Scott Webb: The causes of lung cancer include smoking, secondhand smoke, exposure to certain toxins, and family. The most important thing to know about lung cancer is that early diagnosis is essential to survival. And joining me today to discuss the signs and screening and treatment options is Dr. Curtis Quinn. He's a thoracic surgeon with SolutionHealth. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth.

I'm Scott Webb. Doctor, thanks so much for your time today. We're gonna talk about lung cancer screening, diagnosis, treatment, insurance, and stuff. But before we get there, let's just have a little bit of a baseline. How common is lung cancer? What are the main causes, and what are the symptoms we should be on the lookout for?

Dr. Curtis Quinn: It's very interesting that cancer in general in the United States overall is overtaking heart disease as far as being a killer throughout the United States. We all know that coronary artery disease and heart attack was the number one killer, but in 20 states now because our medical people have gotten so good with taking care of heart disease and people are trying to be more healthy, cancer is now killing more people on average than heart disease.

And so we've tried to really do everything we can to affect cancer, you know, we do mammography for breast cancer and colonoscopy for colon cancer, and lung cancer has always really been the black sheep of the family because people feel that because you're smoking, you're doing your own sort of damage to yourself. And so, it's really taken a backseat as far as research and other issues. Now, lung cancer kills more people than breast and colon cancer combined in the United States. So, it is the number one cancer killer when you look at all the other cancers, and that's for several reasons.

Probably the most important reason is that by the time it's diagnosed, meaning if you are having symptoms of shortness of breath, coughing up blood, chest pain, then it's probably at a very advanced stage, which means it's very difficult to achieve some type of cure. And so, as we've gotten smarter at dealing with all cancers, we realize that screening, in the same venue that mammography images the breasts, if we can find it early, it's going to be easier to treat.

Colonoscopy finds things early. So really, about 10 years ago, there was a large study that looked and said, “Hey, if we do CT scans, very detailed scans of the chest on people who are at high risk, and we do them every year for a couple of years, can we find these cancers before they're even having any symptoms?” So, that is the whole sort of genesis behind how we started doing these lung screens. And what we found is that if we do screening of the appropriate population, the people that are at risk, we can find the cancers early. And finding them early is just a dramatic way to save people's lives.

Scott Webb: Yeah, it really is. Early diagnosis seems to be a common thread. Any cancer podcast that I do, early diagnosis is key. And we're going to talk more about screening. And you mentioned smoking there. Is that the only risk for lung cancer, or is it also family history, genetics, you know, where and how people work? Like maybe you can explain who's at the highest risk for lung cancer?

Dr. Curtis Quinn: You've mentioned a lot of the really important risk factors. When they look at who got cancer, what's going on with them? Really, about 88% of people with lung cancer were smokers, and so clearly, the majority of it is directly related to smoking. Not everybody who smokes gets lung cancer, thank God. However, it is a very significant risk factor. The other, and really the next highest risk factor is radon exposure. Radon is an odorless gas that comes out of the ground. Unfortunately, we're in the granite state, so there's a lot of radon and it's in your basement. If you've bought or sold a house in the last 10 or 15 years, you know that you have to have it inspected for that, and it is clearly a carcinogen.

That accounts for another 10% of the cancers in addition to asbestos exposure, family history, and other aerosolized toxic exposures. And it's very interesting, though, when you combine the risk factors. So, if you have someone who's smoking and was exposed to asbestos, that will increase their chance of risk factor for cancer by 50 times. It's huge.

Scott Webb: Yeah.

Dr. Curtis Quinn: So, that's a really big thing. And now, asbestos itself can cause cancer in the lining of the lung. That's mesothelioma. It's a whole nother cancer in the chest. We're talking about cancer in the lung parenchyma itself. And so that combined with smoking, those things are really terrible. The other thing that's interesting to know is family history. It can be genetic, and what's really unfortunate is a lot of times, we will see this in younger women who never smoked. And so, because of that, no one's really paying a lot of attention to some of their respiratory symptoms, and they will often present with advanced-stage lung cancer.

