Michael Smith, MD (Host): A look at ION Bronchoscopy on this episode of Curating Care, a podcast brought to you by St. Clair Health, expert care from people who care. I'm Dr. Mike, and joining me today is Dr. Richard Maley, the Chief of Thoracic Surgery here at St. Clair Health. Dr. Maley, welcome to the show.

Richard H. Maley, Jr., MD: Thank you very much.

Host: So could you start by explaining what this is, ION bronchoscopy and how is it different from some of the traditional techniques? And, at the end of the day, why was this even looked into and researched? What's some of those benefits?

Richard H. Maley, Jr., MD: I mean, historically, bronchoscopy way, way back when was done with rigid scopes, rigid metal tubes. Really could not reach very deeply into the lung. And then flexible bronchoscopes came out and they were better, and they could reach about a third of the way out into the lung. But in an effort to get further into the lung, to reach out into the middle of the lung or the edges of the lung, about 25 years ago, navigational bronchoscopy was developed. Initially it was used with electromagnetic technology. But this new system, this ION System, is a navigational system that allows you to get further out into the lungs, but use is really very sophisticated computer software, and sort of what they call shape sensing 3D reconstructive maps.

And, it sort of marries the virtual image with the real image very well, so we can get out to these smaller peripheral lesions and hopefully get a diagnosis earlier.

Host: I did some research too. So we're looking at these microthin catheters, they go further down the lung, just as you said, 3D mapping, navigation. It's amazing to me there's robotic assistance in this. How has all of this enhanced accuracy and safety?

Richard H. Maley, Jr., MD: Probably the traditional bronchoscope that crossed any lesion in the lung probably only had an accuracy of 40% at a diagnostic yield. Probably the first iteration of navigational systems had an accuracy of 70 to 75%. And it's a little early to tell because the ION hasn't been compared against other systems, but it's probably in most studies now running about 84 to 85% accurate in getting a diagnosis in in very small peripheral lesions, which is pretty good.

Host: What kind of patients would be best for this?

Richard H. Maley, Jr., MD: Well, I mean, it can be used to diagnose anybody with lung cancer. Big lesions, advanced stage patients, there's a million ways to diagnose them. It's easy. So by the time someone has a symptom, it may just be getting you a diagnosis and the treatment's going to be chemotherapy or radiation.

They're going to be hard to cure those patients with advanced stage cancer. But the new sort of paradigm in, in diagnosing lung cancer is to catch it early. I mean, we've had overall cure rates of lung cancer of only 19%. And that's awful because too many people are found in late stages. But the push is to do lung cancer screening in people that qualify. The push is to work up incidental pulmonary nodules.

Someone, their doctor tells them I want you to go for a scan to calculate how much calcium you have in your heart. And if you have so much, I'm going to put you on a statin. But on that scan, you know, it says your heart's okay, you don't have little that much calcium, but you have two pulmonary nodules.

So now what do you do with those nodules? And so, what we're hoping is to, if we can take the patient with the incidental nodule, the patient who is asymptomatic, the person who just went for their cataract exchange or resection, and they had a chest x-ray and they find a nodule, can you get a diagnosis in those patients?

And the hope is with this ION Robotic System, we can navigate out to that small spot. And right now I'll tell the patients I have a chance of getting an answer at about 85% accuracy. And that's pretty good for these small lesions. Historically, what we've told those patients, well, we don't have a good way to diagnose it, so we're just going to follow you.

Four months from now, six months from now, you're going to get another scan. In some patients that, certain personalities, that's great. They like to kick the can down the road, but other people, it drives them nuts. They're thinking, oh geez, I'm sitting here with a small cancer and he's saying he can cure me if he catches it early. But he says he can't diagnose it, so he wants me to come back in half a year. And so those people are thinking that guy's crazy.

Host: When a patient goes through ION Bronchoscopy, I guess in terms of recovery time and outcomes, how does this compare to the traditional bronchoscopy?

