Darrell Rebouche (Host): Lung disease. When you think about that, some really scary words come to mind. COPD, which is chronic obstructive pulmonary disease, emphysema and, of course, lung cancer. These are conditions that affect millions of people, often quietly at first, and then all at once, changing how someone breathes, moves, and lives their daily lives.

Hello, everyone. Welcome to Health on Point presented by Willis Knighton Health. I'm Darrell Rebouche. Our guests are Dr. Kamal Masri and Dr. Ahmed Virani, who are pulmonary specialists, critical care specialists, lung doctors who take care of really sick people. Doctors, thank you for joining us today.

Kamal A. Masri, MD: Thank you, Darrell.

Ahmed Virani, MD: Thank you

Kamal A. Masri, MD: for having us.

Host: You know, when you see that x-ray or that CT scan, and it's got something that doesn't look normal on your lung, that is scary. that's where we begin. Let's talk about lung nodules. Dr. Virani, what are they? And they're not all the same, are they?

Ahmed Virani, MD: You're right. Lung nodules are a wide variety of things. Typically, it always starts as someone says you have a spot on your lungs. A lot of times, it's found incidentally, a lot of times it's found because you were getting imaging for something else. The question then becomes, "What is this lung nodule that's in your lungs?" Now, remember, we breathe the outside air every second. So, things really go in and sometimes you inhale some stuff and it closes off and it becomes something less compromising. Sometimes it's something that's more malignant in nature. If you have risk factors like smoking, our job as pulmonologists to really use patient's risk factors to try to figure out what the statistical probability is of these nodules being benign versus malignant. And oftentimes, it requires us doing tissue sampling via some very cool and exciting technologies that we have now. But it always starts off as trying to answer the question, "What is this in the lung?"

Host: Dr. Masri, it feels like, historically anyway, it's been difficult sometimes to try to figure out that puzzle, you know, especially stuff deep inside the lungs as Dr. Virani said. Why has it been so difficult historically?

Kamal A. Masri, MD: So usually, nodules are small when they're found. So, they range anywhere between, you know, a couple millimeters, and they can go up. Once they reach the size of about two, three centimeters, we call them masses. And those are easily diagnosed or biopsied. But the small ones, especially when they're like two to four to six millimeters, remember that needle when it goes through the skin to get a sample, it's so small that it's really hard to sample it from the outside.

However, over the last, I would say about 15 years, the advances in technology has got us to a place where we can navigate from the inside and get so close to that nodule that we can collect pieces easier, and that's what we call a robotic bronchoscopy.

Host: Thank you, Dr. Masri. Robotic bronchoscopy sounds scary. It's a big word. It says robot. But really, Dr. Virani, that is anything but scary. This is a major advance, and it really helps patients. Can you explain how please?

Ahmed Virani, MD: Sure. Yeah. As Dr. Masri said, traditionally, the way these biopsies were done is you put a needle from the outside. And our interventional radiologists who do a fantastic job of these procedures use CT scans, and they try to get to areas. Now, the bigger ones are obviously easier to get to; the smaller ones, not so much.

So now, we use robotic platforms and we get special kinds of CT scans that are very thin cuts. And we upload them into these softwares and they use, you know, their artificial intelligence to build us a roadmap. Remember, when you get inside the lungs, think of it like like highways that have multiple exits. And as you exit more, the exits get smaller and smaller.

These robotic bronchoscopies come with very, very millimetric size devices and build us roadmap to get to the nodule in question, it's important because the smaller the nodule is, one, the harder it is to biopsy. But also, that means whatever's going on, it's early. And that's always been our fight with these types of issues in the world of oncology and cancer, is finding things early on, because then you have so many more options to try to help patients. So, we've found that these newer technologies are allowing us to do that earlier, which give patients better outcomes.

Host: You mentioned artificial intelligence. I mean, how is that augmenting helping what you guys do? And should people be wary of it, or is it very reliable?

Ahmed Virani, MD: In my opinion, I think so far all the stuff we've used, it is helped us. You know, we are still the ones making the decisions. We're the ones that are still guiding the robot per se. But the technology has gotten so advanced now that the artificial intelligence side of things just helps us do it in a safer, in a more reliable manner. Wouldn't you agree, Dr. Masri?

Kamal A. Masri, MD: I totally agree that AI and advancing technology is sort of a set of eyes, kind of like dermatology doesn't need all that advanced technology because it's sitting right at the skin. However, when it comes to lungs, we can't look inside. So, AI has given us those set of eyes that will navigate all the way inside the lungs, while we're looking at the screen to see that nodule. It's been so helpful to diagnose early and save a lot of lives.

