Cheryl Martin (Host): This is St. Joseph's Health MedCast. I'm Cheryl Martin. On this episode, we take a look into the complex world of lung cancer, misconceptions, symptoms, the power of early detection, and more. Here to give us a deep dive into lung cancer are two thoracic surgeons, Dr. David Wormuth and Dr. Michael Parish. Delighted to have you on to discuss this important topic.

Dr. David Wormuth: Thank you.

Host: Please briefly introduce yourselves and explain what a thoracic surgeon does. Let me begin with you, Dr. Parish.

Dr. Michael Parish: Good afternoon, Cheryl. Thanks for having us on. I'm originally from St. Louis, Missouri. I went to NYU and did cardiothoracic surgery training. And for years, I did cardiac surgery. I subsequently went back and did minimally invasive thoracic surgery at Roswell Park Cancer Center between 2018 and 2019. And then, I went to Milwaukee for five and a half years, and I joined Dr. Wormuth here in St. Joseph's Hospital about one year ago, a little bit more than one year ago.

And so, a thoracic surgeon is someone who does either cardiac or lung cases or anything in the chest. But for thoracic surgeons, we've devoted ourselves to minimally invasive or thoracic surgical cases limited to the chest other than hearts, other than arteries.

Dr. David Wormuth: Unfortunately, I was actually born at Crouse, not St. Joe's. So, apologies for that. I've been a lifelong Syracuse native, finished my training in 2000. I did my general surgery training in Syracuse. I went down to Rochester for my thoracic training, and then moved back to town in 2002. And I've been here since then doing what we call general thoracic surgery. So, lungs, chest wall, esophageal work.

Host: So, how common is lung cancer and why is it still such a major health issue?

Dr. Michael Parish: So, lung cancer is the third most common cancer in the world. If you think about it, the most common cancer in women is breast cancer. The most common cancer in men is prostate cancer. And lung cancer is the second most common in both men and women. However, lung cancer is more deadly, causes more mortality than any other cancer. And so, it's very common. In a lifetime, about one out of nineteen people will develop lung cancer. And so, lung cancer is very common and it's very deadly.

Host: What are some common misconceptions people have about lung cancer?

Dr. David Wormuth: For better or worse, it has a very tight association with smoking. There's an unfortunate effect that this is a cancer that people who choose to smoke, have chose to bring upon themselves. But we're finding although yes, the smokers and ex-smokers have a much higher risk of lung cancer, we're seeing significant cancers in people who never smoked. Here in the central New York area, that might be because they've got an unabated radon exposure happening in their house because we live on so much limestone.

The other misconception about lung cancer is that when it's found, it's oftentimes so late that there's no treatment available because people, you know, remember the anecdote Aunt Mary was fine, then they found a spot in her lung. And then, three months later, she was gone. And although that does certainly happen, part of what we're hoping to convince your listeners today, our listeners today is screening and early detection of cancers makes a huge difference in how people ultimately do with a cancer.

Host: So, what symptoms should prompt someone to talk to their doctor about lung cancer?

Dr. Michael Parish: Unfortunately, for lung cancer, sometimes, most times, the patient may be asymptomatic. However, if a patient has a cough, a persistent cough, if they're coughing up blood, if they're short of breath and it doesn't go away, if they have pneumonia or diagnosed with pneumonia and their physician sees something on chest X-ray or CT scan, they should absolutely have a followup study to ensure that their signs and symptoms go away, that that cough goes away, that chest discomfort goes away, that if they're coughing blood, that that goes away. If they're losing weight and they're eating properly, that they check with their doctors. And if a sign or symptom doesn't go away, they should absolutely check with their physician or ask their physician if they ought to have some additional studies. But again, most signs and symptoms include cough, shortness of breath, coughing up blood, weight loss. Those are the signs and symptoms we normally think about. But again, patients may be absolutely asymptomatic. Patients may certainly have chest pain or discomfort, which is a late sign.

Dr. David Wormuth: And it's not like that, it's not a symptom. But if you've actually been smoking, particularly if you've been smoking more than a pack in a day of cigarettes, that should prompt the discussion with your doctor really before someone develops symptoms. It's the fact that "I used to smoke heavily or I currently smoke heavily," that's our biggest risk factor, and we're going to talk a lot more about it in the course of this podcast.

Host: You talked early about the importance of early detection. When should a person say, "I need to be screened"?

Dr. David Wormuth: Historically, we see lots of people that have nodules in their lung that never need anything done, and that's been a problem. Because when you do things like let's give everybody a chest X-ray or some kind of screening test like that to the general population, there's a lot of noise and very few people are identified with a problem. You can't prove if you do that, that you're actually saving any lives or extending lives, even though you think it would work.