Richard H. Maley, Jr., MD: Well, I think all bronchoscopies, I would say are minimally invasive, right? Because they're all done, through a hole in your body that God gave you. I mean, it's not a hole that I've created. So they're all done through the mouth. They're generally done under anesthesia or sedation. You come in as an outpatient, you have it done, you go to a recovery room, you go back to outpatient and you go home.

So, the power of this is not that it's less invasive. The power is that it is, accurate and the other, when you want to say, well, what, when you look at the tools that we've used to diagnose lung lesions, we've used bronchoscopy and we've used CT guided needle biopsies.

Now, a CT guided needle biopsy would be, you'd go to the radiology department, you'd be in the CT scanner, they'd CAT scan you, they'd see where the nodule is. They'd numb up the skin and stick a needle right in you. Now, that's pretty accurate, but it has the risk of a pneumothorax, collapsing the lung, because you gotta stick the needle into the lung and then you gotta pull it back out.

And when you pull it out, it can leak air and you can collapse your lung. If you do a navigational bronchoscopy, you know, from the inside and your biopsying it, you don't have that risk of pneumothorax. So a CT guided needle biopsy, which we used for peripheral lung lesions in the past, I think ultimately is going to become obsolete.

As we move into the next five to seven years and we get better and better at this and I think the radiologist would be happy because they don't like collapsing lungs either.

Host: St. Clair Health is well known to be very innovative. So how does ION Bronchoscopy kind of integrate with some of the other treatment methods that are available at St. Clair?

Richard H. Maley, Jr., MD: Yes. So when you look at your lung cancer program, in general, you want to have a robust lung cancer screening program. You want to have an incidental nodule program. So lung cancer screening would be anybody between the ages of 50 and 80 who have smoked, say a pack a day for 20 years. They could, they may have quit, but they quit less than 15 years ago.

So all of those people qualify for lung cancer screening and it's paid for by Medicare and all the major insurance covers coverage. So you have to have a good lung cancer screening program. We started probably back in 2014. I think we screened 200 people. I think last year we screened almost a thousand people.

So it's a growing program. Now, the incidental lung nodule program, you can start that anywhere. You can just pick the ER and say, everybody that comes into the ER that gets a CT scan of their chest for whatever reason, if there, there's an incidental lung nodule, how do you com, how do you communicate that to the patient?

Because a lot of times that gets missed. I mean, it's there in the report, but the report never goes to the PCP or the report never really gets into the right hands. So you sort of sit an AI program over top of all the CAT scans and it picks out all the people that have an incidental module.

Then it goes to a nurse navigator, and the nurse navigator looks at the list, look at the scan, and then picks out the important ones, and somehow gets that patient follow up. So you need a good way to screen people. Then ION Robotic Bronchoscopy is part of our diagnostic program to get the diagnosis.

Once you make the diagnosis, then you need surgeons like me to remove the early stage lung cancers, and that needs to be done in 2025, robotically because it's clear that that is very minimally invasive, has good results and low complication rates. And actually I think the robotic system makes lung surgery easier because I'm an old enough guy that I've done it with a chainsaw.

I've done it with the regular handheld scope, and now I do it robotically, but it's just easier the, it's easier to see. Better vision, better instrumentation, and if you have a bad back, you get to sit down through the whole case. So, and then once you get past that, you may or may not need to go to an oncologist.

And we have our St. Clair cancer group is a joint venture with UPMC. And just, excellent oncologists. We have a radiation therapy program that you may or may not need. And what's unique about that and the technology there is we have a new linear accelerator which delivers enough power to do what we call stereotactic radiation.

And stereotactic is when you just aim an intense beam at a nodule, for maybe a whole bunch of different directions. So you kill the nodule, but you save surrounding lung. And that can be used in people with poor pulmonary function that you want to ablate this or people that aren't a candidate for surgery for whatever reason.

We do that right here at St. Clair. In years past, you'd either have to go to downtown to get that done, but we do that right out here in the community. So we have, and then lastly, to have a group of people in what we call survivorship, which helps people once they're done with treatment, they get follow up and the adequate follow up they need over, say the next five years to make sure they don't have a recurrence.