Host: You guys very often, I'm assuming, strongly assuming, have to have a conversation with patients and families about, "All right, we have to look at this nodule we've indicated that's been indicated by imaging. At what point do patients and families become concerned that this is cancer? And at what point are they appropriately concerned?

Kamal A. Masri, MD: Initially, the screening CT scan is going to tell you there is a nodule on your lungs, which common terms like Dr. Virani said, it's a spot on your lungs, right? When they come to talk to us, we tell them it could be anything—infection, inflammation. We ask them what they do for a living. Maybe they were exposed to something and that's accumulating in their lungs. At that point, there is no talk about cancer. We're talking about, "We don't know what it is. But based on their risk factors, we need to sample it." Once we sample it, we'll bring them back for a different discussion. "This is what we found. And if it is cancer, we'll talk about where it is. we could order some more testing, a PET scan to see how we can stage it, and get them to the right place here at Willis Knighton.

Darrell Rebouche (Host): Lifestyle

Host: and risk factors drive that for you. But Dr. Virani, sometimes, and this is often a good thing, you tell patients, "Okay, it's there, but we're just going to watch it for a while." And that could be a good long while sometimes, correct?

Ahmed Virani, MD: Correct. We do use, as Dr. Masri said, you know, everything's a probability. We base things off of pretest probabilities. Now, of course, not everyone that smokes gets cancer. And likewise, not everyone that has cancer smoke. People do get them either way. So, we start off initially with looking at the sizes. And, you know, there's guidelines and protocols. They classify nodules into what they feel is the risk factor.

For instance, if something is more in the upper lobe, it has irregular margins, that may be a little higher risk than something lower with more concrete margins that could go away from it being something more suspicious. And then, the size is always important too. Something that may be six millimeters may not be as worrisome right now as something that's two or three centimeters as Dr. Masri was saying.

So, a lot of times, you're right, the treatment of choice is to just survey it and see what happens over the next six months or a year. And if it's changing characteristics, we do then pursue biopsy. And we were very vigilant about these, because our goal is always to find things early. And a lot of times, remember everything that we found that was a centimeter at one point was probably five millimeters. And at one point, it was probably two millimeters. It had to start somewhere. You know, we're pretty vigilant or making sure we don't lose track of these nodules here.

Host: Dr. Masri, how accurate do you think these new diagnostic tools are? We've talked about robotic bronchoscopy and the really cool things you can do. And Dr. Virani has talked a lot about getting there early and how helpful that is. You get there early though, is it accurate? Is it as accurate as it would be at some other stage in the diagnosis process?

Kamal A. Masri, MD: So once we find a nodule and we decide that this is a high-risk nodule that deserves a biopsy, the little nodule that we consider, you know, under a centimeter, we pursue them with a robotic bronchoscope. And here, locally, our diagnostic yield to tell the patient exactly what it is has been high 90%. Do you agree, Dr. Virani?

Ahmed Virani, MD: Yep, absolutely. Probably in the 93% to 95% range.

Kamal A. Masri, MD: Yeah. So once we give them an answer, we're looking at in the high 90s this is what this lesion is, and that's very comforting for the patient.

Host: And I want to emphasize something that Dr. Virani said earlier. You're looking—and you didn't use this phrase—but often you're ruling out malignancy or cancer. Sometimes you get in there and you find out it's not cancer at all, and sometimes you find that's really good news. So, there is reason for hope for patients and families. And also, Dr. Virani, would you agree that there's reason for hope that finding something early, if it is the bad news, still has a very positive impact and that because you found it early, your outcome might be delayed or different?

Ahmed Virani, MD: Of course. Whether it's a malignant process or non-malignant process, having an answer always eases the mind. If it ends up being a malignant process, and if it's something that's half a centimeter, your options of cure and curative intent go up immensely versus something that's found that's spread to other parts of the body.

And likewise, if it's something that's not malignant, if it's some type of infection, then we can treat that too or if it's something benign, then we know with reasonable certainty that, you know, this was already addressed and, you know, can watch this out on a non-invasive basis.

Host: You guys are pulmonology and critical care. What's your typical doctor-patient experience like? Do patients come directly to you, to your clinics? Do you see people, particularly in the hospital setting, both a combination? And how long typically is your relationship with the patient? Let's go with Dr. Masri first on that.

Kamal A. Masri, MD: We see patient in all aspects. They get referred to us from primary care. Most of the patients that have had a history of smoking or they come into their primary care doctor with a complaint of shortness of breath, they end up in our clinic at some point. If the primary care doctor has done their due diligence, ordered some basic workup, was not able to find the answer, they end up in our clinic.

