Lung Cancer Treatment Advances, Part 2 – HealthCasts Episode 5

(upbeat music) – [Announcer] From Sarasota
Memorial, this is HealthCasts, a healthy dose of information
from experts you can trust. – Hi, everybody! Welcome to HealthCasts. I’m Heidi Godman. In this episode, we’re going to be talking about advances in lung cancer treatment. In particular, we’re gonna find out how Sarasota Memorial
Hospital takes a team approach to treatment, and we’ll hear about new
technology and surgeries to successfully treat cancer. Our guests are Dr. Paul
Chomiak, a thoracic surgeon, and Dr. Joseph Seaman, an
interventional pulmonologist. Both are leading Sarasota
Memorial’s lung cancer team. Welcome to the program. – Thank you.
– Thank you. – So when you hear those words, “You have lung cancer,” that just triggers a very
long road for the patient, and the patient might
feel a little bit alone or overwhelmed. But that person is not alone because, in fact, you have a
team approach that you take. Can you tell us about it? – Yeah. So at Sarasota Memorial Hospital, we have a multidisciplinary
cancer care conference that we meet once a week, and it includes pulmonary medicine docs, thoracic surgeons, general surgeons, medical oncologists,
radiation oncologists, radiologists, pathologists, as well as other professionals, nursing, respiratory therapists, that come together to really discuss cases in a multidimensional format. So we don’t just look at the cancer. We don’t look just at
the stage of the cancer. We look at the patient as a whole to determine what’s the best
treatment for this individual. Are they a surgical candidate? Are they not a surgical candidate? If they’re not a surgical candidate, which platform and
intervention would be the best for this person to have the
best patient-centered outcomes. – How is it that you’re
coming to a consensus? And you and I talked before we went on, and you were saying that you
really need an army of people to do this. You can’t do it alone. – You do. One of the problems we have in our country is by the time a patient
is identified with a spot to that first point of intervention, on average, it’s 90 days, three months. And every now and then as
I see patients coming in from abroad or they
come down as snowbirds, there’s that timetable. Best practices, we should
be able to bring that down to less than two weeks. So we’re attempting to do that virtually. We have in place lung cancer navigators who are sort of our go-to. I call them the linebackers. Being able to work with everybody and try to facilitate exchange
of information and process. Eventually, when we have
a multidisciplinary clinic here on site, we’ll be
able to manage somebody with a spot and be seen by
seven, eight specialists right away and have a treatment
plan issued immediately and a list of, “Here is
what you need to do.” – But you’re already
meeting right now, right? It’s every Tuesday? – Yeah, it’s every Tuesday. And providers will send
a list in of patients that they would like to discuss, and they take the lead in
discussing that patient’s care and what’s going on, and
what are the questions. And then, they get feedback
from all of the providers that are there in the room with us. – So many ways to tackle lung cancer, but I think a lot of people just assume, well, you have to have the lung come out. But that’s not necessarily true, right? Who’s a candidate for lung surgery? – Well, you look at all patients who present with lung cancer, about 25 percent of those patients are gonna be what we consider early stage, stage one, stage two. Historically, for 50-plus
years, the best long-term survival was an operation. Now, does that operation mean
an entire anatomical region, such as a lobe has to be removed? Is it a small portion of the lung, a segmental resection, or
we call a wedge resection? Or if the patient may not
be a candidate for surgery, could we use high-dose radiation therapy? There are a lot of options. So we have to look at those patients, and one of the things
I do in collaboration with my pulmonologists
and my cardiologists is to stratify the patient. Does the patient have
adequate lung performance? You have to remember,
most of these patients have all smoked or are active smokers. All of them will have some form
of emphysema, in my opinion. What can I project to
be their quality of life if I have to remove one half of their lung or one third of their lung? When we look at lung cancer,
we’re dealing with a population on average around 70 years
of age in this country. We can’t just go in and
take things out of people, and then they’re condemned
to an oxygen tank and their biggest activity is getting up to go to the commode. So I have to balance curative
intent with quality of life when all is said and done. And that’s where we work as