We try to look at all of the things that can lead up to this and try to deal with people appropriately. But for screening, you know, as I said, the study was done. And after that was published, it took a few years to get Medicare to accept it. And in the study, they scanned people from age 55 to 77 who smoked a pack of cigarettes a day for at least 20 to 30 years. So, they picked this category as okay; these people are probably high-risk. We scanned them, and in the original study, one in every 300 CAT scans found lung cancer, and it was early. They weren't having symptoms, and it's taken years, but we've gotten Medicare to accept this. We've gotten most of the insurance companies, really all of them, to accept this, and it's been so successful in finding cancers and saving lives that the criteria changed two years ago.

And now the criteria really is who is at high risk? 50 to 80-year-olds who have smoked at least a pack a day for 20 years. Or maybe you smoked two packs a day for 10 years and you quit within the last 15 years. So, if you quit 30 years ago, you don't meet the criteria. But if you quit within 15 years and you're within that age range and that much smoking, then you should be able to get a lung screening CT scan.

Scott Webb: Yeah. And as you say, have it paid for by insurance or Medicare or something like that, to have somebody else basically foot the bill. So, how does that work, doctor? Do folks just come in and see their providers and say, I smoke, or I used to smoke, and I think I fit the criteria, so I'd like to have the CT scan? Or does it still have to be recommended or sort of, you know, prescribed, if you will, by their primary or by a specialist like yourself?

Dr. Curtis Quinn: I deal mostly with lung cancer, so I am very on this. I'm trying to be vigilant on this. The physicians that are really referring patients for lung screening are the primary care physicians, and they know about mammography and colonoscopy, but as great as the material and the data and the lifesaving papers that have been published on this, not all of the primary care physicians are really up to date or interested in getting this. Some of them are, and they're awesome. They get their people scanned, but we are also relying on patients themselves to say, “Hey, listen, I think I meet the criteria. Can you do a scan for me?”

And what's pretty interesting, too, is that when you look around the country, so lung screening has been done for, at least, maybe 10 years. That's been accepted with papers being published. When you look in the country, about 6% of people throughout the United States who meet the criteria are getting screened, only 6% of them. When you look at the state of New Hampshire, we are the third best in the nation for screening our at-risk population, and we're still only screening 11% of the people in New Hampshire who could get one. So, there's a lot of education. We want this to get out there that it's a quick test.

You should be having it when you're not having symptoms. It should be paid for, and it's very lifesaving. What is interesting is the data is tracked. In the original national study, they found a cancer for every 300 scans. We here at the Elliot Hospital, we've been scanning since 2017. We've done almost 5,000 lung screening CTs. We've found a cancer for every 70 scans that we do, and the majority of them are early-stage lung cancer, which is theoretically terrible as opposed to a later-stage cancer where your five-year survival rate may only be five to 15%.

Scott Webb: Wow. It's a lot to take in, and I think you're so right. Education is so key, and it's so good that we're doing things like this and getting the word out and the importance and the value of screening. So, when you're actually doing the screening, you're actually doing the CAT scans, the CT scans. What are you actually looking for? Because as you said, we're trying to scan people, hopefully, who don't already have lung cancer, to perhaps get them before it gets really bad. So, what exactly are you looking for?

Dr. Curtis Quinn: We're looking for nodules- little, small areas in the lung that are abnormal, and you can have a little nodule in the lung from lung cancer, or maybe you breathed in some mold or some dust or some hay, or you were gardening a lot of your life. And so, every little nodule is not a lung cancer. And so, because of that, the national lung cancer guidelines have said, “Hey, okay, if you're gonna be scanning all these people, you know what? You're gonna find a lot of nodules that aren't cancer.” And in fact, 25% of the scans do that, they find some little abnormality. And do you wanna surgically remove them all or biopsy them?

