Lung Cancer Expert Panel Q&A


– Alright, good late morning everybody. My name is Amie Miller. I am a nurser practitioner here at Sarasota Memorial health System. I work with the Cancer Institute. My primary focus is lung cancer screening, prevention, early detection. And today we are here to welcome
our expert panel presenters to our Lung Cancer Recent Advancements and Future Opportunities panel discussion. So, we’re bringing this to you this month because November is National
Lung Cancer Awareness Month and we just really wanna
help the Sarasota community, and bring some more awareness
about the updates regarding lung cancer and it’s treatment. So, today we have our panel experts here. So really feel free to submit
your questions via Facebook. We will be bringing them forward and bringing them to the presenters. And then to anybody in the
audience is welcome to also ask our experts questions as well. So, I’m gonna go ahead and get started. I’m gonna let them introduce
themselves and then we’ll get started with some questions. – Hi, I’m doctor Larry Silverman. I’m a radiation oncologist
with 21st Century Oncology. – Branch off to Kevin Koehler,
I’m a medical oncologist with Florida Cancer, my office
is in downtown Sarasota. And I work with these guys frequently. – My name is Joe Seaman. I am on of the pulmonologists in the area, and I’m passionate about lung cancer. – Good morning, my name
is Dr. Paul Chomiak. I’m the Director of Thoracic
Surgery and Oncology here at the Sarasota
Memorial Cancer Institute. – Great. So, I’m just going
to go ahead and get started. Again, as you would like to, please submit your questions via Facebook. We’re going to go ahead and
start with some basic questions. I’m going to focus this one to Dr. Seaman. So, one of the questions
that they often get is how do I know if I have lung cancer? – So, unfortunately a lot of folks don’t know that they have lung cancer. Somewhere between 20 and
40 percent even notice (audio cuts out) So, that’s why we try to
focus on higher risk groups, for lung cancer screenings. To identify individuals who
may have a higher risk than average, and we focus
on lung cancer screening for that purpose. But we also have be aware
and encourage people to bring unusual or vague symptoms
to their provider so that we can investigate further. – And what are those systems? – [Male] Is the mic working, guys? – [Female] Its cutting in and out. – [Male] You’re going to
have to project really hard. – [Female] Just talk really loud. – So some of the main symptoms
that folks may have is cough, congestion, non-specific fatigue, maybe some weight loss. And that’s the problem with lung cancer. Sometimes the symptoms are so vague that folks oftentimes
just forget about them or explain them away for other reasons before they actually come
to medical attention. – So, can you talk a little bit more about the screening test for lung cancer? – Sure. So, as I mentioned before, there are high risk
groups for lung cancer. The one that comes up the most
is age and smoking history. That’s why we focus our screening efforts on that group of patients. Because those are the ones that it tends to benefit the most. Unfortunately, it still misses
10 to 20 percent of people, who are lifetime non-smokers, who still go on and get lung cancer. But right now that’s our only identified lung cancer screening program. We do recognize that there are
some up coming technologies that may show some promise. That includes blood tests
for certain proteins and/or markers that could allow for some better lung cancer screening. – Has Sarasota Memorial participated in research regarding that? – So, we’re very fortunate
to have a well developed lung cancer screening program and
we’ve identified several lung cancer in the early stage, and have offered them a surgical cure. And we also are involved in
several different research programs looking at some of
these blood tests to help develop them and looker in the future. – And what would be your number
one recommendation to help reduce risk of lung cancer? – Some things that folks
can do is obviously, quit smoking if they are a smoker. That’s the biggest
identifiable risk factor. There are some literature
that shows that exercise and taking care of yourself also helps to reduce lung cancer risks. I’d offer any other suggestions
from the other panelists. – So, pass the mic to Dr. Chomiak. So, when somebody is
diagnosed with lung cancer, just talk a little bit about
sorta what the first step is. Why would you be able to
or wouldn’t be able to just surgically remove
a tumor or a nodule? – It a good question. What we see in our country is
about 80% of patients that are diagnosed with lung cancer
are already advanced stage. Meaning that the cancer has
spread from the location in the lung to regional lymph nodes, to perhaps elsewhere in the body. But, as Dr. Seaman
alluded to, the problem is we are all creatures of denial, so we don’t have any obvious
symptoms to say stop, you have lung cancer, go see a doctor. So a lot of the symptoms you
have can be confused with cold, can be confused with bronchitis. Or you may not have any symptoms at all. We’re hoping with screening that we can actually change that ratio. And we’ve seen great examples
of this in the fields of breast cancer, in the fields
of colon cancer, and prostate. Where by screening you can actually identify earlier stage patients. We know that 50 years
worth of scientific data, that if somebody has an
early stage lung cancer, and they are strong enough
to tolerate surgery, surgical removal of the cancer as well as the regional lymph nodes, provides the best opportunity
for long term cure. So, we’ve got to find those patients. But because of what I shared with you, the majority of them
currently are more advanced, we have to stage those patients. And what that means is, often
enough a patient will come to me, “I have lung cancer, just cut it out, just get it out of me.