Time from referral to being seen in our clinic, you're looking at weeks, not months. And once we get them into our clinic, the workup goes a lot faster than weeks. So, you're looking at days before they get their pulmonary function test, imaging. We can put the picture together and start them on some sort of therapy.

Host: Dr. Virani, at some point, some patients do the transition from a clinic patient to a hospital patient. Is there a typical way that that transition happens or is every patient different?

Ahmed Virani, MD: Every patient's of course different. We're in a unique professional setting as pulmonary critical care specialists that we kind of do work in the clinic. We do work in the hospital. We're in the ICU arena. We're in the inpatient arena. We're in the clinic arena. We're in the operating room arena. So, we see patients in a lot of arenas.

A lot of times we find things incidentally, and we follow them up outside of the hospital and vice versa. A lot of our patients or some of our patients, we don't like for them to end up in the hospital do end up in the hospital. And we're able to help them there too with whatever their decompensation is.

And we do feel privileged to be able to have that expertise And that experience to be able to take care of patients in multiple environments and be able to transition seamlessly between the multiple environments.

Host: When you implement or deploy these diagnostic tools, specifically I guess the robotic bronchoscopy, explain to people where that is done. You mentioned all the settings. Is that done in an operating room? Is that done in a hospital room? Is that done in the clinic? How does that look?

Ahmed Virani, MD: Correct. For us, it's done in an operating room. A lot of other centers have a dedicated bronchoscopy suite, which functions similar to an operating room. It's a clean room where we do clean procedures and patients are typically put to sleep under general anesthesia, So, it allows us to do it in a setting where they are not moving because we have to be so accurate in these millimeter things that we have to be able to control all the movements. So, of course, yes, you know, for us, it's in the operating room.

Host: And then, the patient expectation for turnaround time. You perform this procedure, you go in there, and you do the bronchoscopy. You're trying to get a diagnosis, you're trying to decide whether it's malignant or not. How quickly do people typically hear back?

Ahmed Virani, MD: Right now, about three to five business days is our turnaround time from our pathologist who do a fantastic job of giving us an answer to. So, would you say, Dr. Masri, about three to five business days?

Kamal A. Masri, MD: Yeah, I mean, we'll give them an idea if we got a good sample right the same day. Usually, about on the third day, we have a final diagnosis for them.

Host: This is Health on Point, presented by Willis Knighton Health. Our guests are Dr. Ahmed Virani, Dr. Kamal Masri, pulmonology and critical care specialists. We've been talking, Doctors, a lot about lung nodules and lung cancer. But you treat and see a lot of different kinds of patients. You see COPD, you see emphysema. What is the most prevalent disease path you see? I'm assuming you see a lot of COPD, Dr. Masri.

Kamal A. Masri, MD: Yeah. COPD is common, especially among patients with history of smoking. Smoking, over the years, has declined. But we still see a lot of COPD patients. There's a very small population that does have the disease that are genetically predisposed. But I would say high 90% of the population is a smoking patient.

Ahmed Virani, MD: You're absolutely right. We see a lot of COPD in our clinics. Smoking is prevalent in the state of Louisiana and Shreveport. And really, the care starts at the primary care physician's clinic, as we talked about earlier. And, you know, people come in complaining of shortness of breath and we utilize physiologic tests like pulmonary function testing to assess people's physiologic lung function, and we can quantify. One, we can qualify them for obstructive disease if they have it, and then we can quantify the degree of it. And then, we can try to get them help as their disease allows us to.

Host: Chronic obstructive pulmonary disease is COPD. For the average person who has not experienced this, what is the obstruction?

Ahmed Virani, MD: Your lungs typically have two big functions. One is to get oxygen into your body, which is what we thrive on. It's our body's nutrients and get carbon dioxide out. And this is done with your lungs that basically are pathways that lead you to these balloons at the end of the pathways that sit there. A lot of times what happens from years of smoking and the caustic nature of that and the toxins that are in smoke, they can remodel those pathways. They can make them rocky, full of potholes, they can get stenosed. And then, what ends up happening is you're able to breathe this air in, but you're not able to get it out because the roads have become really tumultuous. And that's where this idea, this concept of obstructive disease comes from.

Host: And what is the upshot of COPD? I mean, it's often, Dr. Masri, a long road, a scary road, and you don't always get better.