Absolutely not. You're gonna be overkill. You're gonna be creating possible complications on patients. So, what we've found and what is recommended are sort of two things. One is that the primary care physician who's ordering the scan has an educational talk with the proposed patient who is eligible and says, “Hey, listen, if you want to get in this program, you should have a scan. And it's not just one scan. You need to be scanned yearly. Because if we find a little nodule, if it doesn't change over a few years, we're not worried about it, and we're not gonna biopsy it. We're just gonna follow it. So, it's not a one-and-done. It's a continuous process every year. But if you find something that's suspicious, we may needle it.

We may do other tests, and those can sometimes have complications, so we wanna inform patients that, you know what, if you're enrolled in this program, it could clearly save your life, but you have to follow along with it. In addition to just the scan, the images are read by a specially trained radiologist that's a doctor that all he does is look at x-rays and if they think there's a lesion that is suspicious, we here at The Elliot then take all those scans and we review them with a panel of experts. People look at the patient's history and their older images. We're trying to do the best we can to say, “Hey, this nodule is really suspicious.”\

It needs to be biopsied.” Or, you know what? This patient had trauma five years ago. They actually had a little injury to the lung. This is no different. We don't have to worry about it. We'll scan them again in a year so we have a very advanced program to try to catch all the lung cancers, but not overtreat people and possibly cause them harm.

Scott Webb: Yeah, you could see that it would be sort of a balance there of not doing more harm than good by overdoing things a bit. And this has been so educational, doctor, it's so much to take in. And the good thing about podcasts is people can pause, they can rewind, they can listen again. And I'm sure listeners will, and as you said, this is so important to get the word out to educate folks. I think as we wrap up, we just want to find out if something is detected in a screening if someone is diagnosed with lung cancer and they have to have surgery, take us through that briefly. And what's the recovery like? As you said, if caught early, it's, in theory, curable for most folks, right?

Dr. Curtis Quinn: Absolutely.

Scott Webb: So what's that like if surgery's involved?

Dr. Curtis Quinn: Just to look at, say someone comes in, they meet the criteria, they have a nodule, it's suspicious. Usually, we wanna do some type of biopsy, And when I say it's suspicious, meaning maybe it's growing or it has activity or features that could be cancer. We biopsy these things because surgery is a major invasive thing. Even though when I talk about this, we do mostly minimally invasive robotic surgery, it is still stressful on the body and these people, they're all smokers. Their lungs aren't that great, and they may have some heart disease. So, if we can identify that it is a cancer ahead of time, biopsies are very important.

As I said, the nodule, it could be like a chronic little infection, which means you don't have to have surgery and we would just follow it. So, typically, the lung screen says it has a suspicious nodule. You would then meet a specialist, a pulmonologist, a lung specialist, or a thoracic surgeon like myself, who looks at the scan with a team of people. You get ten second opinions, and then you talk with that physician, and they say, okay, we think this is suspicious enough to biopsy. The way we do biopsies, a lot of them are CT guided, meaning you go back in the CAT scanner, and they would numb up your skin. It's like getting a vaccination.

You get a needle that will sample some of the cells through a sheath so they're not spreading the cells. Or you may have a bronchoscopy, meaning you come in, we put you to sleep, we put a flexible scope down the airway, and we biopsy it from the inside. Those two techniques are complementary to each other. They can get the different areas of the lung, but if we know ahead of time that you have a cancer then we look at say, okay, what is the stage of the lung cancer? Hopefully, that's the only spot you have. You would get additional imaging, something called a PET scan, which is in radioactive sugar that goes throughout your body and is designed to see if the cancer spread anywhere to lymph nodes.

We all have lymph nodes, your tonsils or lymph nodes, so anybody that knows someone that's had breast cancer, the lymph nodes in the armpit or sample to make sure it hasn’t spread there. Your lymph nodes are like filters. They trap things. There are lymph nodes around your windpipe, so if any of those are enlarged, they may need to be biopsied. If it looks like the cancer is only in one part of your lung, we know that surgically removing that will give you the best chance of cure. But in order to be a candidate for the surgery, you have to have a pretty decent lung function. So, your lungs would be tested for functioning, and your heart may be tested with a stress test to make sure you could tolerate it.