I want it out of me.” Well, back in the 1970’s when
there weren’t many options, in the early 80’s that’s what we did. And we found for the
majority of those patients, because they were advanced,
they really didn’t see the benefit of long term
survival from the operation. So, what’s very prudent
is to take these patients, put them through certain tests, you may hear a test like a PET
scan or an MRI of the brain, or perhaps some blood work,
and then do some additional testing to look to see
is there any evidence that the cancer cells has
spread into the lymph nodes within the center of
the chest or elsewhere. And once we complete
those staging procedures, which may require a surgical procedure, a minimally invasive surgical procedure to confirm the stage, once we identify the correct
stage one or stage two patient, then we can offer them
surgery for curativity. – Good, thank you. So let me pass it down to Dr. Silverman. Is there ever a time that
radiation would be a preferred method of treatment over surgery? – So, radiation and
surgery are quite similar in that they’re local therapies. And based upon stage,
surgery has indications and when the stage becomes
a little more advanced we move more to the
traditional types of radiation, but there’s also for similarly staged, newer technology called
Stereotactic Body Radiotherapy that we’re using for patients
who either aren’t very good candidates for surgery because
of other medical issues, or just don’t want surgery. So, typically it’s stage dependent, it’s patient dependent whether
they are fit for surgery. And it’s also the psychology
of the patient too. Whether they feel mentally
they can handle surgery. So, it is a good alternative
in certain instances, and then as the stage gets more
advanced it’s preferred over surgery more in that setting. – Thank you. What is the difference between
cyberknife and radiotactic? – So, Stereotactic Body
Radiotherapy is a general term which is inclusive of many
different type of machines. Cyberknife is one of the machines. There’s about five or six
machine companies that make machines that can utilize this technology. So, the cyberknife machine is a machine that can only do that. But the other vendors
such as Very and Elekta, there’s different manufactures,
make machines that can not only do the higher
technology such as that, but also generalized treatment. So, that’s really the difference. Stereotactic Body Radiotherapy
is a way for us to deliver very high doses of radiation
with accuracy and precision. Up until about 10, 12 years
ago we weren’t able to track tumors with the breathing cycle. Now through other technologies
that allow us to do that we know that when we give these
high doses we are not missing the tumor, that was a big issue. – Or radiating. There is
a downturn to radiating. – Right. So it allows us
to give these high doses, know we’re getting the tumor, and really getting very minimal, if any, radiation to the surrounding structures. – So, maybe pass it to Dr. Koehler, and actually I’ll just stop
for a minute and just remind everybody if you’re watching via Facebook and you want to submit a question, please do so and we’ll bring
those questions up front. Is there anybody in the
audience that has a question for panel at this moment? – [Female] I have a question. I have stage four lung cancer, and radiation was never offered to me. That was off the table. Is that okay? – So radiation can be used
in different settings. One, for curative intent. Which means that the cancer
has to be anywhere from stage one to three localized to the chest. Once it goes beyond that,
it becomes stage four, then a more whole body,
systemic we call it, treatment is really indicated. And in situations where
we have stage four, the main indication for radiation becomes what we call dailiation, if the cancer’s in an area
causing a problem, to help. And now a days, with newer drugs
really keeping people alive much longer, sometimes we’re
even getting radiation in situations where the patient
really doesn’t have any issues but there could be one to maybe
a couple areas that aren’t being controlled by the whole
body therapy system treatment. So there’s kind of a shift in
the feeling now given these newer chemotherapies,
targeted agents and therapies. – I can add to that. It’s very contextual whether
or not you get radiation when you have advance disease,
like Dr. Silverman was saying. What we’re finding as time goes on, this is all kind of breaking
news, it’s all developing, but there’s a lot of newer
phase trials that’s looking at short courses of radiation in
different parts of the body even when people develop stage four disease diagnosis. And that seems to be improving survival. We see a big improvement. And sort of a surprising
finding for everybody as well. So, it’s not inappropriate to
not be offered radiation at diagnosis, it kinda depends
on the context of everything. – While you have the microphone,
why don’t you kind of go a little bit further in your area and really start by talking about sort of how things have
changed for lung cancer and treatment over the
last five years or so. – Yeah, so as a medical oncologist what we traditionally did was
we were advised to thinking about chemotherapy and
systemic treatments. And in the last like five years, in lung cancer in particular,
there’s been a lot of development, primarily
in two different fields. One has been in immunotherapies, and the other one has
been in targeted agents. So, the more we learn about lung cancer, the better we get at treating it. So, to start with the targeted
agents, what we do now-a-days whenever someone gets a new diagnosis, we look at their genetics of the disease. We’re all still looking at
things we don’t understand yet, but there’s a certain amount
of mutations that we could find that we could actually treat
with a certain type of drug. So, for example, if you read about this, and you have a loved one,
or something like this, you can find mutation in genes
like EGFR or Alpha or ROS1. And we use newer platforms to
figure that our while sampling the tumor tissue as well as blood tests. So, blood tests we can actually
find circulating tumor DNA and find if some are marked, have one of these what we
call actionable mutations. And that’s probably, roughly
about 10 to 12 percent of all new patients with metastatic lung cancer. And the interesting thing
about folks who have, what we call driver mutation disease, is that they tend to be the
folks who you would never suspect would ever have lung cancer. They tend to be younger,
they tend to be women, they tend to have never smoked. So, we’re finding more and more
about that as time goes on. And those drugs just
continue to get better. And now there’s almost so much redundancy on the
