Scott Webb: Lung cancer screening, especially if you're a smoker, is essential to early diagnosis and survival of lung cancer. And joining me today to emphasize the importance of lung screening and to tell us about the latest advancements in treatment is Dr. Nkem Aziken. He's a cardiothoracic surgeon at Summa Health.

This is Healthy Vitals, the podcast from Summa Health. I'm Scott Webb. Doctor, it's great to speak with you. Today, we're going to talk about lung cancer and screening and diagnosis and treatment and all of that. So, I've got a bunch of questions for you. Just as we get rolling here though, how common is lung cancer?

Dr. Nkem Aziken: I would say lung cancer is pretty common. It is the major cause of cancer deaths in the US. So, about 230,000 new cases of lung cancer are diagnosed every year, and that's pretty much split in the middle between men and women. And then, about 130,000 of those will die from lung cancer. And also, it's a little bit more heavily weighted towards men that die more than women. But it's just give or take a few thousand, it's pretty much close to each other. Again, like I said, it's the leading cause of cancer death in the US. And about one in five of all cancer deaths is attributed to lung cancer. That is actually more than that of colon, breast, and prostate cancers combined.

Scott Webb: Yeah. I've heard that, that it's a significant problem. And I think it's important that we talk about the risk factors. I'm assuming smoking is at the top of the list. I'm sure there's some other things, toxins, whatever. But from an expert here, who's at the highest risk of developing lung cancer?

Dr. Nkem Aziken: Yeah, you're right, the people who smoke are the highest risks of developing cancer. The number one cause is smoking, number one, number two, and number three. Then, you have other things that come in line. Radon exposure is a risk factor for lung cancer. Personal history of lung cancer, if you've had lung cancer in the past, you're more likely to get it again. And along with smoking that I forgot to mention earlier, is exposure to secondhand smoking, that increases your risk for getting lung cancer. If you have a family history, there is something about genetics that make you prone to it. And previous radiation or exposure to things like asbestos, arsenic, silica, chromium, those are a little bit more rare, but those do count for a handful of lung cancer etiologies that do happen.

Scott Webb: Yeah. So, it sounds like much of the risk for us, for people, are things within our control. And it would be a separate podcast to talk about how difficult it is to quit smoking and smoking cessation and all of that. So, let's assume then that someone has been a smoker for a long time, maybe even quit, and quit within, let's say, the last 10 or 15 years. Let's talk about the recent changes to the guidelines for lung screening. So, what's involved with the screening? Who's a good candidate for it, insurance and otherwise? How often should they be screened? Take us through that.

Dr. Nkem Aziken: For the longest time, we did not have lung screening guidelines. Although this was the number one cancer killer, we did not have screening guidelines. It used to be a family care physician would get a chest x-ray, but we've known now that chest x-rays are not the best for diagnosing lung cancer, especially since this is quite treatable when it's diagnosed early. And we do have CT scans which we've used for years and years. And those are better at looking at the lung. And in about 2014, the National Screening Lung trial was done and that showed that we are able to reduce lung cancer deaths by 20% when people are screened.

And so, at that time, it was recommended that people of the age of about 55 to 80 years old get screened if you have 30 or more pack years of smoking and if you have quit smoking within the past 15 years. But as the screening went on, the United States Preventive Task Force realized that was excluding a large number of people. And so, the screening guidelines were then enlarged for age and decreased for the amount of smoking years you have. So now, it's recommended that people between the ages of 50 to 80 years of age; and if you have smoked 20 pack years, that means if you have smoked a pack of cigarettes per day for 20 years, that says that you have a 20-pack-year smoking or if you have smoked two packs of cigarettes per day for 10 years, that is a 20-pack-year smoking, if you have done that and you're between the ages of 50 to 80 years of age, you should get a low-dose screening CT scan every year. And also, you have to have quit smoking if you were successfully able to quit within the past 15 years.

Scott Webb: Yeah. And I think, doctor, I need to tell you of course, you being an expert, but it seems what I've heard about lung cancer is that it often isn't diagnosed until the later stages when the chances of survival go down dramatically. So, how have the screenings impacted that, the early diagnosis and the survival of lung cancer?