The screening criteria is new in the last probably 15 years or a decade, and it's finally been pushed to the forefront where even New York State has now authorized as of January of 2027, that lung cancer screening, I believe, will be free as long as you meet the eligibility criteria. And it's the eligibility criteria that are what distinguishes getting the low-dose CT scan for people where the risk of them having a cancer is higher than the general public. That's the group that really gets helped by this, the lung cancer screening and the early detection.

Before we were doing that, we would have comments with people of, "Boy, that was your lucky fall when you broke your wrist and they did a chest X-ray on you in the ER. And, hey, there's a spot in your lung." Now, we're seeing people very much earlier in their disease course and that saves lives. That's huge.

Host: Can you discuss more about this new legislation? You mentioned the criteria, you touched on that a little bit. Can you just go into more detail and also why it's such an important step for public health in New York?

Dr. Michael Parish: So, sometimes what happens is patients don't get lung cancer screening because of cost, or they stop their lung cancer screening. We know that the screening criteria includes a patient who smokes a pack of cigarettes for at least 20 years, or a patient who smokes the equivalent of that. So if you smoke two packs a day for 10 years, then you qualify lung cancer screening as long as you're between 50 and 80.

In addition to that, you have to have stopped less than 15 years. So if you stopped 20 years ago, then you don't necessarily qualify for lung cancer screening. The unfortunate thing about that is just because you stop smoking doesn't mean you won't get lung cancer. So therefore, the advantage of this new regulation that's going to come into effect starting in 2027 is that patients won't necessarily have to worry about their insurance covering low-dose cancer screening CT scan.

And that's a concern of patients, then that's very, very important. I mean, imagine that you have to come up with a certain amount of money to get a CAT scan that can save your life or detect something that's very important to you. Certainly, there are patients who don't seek medical attention because of the concern of cost

Host: Now, there's been a lot of talk in the past about secondhand smoke. How many people who are diagnosed with lung cancer maybe never smoked and they got it as a result of secondhand smoke?

Dr. David Wormuth: You know, I don't know of statistics on that. Unfortunately, the criteria really only mention packs of cigarettes. So even if you're a pipe smoker or a cigar smoker, or if it was just intense secondhand smoke, we don't really have data that would apply a risk percentage to that. The fortunate thing is the low-dose CT scans, even if you don't qualify to have it reimbursed by insurance, are relatively inexpensive. And so, if someone's truly concerned, it can be ordered. It just might be an out-of-pocket expense.

Host: Have you had patients that indeed they were diagnosed with lung cancer and they will say, "Wow, but I've never smoked"?

Dr. Michael Parish: You have to realize that the number of patients who are non-smokers is increasing, especially in women. And that's attributed to possibly estrogen. It's also attributed to secondhand smoke. It's common in patients in Asia, if they're burning wood or they're using coal to heat their homes or to cook.

We absolutely have noticed that there are increased number of patients who are non-smokers who come in and say, "I never smoked and I have lung cancer. How did this happen?" Okay? And so, the problem you have is that imagine those patients don't qualify for lung cancer screening. And so, therefore, it's important for them, if they have any of those signs and symptoms that I've mentioned, that they absolutely seek care. A lot of times, we may see some of those patients who have had other studies done. they may have gone to the emergency room because of chest pain. They may have fallen, like Dr. Wormuth said and, therefore, had an X-ray or a CT scan for some other reason. They may be getting studies to check their coronary arteries and, therefore, something shows up or they get an X-ray to have in preparation for some other operation and they're diagnosed with lung cancer.

Host: When does lung cancer require surgery? And then, what are the instances when surgery is not needed?

Dr. David Wormuth: When we have diagnosed someone with lung cancer or if we think it's a cancer, we do a mental assessment of what we call staging. And for lung cancers, we kind of have a scoring grid, and we look at factors about the tumor about lymph nodes, and whether or not we think there's any metastatic disease.

And by sort of following the scoring grid for that, we can group people into stages. And lung cancer stages go from 0 to IV, 0 being we actually can't find it but we know it was there to stage IV means gotten away from the lung and into other parts of the body. Once we know what someone's stage is, then we can talk about what are the appropriate treatments.

So if we find someone with an early lung cancer, say, from a screening scan before it's gotten into any nodes or away from the lung into other parts of the body, then surgery really winds up being the best treatment. For stage 0, stage I, or stage II, surgery upfront is what we would do.

And for stage I, often that's all we have to do, and we just do surveillance afterwards. If they're stage II, then we typically will operate, but they might need some chemo/immunotherapy after the treatment. And for stage III, we do divide these into some A and B groups. If someone's stage III, we'll usually try and give them the chemotherapy and immunotherapy, occasionally radiation therapy, before we operate on them to try and shrink things, what we call down staging. And for someone that's a IIIB or C or a stage IV, surgery, it's not the right tool. It generally doesn't help for curing. We sometimes have things we can do to help with symptoms, but there we need a more systemic treatment, which would be the chemotherapy, immunotherapy, and potentially radiation treatment.