market with some of them it becomes a difficult
choice on what we choose. So, that’s been a very big
development in treatment. So everyone who has
stage four cancer has to (audio cuts out) you have to vision analytics done, whether that’s the tissue
itself or it’s a blood test. And there’s really only
a handful of companies who are doing that really well right now. The other big developments
being made in the last three to five years has
been with immunotherapies. Which you’ve probably seen
advertisements on TV for. If you watch like the 6:30 news, like every other commercial’s
for a pharma company. So Keytruda is on there. Usually Opdivo is on there. Those are two of the most
common ones that we use. And essentially with immunotherapies, these type of immunotherapies are called check point inhibitors. They’re infusions, so they’re still IVs, but they’re very different
from chemotherapy. They work by dis inhibiting
the immune system. So, a big part of cancer,
the reason why it propagates, is it evades the immune response. And there’s this fraction
of people who we know would respond pretty well if
we could just get that immune system kind of over the
fence to fight the cancer. We predict that now-a-days
with what we call mile markers. So, predictive mile markers
we also order now, as well. To see if someone could respond to just immunotherapy by itself. And so there’s always a portion
of people who can live long term on immunotherapies and
some of these trials have gone out five years now and there’s
still about 20% of people alive on these drugs
living good quality lives. I have patients like this myself. So, that’s been a big improvement
and then more recently there’s been a lot of trials experimenting with chemotherapy in
addition to immunotherapy (audio cuts out) a lot of us were skeptical
about these trials when they were being designed. (audio cuts out) The survival for someone with
advanced lung cancer in 2018 is completely different than what is was even three years ago. The other thing I’d add
is stage three disease. So, stage three disease is when
you have lymph nodes here in the chest involved but no where else. And typically that was a
very controversial area, and it still is to some degree
where you offer surgery, but if you used chemo,
radiation that was offered, for about 20-25 years that
didn’t change a whole lot. And then just recently we’ve
actually increased the amount of cure rates for stage
three disease as well, because we follow
traditional chemo, radiation with a year of immunotherapy. And that was just, that’s
called a Pacific Trial, that was just updated this past September, and increased cure rates by about 20%. So, there’s been a lot of improvements. – Thank you. Again, does
anybody in the audience have any questions for our panel? – [Male] I have a question. By product of another… Back in 2013, it was discovered that I had a 2.3 centimeters mass. After visiting several physicians the biopsy was performed, it was negative. The mass decreased. The following year, increased. Another biopsy was performed, and the results really were very doubtful, insofar that anything could happen. And the only thing that
was suggested was surgery. Which I did not agree to have surgery where there was no diagnosis. Subsequently, I went to see an oncologist, who in turn suggested that I had cancer. A visual test was
performed, bone marrow test, every possible test. Everything turned out to be negative or really very, very small portion. So, then after this happened, I went through four weeks
full treatment, infusion. Not the chemo treatment,
but infusional treatment. And the results were (audio cuts out) At that point, I had to decide
where do we go from here. I changed physician. I changed oncologist and
we start all over again. When we start all over again
all the tests were negative. And from that instance from 2013 to very recently, November, we have gone up and down,
up and down, up and down, the mass increasing from 2.3
centimeters to seven point centimeters and the next
one is down to four point centimeters with no treatment whatsoever. Is there something that you can…? – We can try to comment on that. It might be a little bit harder since it’s like when we have a friend
at Thanksgiving who’s mom’s friend has an issue and they
give us a few details here and there, you have to see the
medical records, and then any maker or any culture information,
but to maybe rephrase the question, you had a mass in
the lungs of undetermined origin, it sounds like they
were worried for possible lymphoma that’s why they
did a bone marrow biopsy, and they had a couple
non-diagnostic biopsies in the past. So, you look well, so I’m not
surprised that they’re not too worried. But at the same time, the diagnosis of lung cancer
can sometimes be tricky. Getting tissue can sometimes be tricky. And a surgical procedure, and
I can let Dr. Chomiak comment on this or Dr. Seaman as well. A surgical procedure can sometimes
be a diagnostic procedure where you don’t actually have
to take out the whole lobe of the lung where you need just
part of it for a diagnosis. And depending on what they
find in the operating room then they proceed with further
surgery if necessary. There’s also the existence of different diagnostic modalities. Not just a bronchoscopy, but
a bronchoscopy navigation – [Male] That was not suggested. – Well it’s just a different thing. And I can let one of these
guys comment more on that. But it does feel like it’s
really a diagnostic dilemma. It’s probably not what we call carcinoma, or invasive cancer. Where we can sometimes see
things crop up that we don’t understand, that we don’t necessarily put a finger on or label on. I’ll let these guys comment
more on your diagnostic. – So, yeah, the case
that you’re describing is terribly challenging. Because when you have a
mass that comes and goes, comes and goes, and you run
different diagnostic procedures and perform with questionable
results, where do you go? Sometimes there’s a clear path,
you know that one biopsies negative you do the
next, or you do the next, or you do the next. But in your case over
a period of five years, something that’s come
and gone a little bit like that is a challenge. Traditional biopsies
are, in many respects, becoming less and less frequent. Now we’re using more advanced technology with navigation technology. In the near future we’re going to be doing robotic bronchoscopies here. Whereby we use, not just a rivet
technology where can do cat scans of the back of the lung. But we also use specialized smaller, to help drive that in the
lungs into smaller areas where previously we couldn’t get to. So in the future, not just
direct tissue acquisition is going to be important but