Kamal A. Masri, MD: By the time the patient gets to us as specialist, their disease is pretty advanced. Usually, a patient that smoked have some degree of obstruction. But because they live with it every day, they get used to it and, unless they're starting to have symptoms like, you know, shortness of breath, "I can't finish my work. I'm having to stop multiple time. I'm coughing, I'm wheezing," by that time, their disease is advanced.

So over the years, the guidelines have changed. The therapy have changed. We have a lot newer inhalers we can use. And the moment patient stops smoking, their disease will continue to advance, but at a lot slower rate. So, our goal is usually to educate them that, "Let's stop the insult first. Hold off on smoking." Once they stop smoking, those inhalers and even there's newer advances in the technology where we have injectable medication that will stop the inflammation that the smoking is causing, they can live a normal life as long as they understand their disease, comply with their medication, and stop the smoking.

Host: All right. And, Dr. Virani, we've talked a lot about diagnosis. Let's transition to treatment. Dr. Masri talked about some treatment for COPD. So, let's say the bad news comes and it is lung cancer. So, what's next?

Ahmed Virani, MD: If it's lung cancer, then of course, our role as pulmonologist, one, is to give them a diagnosis and then give them a staging. And, you know, we use special techniques to do that. Once we have that, you know, we have a multidisciplinary team here that we all work really closely together. That includes our medical-oncologist, our radiation-oncologist, our surgeons, and we all come together. And we refer patients to each other. And then, a decision's made, like what stage of cancer are they at, and what's the appropriate treatment based off that stage? And that can vary from surgery, which if it's found early enough and you're a surgical candidate, you can get this surgically removed, and that's curative intent to a combination of surgery, chemotherapy, they have immunotherapy or, if you're not a candidate for those things, radiation therapy. It's definitely a big breadth of, you know, what we're able to do from the side of lung cancer.

Now, from the side of actual COPD, which is where we still stay involved is, usually, these people who have been diagnosed with lung cancer also have chronic obstructive disease, and we'd like to improve their quality of life. So, like Dr. Masri said, the best thing is to stop smoking. Getting rid of the insult is always advised. And then, we have inhalers. Now, we have newer biologic therapies as we call them. That used to be used in the world of asthma and is now transitioning over the world of COPD that people have found great relief from as well. Then, furthermore, we also can help manage side effects of any of these chemotherapies, immunotherapies, which can have adverse effects in the lungs. That's kind of like how the transition of all this flows.

Host: We mentioned three things when we started talking. We mentioned lung nodules, which may or may not be lung cancer. We mentioned COPD and also emphysema. So Dr. Masri, what is emphysema? And how do you approach that diagnosis and that treatment?

Kamal A. Masri, MD: Emphysema is destruction of lung tissue directly caused by inhaling either smoke or some kind of particulate over time. And what happen, there's areas in the lungs that are still present, but they're dead areas. They don't exchange oxygen. So,, these patient, you know, we see it all the time where they have a barrel-looking chest and their lung volume is very large, and that's what emphysema is. You have a lot of lung volume, but it is all dead space. It's not useful for exchanging oxygen or getting rid of CO2.

Host: What other tools do you use aside from, you know, the robotic bronchoscopy and the other tools that you have? Are there blood tests, biomarkers, Dr. Virani? Are there things that enhance or complement the diagnostic process?

Ahmed Virani, MD: Certainly, you know, there's blood tests now, there's blood markers for tumors. A lot of these even get used after diagnosis to see if this particular tumor is expressing certain things that can be targeted. You know, 20 years ago, it was a one-size-fits-all. Now, medicine's become very personalized and, you know, you can guide therapy based off of people's markers.

Even before that, there's now newer blood tests that are coming out, that are still being studied, they're still being validated. But you can get blood tests that can be signs of early cancer that you can't see on radiographic—remember, in order for you to see it on a CT scan, it has to be big enough for you to see it. But things can initially start at a microscopic level and they're working pretty diligently to research that side of this type of evaluation.

Host: Dr. Masri, looking down the road, what are you excited about in terms of early detection, maybe disease reduction, the kind of things that are just in the pipeline that get you excited about what you do for helping patients?

Kamal A. Masri, MD: Early detection is so important that, if you look at the lifespan of somebody diagnosed with lung cancer 20 years ago, you're looking at two to three years. And the moment patients were informed about you have lung cancer, it was kind of devastating. They know they're going to die in one, two years.

But now, with the advance in technology and early detection, anything below stage III is surgical. When we're looking at surgical, we're looking at curative intent. That means their survival for five years is over 80%, especially with these small lung nodule, if it is a stage one, it's curative. And, you know, we're seeing patients—you know, I've been in practice for 11 years and seeing patients that were diagnosed with lung cancer 11 years ago, they got surgery, were followed for about five years, and no cancer.

