Maggie McKay (Host): Welcome to the Pulse at Tallahassee Memorial Healthcare. I'm your host, Maggie McKay, Dr. Philip Bongiorno, thoracic surgeon, and Dr. Carlos Campo, pulmonologist critical care physician join us today to discuss lung cancer awareness screening and treatment at TMH. Welcome. Thank you both for making the time to be here today.

Carlos Campo, MD: Thank you.

Philip Bongiorno, MD: Yeah, thanks for having us.

Host: Dr. Campo, who should be screened for lung cancer? And are there any populations considered high risk that doesn't include past or current smokers?

Carlos Campo, MD: So, let me just make the point that 85-90% of lung cancers occur in patients that have been exposed to tobacco. Therefore, that is the biggest risk factor for lung cancer. There are other factors that may play a risk in increasing lung cancer, such as radon exposure and certain toxic chemicals. However, those are a little bit more difficult to quantify. We do know that smokers make the bulk of lung cancer screening.

Just to give you an idea, there are nine different sets of guidelines on lung cancer screening. But for the majority of patients, what we use is the United States Preventative Task Force screening guidelines. And those are patients that are 50 to 70 years old who have had a 20-pack-year history of tobacco exposure and who are current smokers or quit smoking within the last 15 years.

Host: Does that include secondhand smoke people? Like, let's say your spouse smoked but you didn't, but you've been with them for years.

Carlos Campo, MD: So within that 85-90% that I described, yes, people that have been exposed to tobacco secondhand are within that 85-90%.

Host: So, why is this so critical for an eligible population to follow lung cancer screening guidelines? And how does the early detection of lung cancer change outcomes for patients?

Carlos Campo, MD: So, first let me say that, unfortunately, when you look at the data across all people that should be screened, it's only about 15% of people that are eligible for screening that are getting screened, which is really poor. And the big reason why people should be screening, because early detection probably translates to better outcome.

When you look at the five-year survival of a patient with a stage 1A, you're looking at an 82% survival rate. When you're looking at somebody with a stage IVB, you're looking at a 7% five-year survival. So, early detection hopefully translates into early treatment and a better patient outcome.

Host: Dr. Bongiorno, what are some common misconceptions about lung cancer that you or your colleagues have heard often?

Philip Bongiorno, MD: Well, the thing that a lot of my patients talk to me, because I do surgery on them, and patients generally have heard this concept that if they have an operation and air hits their tumor, that promotes spread of the tumor. That's something that I deal with a lot. And I always tell people with lung tumors, especially every time you breathe, the air from outside is touching that tumor. These tumors are biopsied. We biopsy them just by going down the bronchial tree and we can reach out and grab those tumors. Make sure that people understand that having an operation that's not going to cause their tumor to spread. The air is already hitting that tumor.

Host: Dr. Campo, what are some of the technologies used at TMH for detecting a lung cancer diagnosis?

Carlos Campo, MD: So, you know, we are fortunate to have a platform that we call a navigational robotic platform. What this allows us to do in combination with another device called a cone beam CT-- the combination of both of these technologies allow us to go after lesions that are much, much smaller. I think the smallest tumor I have gone after is 6 millimeters, which is quite small when you think of an inch is 25 millimeters. Basically, a 6 millimeter lesion is quite small, very early detection. Again, we're fortunate that we can do this because of this robotic bronchoscopy along with a device called a cone beam ct.

Host: What are the advantages of robotic bronchoscopy over traditional ones and how do the different systems differ?

Carlos Campo, MD: So with traditional bronchoscopy, the ability of the scope, the device itself to navigate to where these lesions are is just not there, because of the anatomy of the lung, how you have to go through the airways. There's only so far you can go with a regular bronchoscope. With robotic bronchoscopy, because of the software that device uses, you can literally navigate using-- I'm not going to use the word breadcrumbs-- but it's a path that the computer generates guiding you exactly through which airway you have to go through to get to the lesion that you're after.

Host: And Dr. Bongiorno, how does a multidisciplinary thoracic clinic or tumor board improve the experience and the outcomes for patients, especially at Tallahassee Memorial Healthcare? Can you walk us through how pulmonologists, neurologists, thoracic surgeons, oncologists, and radiation oncologists collaborate in diagnosing and testing lung cancer?

Philip Bongiorno, MD: I think what you're saying is exactly right. This is a complicated disease that requires the input of a lot of physicians with different specialties, and we all have a role to play. Sometimes there's like a quarterback on a team. But I think for lung cancer, we're playing like positionless basketball. We all have a role. No one's really in charge. And so, we have to meet on a regular bases to really come up with the right strategies for these patients.

We discuss our patients, we teach each other what our own perspectives. And how it really helps the patients is that if they see any one of us, we can present the patients to other physicians. So, they get not only the perspective of the doctor they might have met with, but also maybe five or six or seven other people that all come up from a different angle, a different perspective. It's very difficult for patients in an old system where Doctor A might ask them to go see two other doctors, and they have to get appointments and have to see these doctors. It really prolongs the time to diagnosis and treatment.

With a multidisciplinary group that meets together, we can cut the time down dramatically. We make it so much easier for the patient. They don't have to travel. We do this on a regular basis, but sometimes even when we meet on a regular basis, that's not soon enough for the patients. We'll do it offline. We have virtual tumor boards. We discuss it with each other. We ask each other to review the charts. So, I think that it makes it much easier for the patients, and it's much quicker. And also, they get the right answer. We want to give them the correct answer for how to treat their disease.

Host: I love that idea. The more ideas put together, the better, right, Dr. Campo?