Dr. Nkem Aziken: Yeah. I get this question quite a bit and I'm seeing it in my practice daily. It is certainly easier to treat when you diagnose it early. Easier and the treatment burden is much less.

To give you a survival guide, a five-year survival of cancer that is localized, what I mean is just in the lung, is about 50% all comers for lung cancer. If one of your lymph nodes in the area of your lungs is affected, that number drops to about 25% that you'd be alive in five years. And if the cancer has spread to another organ outside of your lungs or on the other lung, that number drops to less than 5%.

So, it is much, much easier to achieve cure and to treat a patient when diagnosed early. And lung cancer screening has actually been able to achieve that. As I alluded before, there is a 20% reduction in death if you undergo lung cancer screening, and that's very attributable to catching lung cancer early because that's when we are able to get cure most of the time.

Scott Webb: Yeah, definitely, one of the major takeaways from today is being screened, diagnosed early, treated before it gets into the later stages. And Summa's really good about this and including this aspect into their podcast because of the communities that they serve, that lung cancer screenings do catch cancer at earlier stages, but there's still some populations that face worse outcomes from lung cancer regardless of when they're screened, when it's diagnosed. So, maybe you can talk about who those populations are, what they're experiencing, why there are these racial disparities in lung cancer care and so on.

Dr. Nkem Aziken: Again, it's not just lung cancer. I think as you alluded to, this pretty much is in many aspects of our day-to-day life. Whether it's healthcare or social work or just being in the community, there seems to be a disparity to the minority group in some aspects, and that applies the same thing in lung cancer screening or lung cancer.

For instance, black men are about 12% more likely to develop lung cancer than white men and also black men or African Americans are more likely to die of their disease than Caucasian counterparts. The reason for that sometimes is really hard to pinpoint. For instance, you could say low health literacy or medical mistrust or cancer fatalism or the stigma or sometimes their cultural barriers, financial burden, transportation, lack of insurance. Things like that contribute to the treatment in the minority population of lung cancer.

The exposure to smoking, I think, if you were listening to the news recently, there is a push to ban menthol cigarettes and that was heavily marketed to the African American group. And things like that make it that the disparities in the care or the disparities in the way we approach the African American community or the minority community, make it that we don't give as much care as we could to a population that is more likely to develop lung cancer.

Scott Webb: Yeah. I think you're so right, doctor. There are so many disparities, not just in lung cancer care, but in healthcare in general, perhaps in life in general. And we hope that podcasts like this help to educate, maybe help to close the gap a little bit, to help more folks survive things like lung cancer. And I want to ask you about nodules, right? I know that not all nodules in the lungs are necessarily cancerous. Some might just need to have some surveillance, if you will. But when you do find a lung nodule and you suspect that it may be cancerous, what's the next course of action?

Dr. Nkem Aziken: The next course of action is to get a biopsy of the nodule. And now, the way we do that and the way we treat these all depend on the size, the time we diagnose it, or the function of the patients that I'm seeing. But the way it goes is usually we get a biopsy to find out if it is indeed truly cancer. And if it is, then we have to find out how far advanced is it. Is it something that is just localized to the lungs or has it spread to the lymph nodes or has it spread further than that? And after we get a biopsy, we have to do some images to assess how far it has spread. And after the images are done, then comes the treatment time. If it's just in the lungs, usually surgery is recommended if you can tolerate surgery. If it has spread to the lymph nodes, in addition to possible surgery, we add systemic treatment, which is chemotherapy. And if it has spread outside of the lungs and outside of the lymph nodes, at that time, it's way too advanced for surgery to be recommended and usually we treat with just systemic therapy, which is chemotherapy. There's some people who cannot tolerate surgery and, in those people, we offer radiation.

Scott Webb: Yeah. So, there's range there. But focusing specifically on the surgical advancements, I know that everything's being done laparoscopically and minimally invasively and all of that today. So when we think about the cardiothoracic team at Summa, taking advantage of some of the surgical advancements, maybe you can take us through that.

