a company that analyzes the DNA of the tumor, and then we can target the DNA of the tumor itself with a new treatment called immunotherapy that works along with or better than traditional chemotherapy without a lot of the same side effects that traditional chemotherapy has had.

So, we have a lot more treatments available for lung cancer now than we did even a few years ago.

Host: Getting back to the robotic surgery, what's the typical recovery like from that? You mentioned people are usually home within a day or two. And what happens from there?

Richard Leone, MD, PhD, FACS: Yeah, so, after surgery, which oftentimes takes two or three hours, patients go to the recovery area, and then they go to the regular surgical unit. Previously, we had sent patients to the intensive care unit when we did these operations open, but that's not necessary anymore, and now they just go to the regular surgery unit.

They do have a tube in place called a chest tube, which re-inflates the lung at the end of surgery, and when that tube comes out, they get to go home. Oftentimes it's a day or two after surgery. Most people don't have much pain. They do go home with pain medication for a few days, but typically they're back to work in about a week or so.

Host: Wow. That must make the patient comfortable to hear, yeah?

Richard Leone, MD, PhD, FACS: It is, it's a big difference from when we used to do these operations open. Now occasionally we still do need to do an open operation if it's a very large tumor or if we encounter a large amount of scar tissue or something like that, but the vast majority of the time we can use the robot to do the lung surgery.

Host: Couple of other things. Are the procedures you've covered available at Skagit Regional Health, or must people travel further away for it?

Richard Leone, MD, PhD, FACS: Yes, we are very lucky to have both the robotic bronchoscopy system here. We were the third hospital in Washington state to acquire that last year. And we have da Vinci robotic surgery available here. We have two robots at our hospital now, and we've been using that system here for about five years now.

So we have all of the technology and all of the experience, of any of the centers in Seattle or any place else in Washington state. So it's really not necessary for patients to leave the Skagit Valley to have this advanced surgery done.

Host: And that's an often overlooked factor here, isn't it? That when people are having a major procedure done, the last thing they want to have to worry about is travel, especially if it's extensive, right?

Richard Leone, MD, PhD, FACS: Yeah, that's exactly right. Yeah. And, people may not realize that we do have the most modern technology here. And also many of us, previously practiced in large cities. I, myself was in New York and then Seattle before coming here. And so, yeah, we have experienced, physicians here as well.

Host: And so, in summary, Doctor, if caught early enough, generally speaking, of course every patient is different, how treatable would you say lung cancer is?

Richard Leone, MD, PhD, FACS: Well, for a stage one lung cancer, which is one that we have found before it spread, it is up to 80 percent curable.

Host: And that's a big number.

Richard Leone, MD, PhD, FACS: It sure is, yeah. So, if we can find lung cancer early, particularly through screening, it is very treatable and oftentimes curable.

Host: That's great news to hear for sure. Well, folks, we trust you're now more familiar with lung cancer and screening for it. Dr. Richard Leone, keep up your great work and thanks so much again.

Richard Leone, MD, PhD, FACS: Thank you, Joey. I appreciate our chat today.

Host: Same here. And for more information, please visit SkagitRegionalHealth.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks again for being part of Be Well with Skagit Regional Health.

Sources:

https://www.who.int/news-room/fact-sheets/detail/lung-cancer
https://www.cdc.gov/lung-cancer/screening/index.html
https://www.intuitive.com/en-us/patients/ion-robotic-bronchoscopy
https://www.intuitive.com/en-us/patients/da-vinci-robotic-surgery