a team to try to determine, is this patient strong enough physically, from a pulmonary perspective,
from a cardiac perspective to tolerate an operation? – All right. And so, then,
how do you figure out how to remove the part of the lung that might be most appropriate? I mean, I think everyone’s assuming you make those big
incisions that we all know from years ago. Is that still something you
do, traditional open surgery, or what about minimally-invasive surgery? – In training many, many years ago, I was quoted a statement from Harvard where a thoracic surgeon was only as good as the size of his thoracotomy. And so, yes, the stem-to-sterns
incisions were prevalent. They were standard of care. In our country today, if someone has early stage lung cancer, seven outta 10 times, they’ll
be offered minimal invasive or robotic approaches. At our program, we’re at 97 percent that we offer robotic
technology for cancer therapy. The selection of removing
a part of the lung, such as a lobectomy or a smaller part, depends on the size, the location, as well as the reserve of the patient. So the value of doing this
through a robotic approach, I can give you an example in my hands. The patients are only with
us two and a half days after surgery, and they go home. And when they go home,
within about a week, six outta 10 of those
patients are no longer taking narcotic medications, and they’re able to start adjusting back to their baseline quality of life. So it is a game changer. It’s a little more technically
challenging for the surgeon. We probably spend a little bit more time in the operating room. People can argue the
costs of the technology, but the patients get to return back to their quality of life much faster with less complications, and they have the same cancer operation that they would as compared
to historic standards when the chests were opened wide. – And it’s not just that
the incisions are small. It’s also that the technology
has advanced so much. And there are two very
exciting developments: The robotic surgery, also in combination with the
Monarch robotic bronchoscope, which, Dr. Seaman, is
something that you use in diagnosing cancer. – [Joseph] Yes. – Tell us about that. – Yeah. So the Monarch
robotic bronchoscope platform is a unique platform
where a small bronchoscope is introduced through two different arms into the patient through their airway. And we’re able to drive
it with a controller that is an Xbox controller. And we’re able to drive that
visually down into the lungs with the aid of navigation technology to get to areas of the lungs that we have not previously
been able to access. And once we’re there, we’re able to lock the bronchoscope in place. We have full control of it. Once it’s parked, if you will, we’re able to stick our
biopsy instruments in and biopsy lesions that, in many cases, we’re looking at, which is a novel thing because, previously, we
didn’t have that technology and that vision into the
periphery of the lung. – You couldn’t necessarily
detect the cancer as early as you can now. – Right, yeah. The detection rates for
bronchoscopes were not optimal. – So, now, how do you
combine, Dr. Chomiak, the Monarch robotic bronchoscope
with the Da Vinci robot? Because that seems like
a natural marriage, but how do you do it? – Well, I think it’s
quite a novel approach, and recently, our program
published our experience. And it’ll be published
in a national journal later on this month. But in certain situations
where we may have a patient with a very minute nodule, let’s say less than six
millimeters in size, we might not be able to diagnose that. If we’re concerned, you know, if the patient’s nodule grew from three to six millimeters, we may not be able to diagnose that with a needle biopsy or even
with the Monarch platform trying to biopsy something that small. Secondly, if we have a patient that has, we call a ground-glass opacification, historically, this was
thought to be an inflammation. We now know that as patients undergo these CT screening studies,
six outta 10 times, we’re gonna find a
ground-glass opacification. And over the course of time,
if that gets slightly bigger or changes in terms of configuration, well, it’s been a dilemma because, historically, tryin’ to biopsy this with a
needle, didn’t get an answer. Tryin’ to use a PET scan didn’t
really give us an answer. So these are two conditions where we brought both
technologies together, and the patient goes to
sleep under one anesthetic. We use the Monarch robotic bronchoscope to actually drive onto the
little lesion of concern, and then we inject a dye. The dye is almost a fluorescent green dye. We retract the bronchoscope. We reposition the patient. And then we put in the