Host: That is very encouraging. Dr. Virani, you know, heart patients go to cardiac rehab. Is there a pulmonary rehab? And, you know, how often is that employed? And is that certainly something worth pursuing?

Ahmed Virani, MD: Oh yes, absolutely. You know, we have a great pulmonary rehab center here at the Willis Knighton system. A lot of my patients get referred to there. It really does a lot of good for patients, not just from the physiologic level, but also from a mental level. You know, like oftentimes, if I would put myself in their shoes, there's a sense of anxiety, right? When you feel breathlessness, that can create anxiety. And it limits you from wanting to do more because you feel scared, and that's a totally understandable emotion.

Now, pulmonary rehab does a great job of monitoring you, pushing you under a controlled environment with respiratory therapists and nurses. And they check your heart rate and they check your O2 sat and they teach you breathing exercises. And not only that, then you meet people there that also may be going through something similar as you and you get a support group. So, pulmonary rehab is absolutely an essential part of our treatment plans.

Host: People tend to do their own research these days, Dr. Masri. And a lot of that research yields some unacceptable results. So, what is the biggest piece of information, two or three pieces of information, that you find yourself having to battle when the patients come in with preconceived notions about what's going on with them?

Kamal A. Masri, MD: The first one is we do get a lot of referral for spot on your lung or nodule, and the patient will come in freaking out. Usually before their appointment, they're calling the office and saying, "Hey, I have lung cancer. I can't wait two weeks." So, I'll tell them that Not all spots on your lungs are lung cancer. So, be patient. We'll get you in as soon as possible. And hopefully, we don't find cancer.

The second thing is delayed the referral to a specialist has been a problem. A patient will see their primary doctor, and they're having this cough and they've constantly been diagnosed with, like, repeated episodes of pneumonia. And the truth is just their COPD is not under control. So, I tell them, you don't have multiple pneumonias. You just need to be seen by a specialist, get you on the right medicine. And once your COPD is under control, you do just fine.

Three is don't be scared of wearing oxygen. a lot of patients feel like, "Oh, if I wear oxygen, I can't go places. I can't fly." It's not true. You can go anywhere you want, you can fly. Just wearing it will prolong your life. So, Those are the three things that I like to leave my patient with.

Host: All right. Dr. Virani, what's the early warning sign that people should just be on the lookout for that says, "I need to talk to my doctor about this"?

Ahmed Virani, MD: You know it's hard. Early stage stuff is very hard. Most of the time. If you're talking about COPD, you might find yourself more breathless. You may find you're able to do less activity. Like, you used to be able to walk two blocks without getting winded. Now, you can just walk a little bit less and you're still smoking.

A chronic cough can always be, you know, concerning if you have a chronic cough and you're a smoker, you should always say that to, a healthcare professional. A lot of times cancer can also cause cough early on, but so can COPD. It's easy, you know, to go on Dr. Google and try to search that. And the first that you get is, "This could be cancer." But that's something that patients we advise to stay away from. Instead, just talk to their healthcare professionals.

And then, this then ties back into lung cancer screening, is very important. You know, I wanted to emphasize that on this that, as soon as you qualify for lung cancer screening, you should be getting enrolled in lung cancer screening, especially if you've got the risk factors, because it used to be we relied a lot on symptoms, which we still do, but a lot of times these things are asymptomatic. And just like you do mammograms for breast cancer screening, low-dose CT scans are now for lung cancer screening, if you meet the criteria.

Host: I think this is the last question, and I think it's a short answer. But for both of you guys, what is the best lifestyle change people can implement to ward off seeing you guys?

Ahmed Virani, MD: Stop smoking if you're smoking. What do you think, Dr. Masri?

Kamal A. Masri, MD: I would say do what Dr. Virani does, exercise and stay active.

Host: And stop smoking.

Ahmed Virani, MD: Well, and you know I do want to emphasize we understand smoking. When cigarettes first came out, no one told us they were bad for us. So, people smoked, it's addictive. You don't have to do it alone. We have a lot of tools that we can provide. We can help from medications to group therapy. We can do it in a graduated step. But if a patient wants the help, we're 100% willing to give it to them.

Host: And Willis Knight Health has a smoking cessation program. And it's very effective and it's very well done, very well organized, and it has a long successful track record. So, thank you guys so much, Ahmed Virani, Kamal Masry, for your time today and your expertise. As always, it's always a pleasure to see you guys and thank you for joining us for Health On Point, presented by Willis Knighton Health.