Prakash Chandran (Host): You might ask yourself why your doctor is looking to screen for lung cancer when you don't have any symptoms. But early discovery of any type of cancer is one of the key factors towards easier and more successful treatment. Waiting for symptoms to appear could mean waiting until the cancer has already spread. Here to talk to us more about lung cancer screenings are Dr. Matthew Steliga. He's the Chief of Thoracic Surgery for University of Arkansas for Medical Sciences and Patricia Franklin, Advanced Practice Nurse and Certified Tobacco Treatment Specialist for University of Arkansas for Medical Sciences. This is UAMS Health Talk, the podcast from University of Arkansas for Medical Sciences.

My name is Prakash Chandran. And so Patricia and Dr. Steliga, thank you so much for being here today. I really appreciate your time. So Dr. Steliga, I'd love to start with you. When and why do you start recommending a patient to do lung cancer screening?

Matthew Steliga, MD (Guest): Great. Great question. Thank you. Well, not everyone would benefit from lung cancer screening and there are criteria for who should or should not get screening. You might say, well, why not screen everybody? Well, people who are particularly low risk would have a low chance, a very low chance of cancer and might have harm from incidental findings or the cost of the screen or the time or other things like that. But the high-risk group that benefits from lung cancer screening is men and women age 50 years or more with a 20 pack year smoking history. A 20 pack years is a term that we use in our language and to kind of translate that, that means one pack of cigarettes per day for 20 years, or it could be two packs a day for 10 years so forth. And those types of patients with that risk history would benefit for lung cancer screening where we could hopefully find cancer at a very early stage where it is still curable and has not spread.

Patricia L. Franklin, CNP (Guest): And I will add to that, that it's important to remember if you have quit over 15 years, this might not be the test for you. Your risk of lung cancer is going to go way down if you quit over 15 years and that the test is not covered by insurance at that cutoff.

Dr. Steliga: But for those who are still currently smoking or that they've quit less than 15 years, it is approved for insurance coverage and it's supported.

Host: So Patricia, I'd like to ask you a question. You know, you're a provider for lung cancer screenings and a certified tobacco treatment specialist. Tell us what is the process of lung cancer screening and how often should someone do it?

Patricia: That's a great question. Honestly, we do see them once a year and once they come in for the procedure, the test takes maybe five to 10 minutes because it is a low dose CT. So there's no IV contrast. There's nothing that they have to drink. So the test is very quick. Sometimes can be scheduled the same day as the order came in. So if they're still smoking, we do try to discuss with them their smoking habits and see if there's anything we can do to help them to quit.

Host: And Dr. Steliga what exactly would you see in the screening that might be of concern? Like what does it look like when the screening is clear versus when there is something that should be addressed?

Dr. Steliga: Great question. Thank you. The screening scan that's done is a CT scan, a three dimensional image of the lungs with thin slices or thin images of what the lungs look like and what we're looking for is any denser spots or areas in the lung that look abnormal. Now, not every abnormal spot in the longest cancer.

And in actuality, most abnormal spots in the lung are not cancer. As we go through life and age and our lungs encounter different infections or more inflammatory conditions or things there can develop scars in the lung or a area that's solid, but not cancerous. And those could be called granulomas.

That's not a cancerous nodule. It's simply a in a way, a type of scarring of the lung. And it's hard to tell sometimes the benign from the cancerous, but what we first look for is any abnormal spots on the scan. And then we review those with our multidisciplinary team, a team of doctors of all different backgrounds that interface with lung cancer.

And we find the best way to diagnose those spots and determine if they're cancerous or not cancerous. If they are cancerous, then we get together to decide on the best possible treatment plan.

Host: And Patricia, before we get into the treatment plan itself, I'd love for you to talk about the process of the screening itself. Like how long does it take and how long do people need to wait to get their results?

Patricia: It's a fairly quick turnaround here at UAMS. We will get them set up. I typically call the patients to what works best for them as far as day of the week timing. Once we get that set up, then they come in. And the test itself, like I said, only takes five to 10 minutes. And it's no special preparation for it. So it can be done quickly. And typically we have a dedicated thoracic radiologist who reads these, and he's very quick. So typically 24 to 48 hours, and we have the report back.

Host: So Dr. Steliga, one of the things that you mentioned, if something was found that you kind of evaluate possible treatment plans what exactly does that look like? And are there common treatment modalities that are typically prescribed?