also there blunt based markers whereby we order specialized blood tests that’s gonna help point us
in different directions. But I think that we talk about
doing bronchoscopies today, or needle biopsies today, in five years we’re going to be looking
at a different landscape and different tests, but your case is a challenging
case on all measures. – And our goal today is to talk
about next step lung cancer. But when we see patients that
have spots in their lungs, we have to also be concerned
could this be a very slow growing benign tumor of the
lung? And those are rare. And they don’t have the
propensity to spread all over the body but in due time they will grow. Your body regardless, if
you have a benign tumor or a malignant tumor, your immune system is going to try to fight this. If your immune system is a
little but depleted because of medication or age, may
not fight it as much. But it’s not uncommon to see
waxing and waning of nodule concern because of an underlying
inflammatory reaction. This could also represent just
a benign inflammatory scar but what has to be undertaken is you need long term surveillance. If you decide that you
don’t want that removed, something’s gotta really
keep tabs on that, because scars can develop a cancer. We call that a scar carcinoma. I’ve been doing this for 25 years, I had one patient 15 years out, monitor her first scar
which created a cancer. So, just because you’ve
chosen not to have it removed, and you have the test of time,
doesn’t 100% commit this that this is benign or not evolving
into a malignant cancer. Now, that being said, years
ago we would have a needle placed across the chest
under x-ray guidance. The problem is that 30% of the time the lung could collapse
when that happened. And depending on the size sometimes one out of four
we may not have an answer. What Dr. Seaman alluded to with
the navigation bronchoscopy, that allows us to take a
patient, turn her into a three dimensional computer program and under a, almost like a GPS like
they have for your car or on your phone, we can GPS her lung, and we can deliver a tiny,
little, three millimeter tube anywhere in the lung, go into the mass and
take multiple biopsies and our risk of collapsing
the lung is very scant. That works sometimes 85
to 90 percent of the time. Part of this is because it’s virtual. Well, Dr. Seaman also alluded to the concept of robotic bronchoscopy. This is a new technology where
literally with a microscopic camera and a robot we’ll be able to drive a tiny tube anywhere in the lung,
see the area of concern, and take multiple direct biopsies. This technology has just received FDA clearance in our country. It’s been in place in South
America and Europe for years. It’s a proven technology. The company that has
created this technology has chosen ten programs in
the country to start this. Cleveland Clinic, University
of Pittsburgh, Duke University, Sarasota Memorial Healthcare. So in the next few months or so you’ll be seeing press releases on this. We’re going to be one of 10
programs in the country offering this ability to try and get better diagnostics of these nodules. So, let’s say we have a
patient who’s been biopsied, biopsied, we just don’t have an answer. But it’s getting bigger. The concern is is there some
king of a cancer growing there. Benign or malignant? So, surgical resection is appropriate. Sometimes we can remove
a portion of the lung, we call that a wedge resection,
sometimes we have to remove an anatomical component or a lobectomy. Now, in years passed, they
required big incision, you had aches and pains for three months, you were in a hospital for seven days. Now-a-days the majority
of those procedures I perform using a robot system. It’s four small puncture sites, with maybe a little incision like this. For the patients who undergo a wedge resection, a small resection, the
next morning they go home. For the patients that
we do a lobectomy on, on average they go home
two days after surgery. And my patients, at two weeks
out, 60% of them don’t even require pain medication anymore. So, the robotic technology
is a game changer. We have four robots here
that we utilize for all our different types of surgical oncology. As we build our cancer hospital we’ll have additional
robots available in there. So we’ll be able to provide
the services we do now and expand it for generations to come. – Thank you. Does that
answer your question, sir? So basically, you need to
have continued surveillance, someone needs to continue
to watch what’s going on. Alright, while Dr. Seaman
has the microphone, we talked a lot about the bronchoscopy, and sort of that’s a method
for obtaining tissue. What other ways are there
to obtain tissue for biopsy? – So the decision to
biopsy a nodule or a mass on the lung is somewhat complex. It has to take into account
the patient factors, where the location of the legion is, what’s the other anatomy
around the legion. So the decision to proceed
with a bronchoscopy versus a needle biopsy where a
radiologist would stick a needle between the ribs into the lung
or perhaps even a different part of the biopsy is somewhat complex. Typically when we’re
talking about lung cancer, it’s either a bronchoscopy,
a needle biopsy, or a surgical approach. As Dr.
Chomiak alluded to earlier. – So, what kind of
anesthesia or recover time are required for either
of those procedures? – So, for bronchoscopy it’s
usually just a half a day at the hospital and you
come in in the morning, nothing to eat or drink,
you’re hooked up to the heart monitors, oxygen monitors
while we do the testing. It takes an hour to do the
bronchoscopy, monitor for an hour and a half afterwards and
then you go home that morning. A needle biopsy is very similar
you come in that morning, nothing to eat or drink. The radiologist does a quick
cat scan that localizes the nodule or the mass, and sticks
a needle into your chest wall with it numb, with you comfortable. And typically you go home later
that morning or early that afternoon if you’re monitored, to make sure they are no complications. Surgery as Dr. Chomiak alluded
to, it kinda depends on the complexity of the surgery,
generally it’s at least a one day stay, maybe a little longer
depending on the complexity. – What are some potential complications for either of those procedures? – So, with needle biopsies
through the chest wall the biggest complication risk
is the collapsed lungs, it’s called a hemathorax. Into the lungs it’s kind of
like a balloon, as you put a needle in it it pops the balloon, most of the time it’s inconsequential, you’re monitored for a few
hours and you get to go home. But as many as 10 to 20
percent of patients may have a hemathorax and may have to stay in the hospital for a few days. With bronchoscopy as
Dr. Chomiak alluded to, it’s pretty uncommon.