So, it kind of depends on where we find someone. Again, because there's been no symptoms, historically we found people very late. Now, with the screening and the better awareness, we're actually finding people in earlier stages, and that's really what's allowed us to say we are improving the overall survival of patients that have lung cancer, because we're finding them early, getting them into remission, and keeping them there.

Host: So, how have minimally invasive or robotic techniques changed recovery for patients?

Dr. Michael Parish: So, the minimally invasive surgery implies that we use small incisions to do the patient's operation. Years ago, we used to make a large chest incision thoracotomy to do these operations. But over the past twenty years or more, people have developed robotic surgery, VATS operations, where we talk about video-assisted thoracoscopic operations. And this allows the patient to have a similar operation, get out of the hospital faster, recover faster, hopefully have less pain and decrease the blood loss, minimize morbidity and mortality, allow the patient to recover a lot faster. And so, this has significantly improved what we can do for patients and for different types of lung cancers.

Host: So, how do you work with other specialists such as medical oncologists and pulmonologists in caring for lung cancer patients?

Dr. David Wormuth: Well, oftentimes, either we'll start the workup or the pulmonologist will start the workup, or sometimes even medical oncology will do it, although usually they're so busy with known cancers that they're happy that someone else is doing the time to do the workup. We make the diagnosis, we establish the stage, and then figure out is this early enough that we can just operate? And we send them to medical oncology afterwards if we know they're going to need chemotherapy and immunotherapy or further treatment. Sometimes it's obvious from the get-go that we need medical oncology. One of the great things that happens every week is we have a tumor conference where we meet with, present cases to other thoracic surgeons, medical oncologists, radiation oncologists, with radiologists looking at the images and helping us interpret them, and pathologists looking at the tissue slides to sort of go over what we think the cancer is, what the treatment is.

And, you know, it's a collegial discussion about, hey, this option might be good for this person, that option might be good for that person based on different factors that they bring with them to their healthcare situation. We start it once we identify somebody who's a little more complex. We have conferences with those other specialists and vice versa. And then, we agree on treatments and get them done.

Host: What would you say are some of the most exciting advances in lung cancer treatment today? And then, how hopeful are you about the future of lung cancer care?

Dr. Michael Parish: The most cutting-edge information that we have has to do with chemoimmunotherapy and therapy that's directed specifically at the patient. And so, that's significantly changed the recurrence rate, the risk of patients being allowed to live their lives and hopefully be cancer-free.

Imagine, we know that the survival rate for stage I lung cancer is about 68% to 92%. For stage II, it drops down to about 53% to 60%. And for stage III, it's 53% to 36%. And so, the good thing about using chemoimmunotherapy or using definitive chemoradiation is that sometimes those patients may be cured of their cancer. They may develop recurrent cancer two years later, three years later, five years later, but they're cured of that cancer, and they may go ahead and progress to another cancer, or they may be just cured. I had a patient who had stage IIIA cancer, where the patient had a very large cancer and had lymph node involvement, preoperatively, but they had chemoimmunotherapy. And by the time I did their operation, there was no cancer, no residual cancer found in their lung or in the lymph nodes.

Host: Any closing thoughts from either one of you? Something else you'd like to add?

Dr. David Wormuth: We're really excited about the availability of the low-dose screening. For breast cancer with mammograms, the statistics are about nine out of 10 people that are eligible for mammograms are getting them. Unfortunately, for the low-dose lung cancers, it's closer to one to two out of every 10 that are getting it.

So, we're really trying to raise the awareness of the power of the low-dose scan. And actually, it's the second, and the third, and the fourth scan that you get where we might be able to detect something that was in retrospect present on the first scan, but not obvious. And then, you see, hey, this area is changing, which is a worrisome feature.

So, we're just getting people that qualify for low-dose scan or that want to get one may have to pay for it out of pocket, is really improving lung cancer survival for those unfortunate enough to develop it.

Dr. Michael Parish: I'll just comment about the recurrence risk for lung cancer. Years ago, I thought that if I operated on a patient who had stage I lung cancer, that they were cured. I realize now that for stage I lung cancer, about 10% to 30% of those patients will go ahead and develop a recurrence. And therefore it's incumbent upon us, one, that we take care of those patients in terms of doing a good operation, being thorough in terms of taking out lymph nodes and resecting the cancer, not leaving any cancer behind. But those patients also need to be followed, followed very closely because they have an increased risk of recurrence.

Host: Dr. Michael Parish and Dr. David Wormuth, thanks so much for educating us on lung cancer and especially emphasizing the power of early detection. Thank you so much.

Dr. David Wormuth: Thank you.

Dr. Michael Parish: Thanks for having us.

Host: For more information, visit sjhsyr.org. That's sjhsyr.org. If you found this podcast helpful, please tell others about it and share it on your social media. You can check out our entire podcast library for other topics of interest to you. Thanks for listening to St. Joseph's Health MedCast.