Dr. Steliga: Sure. Sure. Great question. Well, I like to think of this process along a pathway of screening which is the screening scan. And if there's anything abnormal on it, we go from screening to diagnosis. If we diagnose cancer, then we go from diagnosis to staging and staging tells us how early or advanced the cancer might be. And then after we've done screening and diagnosis and then staging, then we can formulate a treatment plan because the treatment for an early stage lung cancer, like a stage one is very different than that for a more advanced stage. So, what we see is people come in to get a screening scan, and most of those screening scans are normal.

A few may have abnormalities on it, and we all look at those together and determine if those abnormalities are likely to be benign or cancerous, sometimes that would take a biopsy. Those biopsies are not typically done with an operation, but they're done with a needle biopsy. Either a needle poke in a CT scan or a needle biopsy that's done with a bronchoscope or a flexible tube through the mouth while the person's sedated. So once we do the needle biopsy, we would find if something's cancerous or not. And the key is to have a good treatment team that looks at it from every direction. If we have early stage lung cancer, which is the best prognosis and best chances of cure and survival, oftentimes we'll go to surgery to take those out. If it's a more advanced stage, it may need other treatment like chemotherapy or radiation.

Patricia: And I will add to that. There are times when the team recommends simply a three month to six months follow-up, it's not always, if we see an abnormality on the low dose CT that we recommend they come in immediately have a biopsy. Could be that it just is a follow-up that's needed. And like I said, three to six months and sometimes on those follow-ups it's been resolved. So it, it is not a foregone conclusion we're not going to call somebody and say, you need a biopsy with every abnormality.

Host: And Dr. Steliga, if an abnormality is found and a biopsy is needed, do you have a sense around the percentage of times where it is actually cancer versus whether it's something benign?

Dr. Steliga: That's a great question. So we have been looking at that and we want to catch every possible cancer. We don't want to miss any cancers, but we also want to minimize the amount of biopsies, minimize the amount of biopsies we would do for benign nodules are benign disease. So when we do that, most of the time that we do biopsies, it is indeed cancerous because we've looked at it as a team.

It has high-risk features, or it looks very suspicious on the scan, not just the size of it, but maybe the shape or the texture or the kind of dimensions of it. And oftentimes it's, if we're on the fence, we'll maybe scan it over time. Three months follow-up scan and like Patricia was saying, if it grows, it's more suspicious than if it shrinks or disappears, it isn't.

So most of the time that we are doing the biopsies, it, it actually is cancerous. But with that being said, most nodules, we find we do not biopsy right away. So we typically would biopsy only when we have a higher suspicion for cancerous diagnosis.

Host: Patricia, I have a more general question. I'd love to understand a little bit more around who lung cancer actually affects. Like, does it affect all demographics in the same way or are some people more at risk than others?

Patricia: I'd have to say that typically a lot of the diverse population we have out there is affected more with the lung cancer diagnosis. So, we have some interesting folks who come still smoking. Some of those are not smoking and it really does impact our smoking population. We've been trying to study that to know how many percentage wise, but it is a high risk group that we're screening. So we sometimes have a pretty high amount people who are affected by it, meaning they have to come back for three months, which is scary and concerning to them. So we do try to get them in, to see one of the surgeons fairly quickly so they can get their questions answered.

Host: Now Dr. Steliga you've written a piece talking about how smoking cessation support improves lung cancer screenings. Could you discuss and briefly interpret your findings?

Dr. Steliga: Well, if we look at the whole picture, what are we trying to do? What are we trying to do with this program or with any program in healthcare. Are we trying to just find more abnormal x-rays? Are we trying to just find cancer or just trying to find things to poke a biopsy needle at? No, the overarching goal of what we're trying to do and kind of the root of what we're mission is to help people live longer better lives and a part of that is finding cancer when it's early. Great. We all can agree that finding lung cancer early can help people to build longer, better lives. But when we were looking at some of our institution's information, we looked back at the first five to 600 scans we did here, and we found a little under one and a half percent of those people had lung cancer. And you might say only one and a half percent. That's not that much, actually about 1% to 2% is in line and pretty common rate of finding cancer in screened populations. So, okay. We found maybe one to two out of a hundred people that we screened had cancer, but that doesn't mean the other 98 to 99 were totally healthy that we couldn't improve on. We found that of those coming in for lung cancer screening, even though only one to 2% had lung cancer, a little over 70% and I think it was nearly 71% of those getting screened were smoking. They were unable to quit on their own. Now this is a motivated group of people. They're coming in, getting scanned.