Dr. Nkem Aziken: Yeah. We used to do all lung resections, this is before I trained, it used to be big incisions in the side of your chest where sometimes some ribs have to be divided in order for the surgeon to get a good working space to get the lung out. Nowadays, we don't have to do that. We have small instruments. And in the past, how I trained was something called a thoracoscopic surgery, where I used small incisions and long instruments. But that was ergonomically not very sound for me, just because of the way I have to control my body and because of the way the ribs are, trying to get rigid instruments in between the ribs that are not flexible was not very good ergonomically for me. And so, as there has been a new platform that we now offer at Summa here and we've done very well with it and patients have had really good experience with it, and that's robotic surgery. It's also minimally invasive and it uses very small incisions and it's actually faster than previous minimally invasive surgery we were able to do. If the removing the lung is not a very complex one, it takes us about an hour to remove a whole lobe of a lung, which is a cancer treatment because the platform is quite suitable for us. And so, the patient is exposed to less anesthesia time and we are ergonomically better able to provide care.

In addition to having the robot, which is a new technology, we are also able to remove very small tumors because we have the pulmonologist here who can find the small tumors with a camera in the airway. And they're able to mark it for us with a dye. And when we go do surgery, we can find this dye and we can resect the entirety of the dye, which gives us good resection margins for the tumor. And that's an advancement that we just started this year at Summa. So, this is a big advancement for us and it really helps in the way we have been treating lung cancer. We tend to be more aggressive because a late cancer is really bad, but an early cancer can definitely be cured.

Scott Webb: It's really amazing. Wondering what are some of the myths or misconceptions about lung cancer? Like what do people think they know about lung cancer, but you wish they really knew?

Dr. Nkem Aziken: Yeah. The first thing I would say is it's easy for things to spread in the community. And with every one person that spreads it, a little bit of misinformation gets passed down. And so, as I always tell patients, it's nice, my doors are open all the time, you can always call me to talk about the questions that you may have if it is that your information is solely from the community.

For instance, a myth is only smokers can get lung cancer. We know that's not true because about 10-20% new lung cancer diagnosis are in people who have never smoked. There's some genetic predispositions that you may have, and even though you have never touched a cigarette, you can still get lung cancer.

Another myth is if you are diagnosed, you don't have to stop smoking. If you remember earlier in the talk, I said that if you have lung cancer, your risk of getting lung cancer is high because you have now proven that you can get lung cancer. So, there's something about it that shows that you are prone to getting lung cancer. And so, it's a myth that you don't have to stop smoking because smoking increases your risk of getting lung cancer.

Another myth is that lung cancer has no treatments. Again, I just alluded to many modalities that we can have. We even use combined modalities, surgery, radiation, and chemotherapy to be able to give you a chance to cure of lung cancer.

And there's another myth about there's no way to find lung cancer before it spreads. And this is the reason why we talk about lung screening, to be able to find this earlier because the myth out there is that we can't find it early enough, but I do disagree with that myth.

And there's a myth about only cigarettes cause lung cancer. But we do know of a lot of celebrities who were proponents of cigars who ended up getting lung cancer. Pipes cause lung cancer. Hookah can cause lung cancer. Although littler than cigarette smoking, they do still cause cancer.

Not all lung cancers are the same. There's a myth out there that lung cancers are all the same, but there are different varieties to lung cancer. And again, people who have lung cancer, it's not productive to blame them when they have the disease. I think it's very productive to help them and help them get through it and help them get through the behaviors that have exposed them to having the risk of lung cancer. And the medical doctors are really trying to help. And so, I think there's a mistrust of medical doctors out there and I think trusting your medical practitioners to provide you the best care will go a long way to help us treat lung cancer and help us not propagate some myths out there.

Scott Webb: Doctor, that's perfect. You are a fantastic guest. I have never had a dud in all the Summa podcasts that I've done, but you are right up there at the top. So much great information and compassion and just trying to get the word out, trying to educate folks, right? So, early screening, early diagnosis, many treatment options, including minimally invasive surgical options. So, all good stuff. Doctor, thank you so much. You stay well.

Dr. Nkem Aziken: Thanks for having me on.

Scott Webb: And for more information, go to summahealth.org/lungscreening. And if you found this podcast to be helpful and informative, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well, and we'll talk again next time.