It’s like less than 1%, and again if the lung collapses then you have to stay in the
hospital for a couple days. – So, I just wanted to open
up any questions from our audience or if you have
any questions again, if you’re watching our
presentation today from Facebook, please feel free to submit your questions. We have our panel of experts
right here in front of you, and they’re ready to answer
any of your questions. So, is there anybody that has a question at this time in our audience? – [Female] I have a question. I’m looking at the
topic here, and it says, lung cancer recent events
and future opportunities. What about those of us that
already have stage four? Are there any advancements
in treating that? – Sure, I’m going turn you
over to Kevin to review that. – There’s a lot kind of in the works. Right now, kind of, biggest two areas that
have been built on are the immunotherapies and the targeted therapies that we talked about before. But on top of that there
is new work legions, So, whenever in oncology we’re
talking about what’s next, and we kinda go into what we say is earlier phase clinical trials. So, right now there’s a lot
of these immunotherapies that are coming out, especially
the checkpoint inhibitors, which is usually what most people get exposed to at some point. But in the future there’s
gonna be even more development in that technology in a
couple different ways. One is going to be
genetically modified T-cells, there’s something called CAR T-cells, these are already in development for certain types of lung cancer. These are available in
certain centers for cancer and lymphomas that have been kind of the factory of treatment, that’s probably going to be moving into the solid tumor area in
the next several years. But that’ll probably be around. There’s another technology
called crisper technology. So, a crisper helps you edit the genome in a way that no one ever
expected they’d be able to. And you can make these, basically, side effect profiles a lot safer. I don’t think that’s gonna
be something that’s available for non-small cell lung
cancer for years to come, but I do think that’s
probably gonna come down at some point. It’s available in clinical
trials in certain areas of the country but not
right now, that’s true. So, other areas of immunotherapy
that are being developed are giving the check point inhibitors in addition with another drug. And those, again, are early phase trials. Meaning they’re not on the market. Whenever we’re studying a new
therapy it kind of has to go through a certain, rhythm, or a certain developmental processes. Where we start with early
phase clinical trials, that figure out the safety profile of whatever the drug
under investigation is. Then you go into a second
phase clinical trial, we’re trying to get a signal response, and then a third phase,
we’re actually trying to see if this stuff is better than
what’s already being used. It’s a very difficult,
costly, long term process that takes a long time to figure out. But in development right now, are drugs that are trying to be logistic with the current checkpoint inhibitors. So, we have some of those housed in our drug development unit as well. Where they’re giving these
in combination with a checkpoint inhibitor to see
if that augments its response. But we don’t know the answer to that. That’s why it’s in trial. So, those would be the two kind of areas right now in lung cancer. The other thing I’d mention is
that the better we understand the biology of a disease, the better we understand how to treat it. And every year there’s
always a couple new mutations that get put on the
cannon of actual mutations that we didn’t know about before. So in the past year,
there’s one that’s B-RAF, that’s usually seen in melanoma, so we know that works well in lung cancer. There’s something called BRO-2, we know that worked in
breast cancer before, and it turns out that works
in lung cancer as well. And then there’s a new one
called T-R-K or TRK and I just saw an advertisement for this in one of the medical journals I read. And thought, “wow that’s
crazy because that’s 0.01% of all patients with metastatic lung cancer. So, understanding the biology as time goes on will
also be real important. – Dr. Koehler, what would
you suggest for somebody, if they want to participate
in a clinical trial and it’s an earlier stage,
stage one, earlier trial. For people to get active and
be able to participate in one? – Yeah, clinical trials are
really important for what we do as medical oncologists, simply
because it’s how we develop new therapies and new drugs. We’re really active in looking
at all phases of development. Phase one through phase
three in our clinics. Right now, I’d say, for the most part, the people are doing well. We don’t usually shake,
or rile the boat too much, we kind of like to let things
be when things are going well. But sometimes we don’t have a choice. We’ll find something, or we
might have an actual mutation that we have a drug for
and it’s being studied. And so the way we work locally
is all phase two and phase three trials we involve our
clinics and there’s a couple clinics in town and we
all kind of manage that. If its an earlier phase trial,
so like a phase one trial, then there’s our drug development unit. They’re on the east side of town. And that’s different because
in a phase one trial they’re running a pharmacokinetic studies. They have to do frequent lab draws. It’s a different animal all together. And a lot of those, if you
look at what’s available on our Facebook menu, there’s like, literally no chemotherapy trials anymore. So, to kinda get to your
question a little bit, because I don’t know the answer, it would be predicting
the future a little bit, what’s the future of managing
metastatic, non-small cell lung cancer three years from
now, five years from now? Well, chemotherapy is not
really the answer, right? You can say that. There’s a role, and it probably will still play a role, in at least through our adult life, but I don’t think that that’s what the orgs
are excited by anymore. There’s a lot more to look
into, kind of various types of immunotherapies and targeted therapies that I’m talking about. – So somebody should just talk to their oncologist about a trial? – Yeah, so if you’re ever interested. So, clinical trials can be tricky. We do address it whenever
we have one that’s open, but if you’re ever interested always ask A) I’m interested in