They want to make their lives better and healthier. They want to find cancer early and yet the very risk factor that puts them at risk for lung cancer and qualifies them for the scream, they're unable to quit on their own. So, we thought what's the best way to help this program and this population. If we give people a quit number. The one 800 quit now toll free number works in every state.

It's a great program, but the patients have to call it. They have to follow through and sometimes that's tough or it may not stick and they may not be able to follow through with that. So even though we only had one or 2% with cancer, that's 70% unable to quit, we saw as a target population, at a teachable moment with a modifiable risk factor, was something we could change, something we could improve on right there in our office.

And so what we did is we got certified tobacco treatment specialist training for our nurse practitioners. And I went through the training program myself and others, and we've helped each person to get a quit plan, to set some goals to try to get a plan, to get rid of the cigarettes. And overall, we found that was a great way to integrate a cessation program in a workflow, a quit plan right there in the normal line of their patient care.

And a lot of patients who go through it are very willing to talk to expert when they're getting the scan, they're willing to talk to somebody and get some advice from the right person at the right time in a convenient, easy place. And so, we just found this is a synergistic or, you know, works together way to do things.

And I think that we've helped a lot of people to quit smoking who otherwise wouldn't be able to, or wouldn't reach out and get resources or I think that's a huge benefit because many of our patients who come in for screening, they don't have cancer, but we can still help them in other ways.

Host: Yeah, it definitely sounds amazing that you are able to leverage them already being there and really integrating it with the workflow of the screening to actually get them to do something. So that is amazing. You know, Patricia, one of the things that Dr. Steliga mentioned was the findings with a screened population, which means that there is a whole other set of the population that isn't coming in for screening. So, what is the main factor that contributes to patients not getting screened? And what might you do to change this?

Patricia: Well, that's a great question. We do think that there's a lot of patients out there, population who do not know about the low dose CT screening. It's something that has been out since 2014. Not a lot of people know about it so what we're trying to do here at UAMS, we have a lady at this point who was going on the mammo van to different counties across Arkansas. And when she's there, she's passing out information. She's educating people about the need for this. And this is to try to increase the knowledge base of Arkansans to get them screened.

Host: So Dr. Steliga, just before we close here today, is there anything else that you'd like to share?

Dr. Steliga: A lot of people who come in for lung cancer screening also hear about it by word of mouth from neighbors, friends, relatives, or other people they know. And if people have any questions, you know, we're always willing to answer questions, see if someone is eligible for lung cancer screening or not.

And for those who are smoking and unable to quit and unable to quit on their own, I'd encourage everybody to reach out and get some help, get some help from some experts like the ones in our program, because yes, they've tried to quit and they haven't been successful before, but they haven't tried to quit with our program with the right people, with the best support and, you know, we won't succeed every single time, but we want to give people the absolute best chances that they can of kicking that habit to help them lead a longer, better life.

And that just matches in really well with our screening program to detect cancer early. If it's there and now most people won't have cancer, but we want to help and benefit every single person we can. Especially those who are unable to quit on their own.

Host: And Patricia, I'll give you the last word. Is there anything else that you'd like to share with our audience today before we close?

Patricia: Well, not to be afraid of the screening. You know, screening can be a little bit scary in that when you come in, you think, what are they going to find? But you get a lot of good information about your lungs, the status of your lungs, the efficiency of your lungs. They look at pretty much all the areas, your heart. So, you can gain a lot of information about the health of your body and the comfort of knowing that your lungs are okay. So please come and get screened.

Host: Dr. Steliga and Patricia, thank you so much for your time and thank you for educating us today. I think that's the perfect place to end. And I think the one takeaway is don't wait, you know, if you fall into that age group that Dr. Steliga and Patricia were mentioning, it is worth it to call in and get things looked out for all of the reasons mentioned. So, thank you both so much for your time. I really appreciate it.

Patricia: Thank you.

Dr. Steliga: Thank you.

Host: That was Dr. Matthew Steliga, Chief of Thoracic Surgery for University of Arkansas for Medical Sciences and Patricia Franklin, Advanced Practice Nurse and Certified Tobacco Treatment Specialist for University of Arkansas for Medical Sciences. Thanks for checking out this episode of UAMS Health Talk. For more information about UAMS's lung cancer screening program, you can call 501-944-5934. If you found this podcast to be helpful, please share it on their social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks again for listening. My name is Prakash Chandran and we'll talk next time.