Lung cancer is a dreaded diagnosis, mostly because, for 75 percent of people who are diagnosed, the cancer is already in advanced stages, which means it’s too late for curative surgery. Lung cancer remains the leading cause of cancer death in the United States, claiming the lives of more than 158,000 people — more than breast, prostate, and colon cancers combined — each year.
Studies have shown that early low-dose CT scans can reduce lung cancer deaths by 20 percent. And fortunately for high-risk Westchester residents, White Plains Hospital offers lung cancer screening.
I spoke with thoracic surgeon Cynthia Chin, MD, FACS, one of the members of the multidisciplinary team at White Plains Hospital who’s involved in the screening protocol, about what makes a person high-risk, about the screening program, and about some of the inherent difficulties in treating lung cancer.
Q: White Plains Hospital’s lung cancer screening program is open to people who are 50 or older, have smoked for 20 pack years, and are currently smoking or have stopped smoking within the last 20 years. What is the formula for determining ’20 pack years’?
A: If you smoked for 20 years, and smoked a pack a day, that’s 20 pack years. The calculation is based on many packs of cigarettes you smoked, multiplied by how many years you smoked.
Q: Why is the screening open only to those age 50 or older?
A: As with any type of screening program, you have to weigh the risks vs. the benefits. So if someone doesn’t have a long smoking history, then the risks of screening outweigh the benefits.
Q: Is this screening for any type of lung cancer (small-cell, non-small-cell, etc.)?
Q: Is any candidate whose cancer hasn’t spread outside the lung a candidate for surgery?
A: Every patient is treated on an individual basis, but there are some instances where a patient’s cancer has spread outside the lungs, and they will receive tri-modality treatment, which is a combination of chemotherapy, radiation, and potentially surgery.
Q: Is there any type of lung cancer that is inoperable, even in earlier stages?
A: With early-stage lung cancers, which are identified as Stages 1-2, we prefer surgery to offer the best chance of a cure. Patients who have those cancers, though, may not be able to have surgery because they have other health issues, like heart disease or lung disease that keeps them from having an operation. People with Stage 3 lung cancer may have surgery as well, but that may be part of a tri-modality treatment. Also, a certain type of lung cancer called ‘small-cell’ is best treated with chemotherapy and radiation, even in its early stages.
Q: What other types of surgeries for lung cancer do you perform other than segmentectomies?
A: At White Plains Hospital, we offer the full gamut of surgical procedures for lung cancer, from segmenectomy to lobectomy to pneumonectomy. We’re able to stage patients through a procedure called a bronchoscopy, which offers a minimally invasive way to biopsy their mass. We perform navigational bronchoscopy, which uses GPS to help identify masses. We can perform endobronchial ultrasounds to stage the patient. Staging is very important because it tells us which way to treat the disease.
Q: Since the lung is spongy and porous, how can you be sure you’ve gotten all the cancer via surgery and that chemo and radiation are not needed?
A: The CT scan that’s available today gives a better view of the patient’s entire body, including their lungs, and we can see the extent of disease better. At the time of surgery, we generally do an anatomic resection, which not only takes out the mass but also the draining areas and lymph nodes around it. This allows us to not only take out the mass, but also the roads that it would have traveled, which gives us the best chance of it not coming back. We also send the lymph nodes to pathology, and, if none of the nodes were involved, the chance of the cancer going out further in the body is less likely. So the next steps in treatment are usually determined by what’s found in the specimen that’s removed.
Q: What advances have been made in lung-cancer treatment in the past 20 years?
The answer is a lot!
- We’ve made advances in the surgical resection of lung cancer; it used to be that surgery always involved large incisions that would require a long recovery. Now we can do robotics, which use small incisions that decrease recovery time.
- Not only do we have minimally invasive surgery, we also have minimally invasive biopsies, with new technology like navigational bronchoscopy that use GPS to find nodules that we can’t see.
- Radiation has also improved greatly over the last 20 years. We used to have to radiate the whole chest, but now we can pinpoint a certain spot.
- Chemotherapy has improved tremendously, too. We have digital targeted therapy, so if someone has a particular mutation in their tumor, we know that certain types of chemo work better.
- We now also have immunotherapy, which is having promising results for lung cancer.
- The best news for people in Westchester is that White Plains Hospital is on the cutting edge and offers all of the new surgical, radiation, and chemotherapy advances. We also offer clinical trials, one of which is the Checkmate Study, a new clinical trial of experimental treatment for patients with advanced lung cancer.
Q: Have the incidences of lung cancer decreased in proportion to the number of people smoking?
A: Not really, although it looks like it might leveling off. The only way to know is over longer periods of time. It’s not like you start smoking today and you get cancer tomorrow. It is an effect of many years of smoking.
Q: How big a risk is second- and third-hand smoke?
A: There have been studies showing the risks of second-hand smoke, but it’s hard to know. As far as exposure to third-hand smoke, again, it’s difficult to know.
Q: How is it determined that a treatment is simply palliative rather than curative?
A: The goal is always curative. But you only want to put someone through curative treatment if the benefits outweigh the risks. We base our treatment strategy on the patient’s stage, and that’s based on data that’s been collected for decades. Staging helps tell us what treatment will offer the greatest benefit. It tells us what’s worked best, and what’s an acceptable risk. We take a team approach to treatment. We have the benefit of being in a place where many specialists are all under one roof, so your surgeon will be conferring with your primary care doctor and your cardiologist, and we’ll all work together to make sure you are fit and ready for surgery.
Q: Tell me about White Plains Hospital’s cancer care.
A: Our cancer care is comprehensive, so we work together as a team. Every other Friday, we present cases in our thoracic conference, and we’ll share ideas, or information about new studies or technology. Here you get the benefit of many top physicians coming together and consulting on your case.
Q: Are there any promising treatments on the horizon?
A: Immunotherapy, which is very new, is already very promising. Also, targeted therapy is extremely promising.
Q: What are the primary warning signs of lung cancer?
A: The symptoms of lung cancer, which usually don’t appear until it’s already advanced, are coughing, weight loss, vomiting up blood, fatigue. That’s why lung cancer screenings are so important, to identify cancer before people are having symptoms, – when it’s in a curative early stage.
Q: If a person is worried he or she may have lung cancer, but is under 50 or has not smoked for a long time, what can he or she do? Is there a test the patient should ask the doctor for?
A: Routine screening for lung cancer without significant smoking history is not recommended. The risk of the screening probably outweighs the benefit. If a patient has concerning symptoms, they should speak to their doctor to discuss whether screening is advisable. About 20 percent of patients with lung cancer have never smoked, but it’s difficult to identify that. For anyone undergoing cancer screening, though, it’s important to go to a place that has a multidisciplinary approach. You want to be sure a team of physicians reviews your CAT scan. Not everything that turns up on a scan will need to be biopsied. When a good medical team puts its minds together, then they are best able to see the whole picture.
The clinical trial at White Plains Hospital offers low-dose scans, plus smoking cessation counseling. Follow-up testing is immediately scheduled if findings are suspicious. Those who show no signs of the disease are encouraged to do a follow-up scan one year later.
In addition to Dr. Chin, the multidisciplinary team at White Plains Hospital that’s involved in the screening protocol includes:
Todd Weiser, MD, FACS, thoracic surgeon
Scott Berman, MD, FACS, thoracic and vascular surgeon
Sean Kwon, MD, FACS, thoracic surgeon