doing a clinical trial, anything you have available here? If not, is there anything
available anywhere else? Alright, so the biggest
cancer center to Sarasota, that’s called an NCCS
center would be Moffitt. You can always ask for a
second opinion there as well, to see if they had anything available. That’s typically what we do
for our patients in clinic. Trials can be tricky though. You need to be close to
wherever you’re doing that trial because it’s going to
require frequent labs, you’re going to have to have
a certain health status, sometimes it’s difficult to enroll in trials for various reasons. It could be as simple as
someone’s magnesium level or something silly like this. In general, there are
many trials out there, you just ask if you’re curious about it. – Okay, while you have… Do you want to add– – I can actually add in from
the radiation standpoint what Dr. Koehler had alluded to before. There are some ongoing
trials that are phase three that are looking at, in
addition, adding in radiation for people who have limited
metastatic disease. Just a few sites. The definition
of that varies for most universities from one site
even up to five sites, and I think one area or one
university up to eight sites. Where with this newer
technology that we’re using this stereotactic body radiotherapy
which is giving very high doses in five or less
treatments, the side effects are practically nothing depending on the site, as oppose to how more
standard radiation works. And attacking the areas beyond
the lung with this technology and then even coming back
later and treating the mass in the lung with some radiation and chemo, and more standard approach. Right now those trials are on
going but as far as the future for a number of different cancers, the trials that are coming out that are the phase one and phase two are positive. And in cancers such as melanoma, with the immunotherapies there’s
actually something called a skolpol effect where the
radiation in a single, high treatment to an area that’s
spread such as the brain, has been shown to rev up
the influence even more, and by getting that radiation
it makes the immunotherapy work better than if that
radiation wasn’t given. So, whether we see this in other cancers, and depending upon how things play out. Imaging now has improved so
much that when we do start imaging we can really
tell as best as possible, it’s not perfect, that things
can maybe be more limited metastatic disease as oppose
to extensive metastatic disease, as opposed to the past where MRIs quality wasn’t as good. PET scans are improving,
different imaging. Different imaging is really
helping us along with this too. And the immunotherapy
drugs, and (audio cuts out) (audio cuts out) It’s really reserved for trials, it’s not ready for
primetime at this point. It’s still in trial. (audio cuts out) – A hint of malaise, kind
of tiredness with what is available. And so you do have
to have humility with this disease, and at stage
four it is a difficult kind of disease to manage. We’ve seen unprecedented
results with what we have now. (audio cuts out) Audio cuts out – I had tremendous in person
experience with sort of the processes of lung cancer management. Currently in our country,
the majority of our country, if you are diagnosed
with a spot on your lung, by the time you have the
opportunity to get all the testing, the biopsies, see every specialist, to the first implementation
of your treatment plan be that surgical, be that observation,
be that chemotherapy, or radiation, that
timeline is about 90 days. And that sort of standard
care in the United States. One of the visions we have, is to get to the point, and
it’ll be much easier once we have our cancer hospital, to have a multidisciplinary experience. Imagine that person who’s
identified with a spot, not only accidentally,
but the folks that we actually screen for to find these spots. That person bypasses all
those customary processes, enters through a lung cancer navigator, into a multidisciplinary format. Where you’re met real time
with all the specialist, the folks you need, and a
treatment plan is generated, and you’re provided a list of homework. You’re gonna get this on
this day, this on that day, this on this day, gonna
have surgery on this day. And it’s all done real time. And it can. I’ve been involved in two
other programs who reduced that from 90 days to less than two
weeks, that is our goal here. So, let me tell you what
we’ve accomplished right now, virtually, because we don’t
have our building yet, but its coming down the pipeline. So, virtually we are blessed
to have two lung cancer navigators who help as point
guards to coordinate all that. What you’ve seen here today
this is the multidisciplinary approach to lung cancer management. We’d do this every week. Every newly diagnosed
lung cancer is reviewed on a weekly basis in our group. As well as the abnormal scans through our lung cancer scanning program. And we as a group, essentially
about 25 people, put together a treatment plan, recommendations
and try to get that patient to the right people
as quickly as possible. Now, the big vision is once
we have our cancer hospital and our multidisciplinary
clinics, we’re gonna be able to manager real time breast
cancer, neurologic cancer, urinary cancer, gastrointestinal cancer, lung cancer, and any other major cancers. So those patients will come in, and right there have a
treatment plan rendered. So, that’s one of the key advances we’re working on here at our program. We have it now virtually,
soon we’ll have it real time. – Thanks. So, I still have two,
Dr. Koehler for a minute, and you’re talking about your
different chemotherapies that you offer your patients,
can you talk a little about side effects and sorta how
people feel while they’re on those chemos and do they differ
from treatment to treatment? – Yes. Side effects for systemic
therapy differ remarkably depending on what we use. So, to start with the easiest,
the newer immunotherapies, in general are really
well tolerated, actually. There’s only about 2 to 3
percent of people who ever have to discontinue those
drugs because of side effects. We general say that any sort of itis, that means an inflammatory
process someplace in the body that can happen, that’s
the main side effects that we see as we’re (audio cuts out) So, for example, it might
inflame the immune system that affect the thyroid,