So if all those things fly and the cancer's only in one part of your lung, we would remove that lobe of the lung. And what we do now, mostly for the surgery, is minimally invasive. So minimally invasive means you know, we're not cracking open somebody's chest if we don't have to. It's four small little incisions that reach about an inch long. We put a TV camera in, and we divide the blood vessels and the airways to that part of the lung where the cancer is. Once that's all separated, we actually put that lobe in a Kevlar bag. We don't want to spread anything out throughout the body. A lot of people will come to me and say, everything was fine. But then the biopsy spread the cancer around, or the surgery spread the cancer around.

A lot of techniques are done to make that not happen. We've very conscious of that. And so, then we remove that part of the lung. If everything said you could tolerate it, it's about a three or four-hour surgery. We do something here at the Elliot Hospital that is really great. It's called cryoanalgesia. Even with these little incisions, the ribs are very sensitive. There's a nerve that’s with each rib and anybody that had a broken rib knows how painful that is. So, we freeze the nerve, which takes it outta commission for about six weeks. So, we trade pain for numbness, and that has dramatically cut down on our patient pain scores. Half the people we operate on get zero narcotics, so they're usually in the hospital for three days. When they go home, they can walk up and down stairs.

We recommend they don't drive a car for a week. We usually see them every two weeks, and in about four to six weeks, they're back to doing their full activity. And anybody that has lung cancer will now be followed closely with additional scans to make sure nothing comes back or nothing else crops up, but some people are like, listen I don't want surgery. Or maybe they're older. They can't afford to be in the hospital for three or four days. They're taking care of their loved one, or their heart's not that good. We have additional therapies. We have something called stereotactic body radiation therapy. So, if we can't put you through the surgery to remove the cancer, we can treat it with focused radiation and turn it into scar tissue, and that can often put it into remission for a good five years or more, and you still would be followed.

So, what we try to do is we treat every single cancer patient individually. We diagnose what it is, figure out the stage, and look at their lung function and their heart capability. What's their social home situation? What is the best therapy to treat their cancer, minimize the side effects, and keep their quality of life as good as possible? And so usually we can offer people things that fit in with their lifestyle and educate them and let them really try to make the decision. I really tell all my patients that if somebody says something to you that doesn't make sense, don't do it. Get a second opinion, or get it explained to you why they're recommending that. Even though you're not a doctor, nobody knows you as well as yourself, and so the onus is on your physician to explain why they're recommending a therapy and why that is probably the right therapy for you. But we like getting lots of second opinions.

There's nothing wrong with that. Someone's going to operate on your body. It's a big deal. You need to have faith in that surgeon. You have to follow their instructions and work together with them, so you know what, even if you like them, get a second opinion. And if everybody's telling you the same thing, then you're probably going on the right track.

Scott Webb: Yeah, you probably are. Doctor, you are amazing. I do a lot of these you know; all the experts are great and some are amazing and some are even more amazing. You're in that latter category. We squeezed about three hours’ worth of information into roughly 20 minutes or so. So awesome, so great. And nobody wants any kind of cancer, lung cancer or otherwise. But it is good to know at The Elliot that the screening is available, emphasizing diagnosis and specializing in customizing things for the patient. You said, like the panel of experts, second opinions, and so on. So again, nobody wants this, but if you get the screening and you have it, you're in good hands at The Elliot. So, Doctor, thanks so much for your time. I wish we could stay on longer, but this is probably enough for one podcast. So, thanks, and you stay well.

Dr. Curtis Quinn: Thank you. I appreciate your time and glad that you're getting the word out. It's such a life-saving thing.

Scott Webb: And for more information, go to elliothospital.org.

If you enjoyed this podcast, please be sure to tell a friend and share it on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.