Carlos Campo, MD: Absolutely. You have the advantage of having several people in the same specialty also contributing to management. So basically, you're getting a second, a third, a fourth, a fifth opinion there on how to best manage the patient. And once we have decided on how to approach each patient, whoever is going to be taking lead for that patient will do so.

Host: And Dr. Bongiorno, what makes the Tallahassee Memorial Thoracic Oncology Clinic unique in how it brings specialists together for patient care, especially in this region?

Philip Bongiorno, MD: Yeah, I think what's unique about it is our region. And we're a little bit spread out as far as our patient population over large geography. What we're doing, we model what is done at other medical centers around the country. There's no doubt about it. We're not reinventing anything, but we're able to bring these clinicians for our patients in this region all together. And I think that's what's unique, because I don't think there's any other place in the panhandle that can do what we do at Tallahassee Memorial.

Host: Dr. Campo, are there any recent advances in lung cancer treatment that are exciting or promising to you right now?

Carlos Campo, MD: Sure. Think the lung cancer screening is certainly one of them. You know, it started really-- the data came out in 2014. I think robotic bronchoscopy is also great, because it allows us to go after much smaller lesions. I think what's called immunotherapy, which are medications that help your immune system fight off cancer, are game-changers. You know, it used to be that basically a stage IV cancer, 10, 15 years ago, the outcomes were not good. But in this day and age, I have patients that are now stage IV and there are beyond five years and still doing well. So, immunotherapy has changed the treatment of lung cancer tremendously.

Host: Dr. Bongiorno, how do minimally invasive surgical techniques like robotic-assisted thoracic surgery, impact recovery and outcomes for patients?

Philip Bongiorno, MD: Easy answer, it impacts it in a positive way at almost every level. When traditional lung cancer surgery was done with big incisions, we call a thoracotomy, where there's spreading of the ribs, there's a tremendous amount of trauma to the chest wall. And the patient literally would spend weeks trying to overcome that trauma. The robot allows us to make very small incisions. The big incisions are 12 millimeters, and the little incisions are 8 millimeters. We're talking half inch, quarter inch incisions. And so, there's much less trauma to the chest wall. Some of our patients experience pain, but some of them are managed just with Tylenol. And that's the most gratifying for us.

The robot has an amazing camera. It's a binocular camera that has 10 power magnification. I can assure you, I can see better with the robot camera than I can see with my own eyes. And so when we bring that camera into play, the surgery is much more precise. Robotic instruments are mini instruments, and so the dissection that we do, that surgery that we do is at a very fine level, a big advantage over any traditional surgical instruments. So, we're making small incisions that allow the patients to leave the hospital in one or two days after having lung surgery.

When I was a resident trained to do this, our patients stayed probably on average a week. They have no restrictions when they go home. We ask them to take it easy for about a week and not to soak in a tub. But otherwise, if it doesn't hurt, you can do it. And people get back to work. Well, here's what I would say when I talk to the patients, it's like very frequently, "I'll see you back a week after surgery." And a lot of my patients drive themselves to the appointment. They don't come back with their family. So, the ability to offer them lung surgery and have them come back and see me in a week for a checkup driving their own car, that level of independence, that's really gratifying.

The other comment I would say with the robot, is it's better surgery. Robotic surgery is better surgery. We do a more complete operation. We can do more precise operations. We can do, you know, surgery that's better for the patients, remove less lung tissue than we would in traditional operations. So you might be able to tell I'm a big fan of robotic surgery. It's like my passion ,and I'm really grateful to be able to offer that to the patients here.

Host: Absolutely. I can see why. Dr. Campo, is there a particular message that you'd like to leave with your community about taking lung health seriously and getting screened if eligible?

Carlos Campo, MD: Main point for me would be, of course, stop smoking, right? But easier said than done. I think that for those patients that are eligible for screening, that they should be screened, and this is more for their providers to be aware of the guidelines and to promote screening. Of course, that's a discussion that has to be had with the patient. That's my message. I think that treatment for lung cancer has come a long way, and the way we advance, improve survival is early detection and early treatment.

Host: Thank goodness it's come a long way. How about you, Dr. Bongiorno?

Philip Bongiorno, MD: I would say that, you know, lung cancer, it's a scary diagnosis. And so, I really empathize with patients and their families when they're faced with that. But we have to let them know that, this is not a hopeless situation. In many cases, it's a very curable situation. In some ways, there's been lots of improvement in cancer care for certain cancers. I think prostate cancer is a good example where their survivals are so much better today than they were 30 years ago, 40 years ago.

In lung cancer, it's been one of the ones that's much tougher to improve outcome stage per stage. What we can do now that really helps our patients is we detect it earlier. We have cancer screening for people that are high risk. When we can find small cancers, people can come in and they can have surgery in a minimally invasive way. Maybe only take a couple days outta their lives, get back to their life within a week, and we can totally change their trajectory of this disease.

But when we're faced with folks that are picked up late, maybe they wait until they have a symptom before they get checked out, it's not as positive a situation. So, I think that we have an ability to help the people in early stage, and that's really what we'd like to focus in on, is try to get this thing before it gets to a difficult place to treat.

Host: Absolutely. Well, thank you both so much for sharing your expertise. This has been so informative and enlightening. We really appreciate it.

Philip Bongiorno, MD: Okay. Thanks for having us.

Carlos Campo, MD: Thank you.

Maggie McKay (Host): Again, that's Dr. Carlos Campo and Dr. Philip Bongiorno. To learn more about lung cancer treatment at TMH, please visit tmh.org/lung cancer. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. Thank you for listening to The Pulse at Tallahassee Memorial Healthcare.