where the lung tissue get pneumonitis, or the colon you get colitis, or the liver you get hepatitis. Sometimes you can see a rash. But for the most part they’re actually pretty well tolerated. Not a lot of people have
to come off those drugs. Sometimes people look kinda
tired and flu-y for the first couple months but after that they actually feel relatively well. Chemotherapy is what everybody fears. So, chemotherapy is the one
it can make people feel kinda tired, and maybe a little bit groggy. For the most part nowadays we have a pretty good handle on controlling nausea. With all of our newer antinausea
medications so that doesn’t tend to be as much of an issue. Which in the past that tended
to be a very big issue. In my experience most people
feel, kinda just tired. Usually three to five days
after they get the chemotherapy. And then that is a cumulative side effect, meaning it adds over time. So you can really only
do that for so long. If you’re using a maintenance strategy, so kind of a lower dose, a
drug that’s more tolerable, then someone can take on long term. But for the most part the
chemotherapy is the one that people fear the most,
simply because of that. Kinda gotten away from a lot
of the regiments where you lose your hair, but you still can
lose your hair with a lot of the newer drugs we use. And as far as target therapies, these are sort of a
miracle in a lot of ways. Because most of these newer drugs, it’s like taking an Asprin once a day. So for example, I had a patient
the other day, never smoked, we sent out blood tests that
looks for molecular genetics and she had one of these
canonical EGFR mutations. We put her on the newer drug
that was just approved called TrueGresso and she was kind of shocked. She hasn’t felt any
problems from this drug yet. And so, as we understand the
biology of the disease over time and drugs are more specific
to what they’re targeting, then there’s less side effects. So targeted therapy is very
specific but traditionally that used to also target
healthy versions of those genes, so people can have like
rashes and things like that. But that just doesn’t
happen as much any more. So, side effects
fortunately are improving. – Is it a myth that with
immunotherapy that the worst the rash is the better the
treatment is working? – Yes, that’s an absolute myth. I love talking about
myths, so if you want more, we can talk more about myths. So, that is true with what
we call EGFR inhibitors. These drugs that aren’t used
as much, for metastatic colon cancer in particular, because
again as we understood that disease more and more, there
were things called RAF or RAF mutations that come
up, and those people do not respond to EGFR inhibitors. So people kinda got away
from using those drugs. Because they are drugs where, there are monoclonal antibodies,
so they’re infusions, and we knew some research that
the greater degree of rash someone’s getting from these drugs, the more likely they would respond. So people would sort
of hope to have a rash. It would cause a lot of anxiety. But the field in general
got away from those drugs. – Thank you. So kinda the same
question for Dr. Silverman. What are some of the common side effects for radiation treatment? – So radiation side effects are broken into two categories generally. There’s what we call the early effects, these are the ones that happen
during the course of the radiation and are all temporary
and then the late effects which may not even set
in until six months to a couple years later
but they’re fairly rare. And depending upon the body
site that’s being treated, because radiation is
a localized treatment, the side effects are really glued to the surrounding structures in that area. So when it comes to lung
cancer, when we do a more traditional type of radiation
for more advanced cancers, when we’re treating a lone
mass plus the lymph nodes, the side effects during a six week course, setting in usually about
halfway through may include, fatigue, being a little more tired at the end of the day
is a typical scenario. Maybe a dry cough and potentially
feeling of food sticking in the esophageus around
the area of the lymph nodes. Maybe some heartburn. If we’re talking about a
stereotactic body approach, we’re just treating stage one. A solitary lung mass nodule,
then 90% of the time there’s little to no side effects. About 10% of the time there
could be some fatigue, maybe some night sweats
or fevers with nights, that is now 10%. And these
things are temporary. Getting into the late effects. The late effects are ones
that are pretty rare, usually. We keep them to less than 5%
and there’s guidelines that have been established over the years, that have looked at what doses each normal organ can tolerate,
what percentage of the normal organ do we have to keep
the radiation doses below. So, if you adhere to the
guidelines than the risks are typically anywhere from 5% down to, in some cases less than 0.2%. And we definitely don’t want
late effect side effects. Are a more permanent type of
side effect. (audio cuts out) The biggest issue when
it comes to lung cancer, is a kind of (audio skips) called subacute effect which
can happen less than six months but usually a couple weeks after, it’s called radiation pneumonitis. It’s this inflammatory
response where they’re changes on imaging but also the
patient could have fatigue, could have a dry cough, fevers at night, some shortness of breath. And guidelines have evolved over time with what to keep different parts of the lung to with the
different technology. So, again, we usually try to
keep that risk less than 5%. But there’s treatments for
short term side effects and long term side effects that they need. – Like what are those kind of treatments? – So, for radiation
pneumonitis, which thankfully we are seeing less and less of with the new guidelines
of what to keep the normal structures to, sometimes steroids produce, sometimes we have to use oxygen. – So, I have one other
question for Dr. Chomiak, since we have so many
advancements in robotic surgeries, why would we ever do an open procedure versus a robotic procedure? – Well, the open procedure,
and there’s even a couple different ways that the open
procedure can be performed for smaller incisions. Trying to spare some of the
muscles that control your shoulder blade versus
traditional fighting them. (audio cuts out) much less down time, much
less aches and pains, quicker return to quality of life. But from the surgeon’s
perspective that operation is actually more technically