Host: So you mentioned you've been a thoracic surgeon for a while. You've done it all. What kind of training requirements did you have to go through to do the ION Bronchoscopy?

Richard H. Maley, Jr., MD: Right. So I pro I started with navigational bronchoscopy probably when it first came out. The ION system is a little bit different. So, when we knew we were going to get one, I went to Atlanta where they have a training center and, you spend a day, a whole day, about half the day is didactic and the rest of the day is on cadaver lungs, doing procedures, and then when you come back, then you have sort of a, the company sends representatives, expert representatives to help you with say your first 10, to get you up to speed. So, you know, I'm only at about 10 now because we've only been doing it for a little over a month.

But I mean, I probably will be, the more you do, the more you realize the power of this system. And I'm probably not fully utilizing all the power of this system, but it's really in its computer software and it's, modeling that the power of this because I think the engineers that built this system are quite unique.

Host: How have the patients responded? Any feedback from them?

Richard H. Maley, Jr., MD: I mean, I think all the patients have done well. We haven't had any complications, no bleeding, no pneumothorax. And right now we're running at about eight. I've done 11, I think and, and eight people gotten an answer. Which, I think for a new user is probably pretty good.

These people that are saying, well, I'm 85% accurate, they're probably a hundred procedures into it when they can say for sure what their accuracy rate is.

Host: So what's next for you and St. Clair? Where do you see all this going in the near future? Far future? What are you most excited about?

Richard H. Maley, Jr., MD: I think it's important in lung cancer treatment that we push that cure rate. It really, when I look back, when I started in medical school and at the end of medical school and through the first, a lot of my career, I mean, lung cancer survival was stuck at about 20%. A lot of the big surgeons in my field, spent their whole career in doing studies talking about how they do surgery.

In other words. I take, out your esophagus, maximally invasive, minimally invasive, through the chest, through the abdomen, through the neck, all these different techniques. But if you look at techniques, it doesn't change survival rate. It may change complication rate, it may change the time in which it takes you to do it, but it doesn't improve overall survival.

So to really make an impact, it's like anything, it's like in breast surgery, you know, you do screening mammograms. It's like in colon surgery you do screening colonoscopies. I think in lung cancer we need to find people early. And we need to treat them early and then we'll get cure rates of maybe 80%, which are the stage one patients.

The trouble is the stage four patients have a 0% cure rate, and the stage three is low, but, more than half of the people are stage three and four. When we need that to be a small group of people, we need most people to be stage one or two. What you really do is you want to push, people into finding them early and treating them early.

And that may come in the form of blood tests, you know, I mean, prostate cancer and PSAs, for instance. I mean, maybe someone will discover a way to detect something in the blood or something that will pick up these cancers early. And, maybe 20 years from now they'll say, oh, look at this.

They used to cut cancer out to treat cancer. You know, they were barbarians. But, um,

Host: That would be a good thing. Right? In 20 years, that'd be great.

Richard H. Maley, Jr., MD: Yeah, hopefully we'll get to a point where we can detect things early and and that doesn't even go into the whole situation of smoking cessation, because that's a big part of what we should be doing. And now, secondhand smoke is not the second leading cause of cancer, but radon is the second leading cause of lung cancer. And, people need to pay attention to that a little bit. I, talk to some of my patients and they'll say, oh yeah, I have high levels of radon in my house, but I'm only going to take care of that if I sell my house.

I'm going to wait till I sell. I'm like, why wait till you sell for heaven's sake? Why fix it for the next poor bloke that's going to live there? I mean, fix it for yourself.

Host: If you knew it needs to be fixed, fix it. Right.

Richard H. Maley, Jr., MD: Right, right.

Host: Dr. Maley, this has been fascinating. What a great podcast this has been on ION Bronchoscopy. Love to hear about the exciting developments over at St. Clair Health. So thank you so much for coming on today.

Richard H. Maley, Jr., MD: Okay. You're welcome.

Host: If you're interested in learning more or need to schedule an appointment with Dr. Maley, please call 412-942-5710. That's 412-942-5710. We hope you enjoyed this episode of Curating Care. Until next time, stay informed and take care.