challenging and it takes longer. I’ve been doing this for, I guess I can say a
quarter of a century now, I think part of what I utilize
is my six degrees of freedom of my hand and the ability to touch. So, if a patient has a varied anatomy, or scar tissue from a prior operation, or scar tissue from an old pleurisy, where I can’t visualize the
blood vessels or the air way, or the vein cutting of the heart, that has to be disconnected I have to use my finger to do that. The robot, under current
technology, does not have touch. We call that haptic feedback. So, it’s a visual operation. So, what I tell patients
for offering the robot, we go ahead and go forward with that. But If I get to the point where safely we just can’t
complete the operation, then it’s okay to proceed with what I do. It’s called a vertical
thoracotomy, its only a four inch incision not these old barbaric incisions that were done decades ago. And with that I have the
ability to use my hands to feel things that I
may not be able to see. Now also, we may have patients that come in with large tumors. In those situations we would
proceed with an open procedure. Because when I place four,
eight millimeter puncture sites on the patient, and perhaps a
two inch accessory incision, sometimes I have to tell
the patient we can’t remove this out of an eight millimeter hole. So, in situations where we
have a very large tumor, or we have a tumor that’s near
the heart, we’re not going to be able to (audio cuts out) without the sense of touch. In those cases we would
do an open procedure. And there’s nothing wrong with that. So, it’s scaled to the the patient. – Thank you. So again, I want to open
it up to the audience. Does anybody here have any questions for our expert panel here? Or if you are watching from Facebook, please feel free to submit
your questions to us. And we can get those
questions answered for you. Anybody here have a
question for our panel? Any Facebook questions? – [Male] We have one. If someone is a non-smoke,
never smoker even, but they’re concerned about
their risk of lung cancer, how do you go about the screening process? How do you start that? – Yeah, so that’s a question
that comes up quite a bit. Particularly in individuals
who have a rich family history. Multiple family members
who have lung cancer. Often times that’s a discussion that they need to have
with their provider. Their primary care provider,
or if they want to seek out consultation and discuss that. Because there is a possibility
that the lung cancer screening CT, that a nodule
or a mass may be found. But that comes at a cost
of some radiation exposure. We’re very fortunate now
that most cat scans are done with dose reduction techniques so that the dose and the
danger of radiation is less. But it is something that they’d
have to really discuss with the patient so they
understand there’s risk. That being said, I’ve
counseled many patients and many of their concerns are substantial. And often times we move
forward with a low dose, cat scan, screening technology. It’s a discussion you have to have and you have to kind of map out
also where you go from there. If the cat scans negative,
today, that doesn’t mean in five years your risk profile changes. In fact, you have the same risk profile and you have to have
that discussion again. The background of that is
also more complex because insurance companies may not pay for that cancer screening study if you
don’t have the risk factors that they acknowledge. Most programs like ours have a cash rate that patients can pay. Just because we feel
it’s an important need that we offer the community. ’cause we also have a lot
patients that aren’t on insurance, but they want this lung
cancer screening program. – How much is that priced for? – So Amie, what’s our– – So our self pay price
for our low dose CT scan for lung cancer screening is
$150 for the actual cat scan, and it’s a $50 radiology
interpretation fee. So it’s a total of $200. And with most patients that
don’t fit those eligibility criteria guidelines,
and those are basically, you have to be between
the ages of 55 and 77, you have to be a current
smoker or someone who’s quit in the last 15 years,
and you must smoke about a pack a day for 30 years or more. So, that’s really what insurance
companies, or medicare, CMS, really will look at when
they’re looking at eligibility and paying, reimbursing for that service. So if you don’t fit that
criteria it doesn’t mean you can’t have a cat scan
done, a low dose cat scan, but it does mean that you’ll
likely have to self pay for it out of pocket, and we do offer that. Sure go ahead. – [ Female] You mentioned
familial history. I’ve heard both ways that
lung cancer is hereditary and that it isn’t, what is your take? – So there’s certainly family
histories that we take that there’s an unusual richness of cancer. They may have family members
that have colon cancer, pancreatic cancer, thyroid cancer, and I think a lot of our
limitations is we have such an infantile understanding of how cancer is transmitted along with the risk. We know that many molecular,
genetic abnormalities pose a risk for cancer. But I think it’s more
that we take that history, we take that into account when
we’re giving recommendations. The National Cancer Center
Network nationally recognized that in one of their
dispatchers for cancer, and they have different recommendations, that other professional
societies based on. – It’s a really interesting question. So, I would just echo
what Dr. Seaman said. There’s a lot of mutation that we do know right
that are inheritable. We call those germline mutations. Meaning that you got a
copy from mom or dad, the most common one you’ll
hear about in this instance is called BRCA, B-R-C-A. That puts you at an increased
risk for breast cancer, ovarian cancer, but
also pancreatic cancer, it’s the mother of cancer,
prostate cancer included. It’s a lot, it’s a lot on the body. – [Female] What about lung? – No, so lung cancer we just don’t know. It doesn’t turn to be… It’s not these germline mutations that seem to be the same
kind of risk factor. It seems that for whatever reason, some people are more likely to
develop these other mutations that then drive these diseases, even if they’ve never
had a history of smoking. So we’re still (audio cut out) to understand, and we
certainly see family histories where disease clusters. Even if I’d see five or six
family members with lung cancer, that’s unusual even if everyone did smoke.