Da Vinci robot system. Through a few puncture
sites, I’m then able to look at the lung. Normally, when I look at the lung, I may not see an obvious abnormality. We changed the configuration of the optics where everything literally
turns black and white except for this fluorescent green spot that glows in the dark, and now we can find the area of concern, do a limited resection, send that off immediately to a pathologist right across the hallway, and in 10 minutes, I have an answer. And if it’s benign, those
patients are usually with us overnight, then they go home. If it is a cancer, then
we do the appropriate cancer operation through the robot, and those patients usually go home in about two days after surgery. So it really gives us a one-stop shop to go after some of the
most challenging nodules and ground-glass
opacifications that, otherwise, all we could offer was further observation ’til it got big enough
to try to biopsy it. – So everyone’s going to wanna
have lung cancer removed, but what about safety? Is it safer than the old-fashioned way of that very large incision? Is it safer, this new
minimally-invasive way? – The new minimal invasive
way has been published and demonstrated higher
levels of accuracy, lower complication rates as compared to the traditional way of just putting a needle across the chest. – So everybody’s going to want that. And then, what about recovery? Because you’re also doing
something new there, too? – Yeah. Traditionally,
patients came in for surgery. They received a high-dose
narcotic anesthetic. It would take the
patients a couple of days just to sort of get their
facets back in order, and then we would recover the patient. What we found historically in our field of thoracic surgery is we ended up putting those patients on so many narcotic medications that some of those patients
got addicted or near addicted to those medications. And, of course, there’s
been a national movement to try to limit the amount of
narcotics available out there for treatment as well as for abuse. So we’ve implemented a new process called enhanced recovery
after surgery, ERAS, E-R-A-S. Historically, this was
designed about a decade ago out in Europe, and it was used for orthopedic patients. About five years ago,
people in our country began exploring this in thoracic surgery. Last year, a group of 42
members came together, and we took best practices
from other institutions and universities for thoracic ERAS, and we implemented. We went live in December of 2012. What we do now is we take the patient and literally put ’em into a boot camp for about a week and a half to two weeks. They’re on a high protein load diet. They’re doing daily
exercise, recording it. They’re using an incentive spirometer, which is bellows to
measure their lung volume. And they’re recording it
and pushing themselves. I call that the boot camp. When they arrive on day of surgery, we actually begin treating
their pain before the operation with nonnarcotic agents. The anesthetic is completely different. It’s a nonnarcotic-based anesthetic. I always tell my patients, “You’re asleep. “You’re on some island in the Caribbean “from when all this is happening.” At the same timeframe,
we inject the nerves of the inside of the chest
during robotic surgery to blunt them for a period. And then patients are offered scheduled nonnarcotic medications, and if they need, they have
additional narcotics needed. What we’re finding is my
patients arrive on the floor and have a regular diet. That evening, they’re
walking the hallways. The next morning, the
majority of the patients have their drainage tubes removed. If we had a small little resection done, they go home the first day. If I did a lobectomy, they
usually go home the second day. When we look further
out, the use of narcotics as an outpatient are dramatically reduced. These patients can get
into their quality of life very quickly. We’re actually beginning
to acquire our research, and our hope is to be able to prove that, in the inpatient setting, we
give less narcotic medications compared to other standards
of robotic surgery, even open surgery. – But there’s still no pain. That’s so encouraging. – Well, we minimize the discomfort. – Well, yeah, yeah, we should point out. – Yeah. There’s always some level of discomfort. – But not during surgery? – Right. No, not during surgery. (Heidi laughs) They have no pain at all. – All right. And so, then, if you are
a candidate for surgery and you have the surgery, are there any nonsurgical treatments that you might have to
undergo to treat your cancer? – Sure. So the treatment of cancer really depends on the stage
and the type of the cancer. We always wanna find
the early stage cancer to offer them a curative surgery so that their treatment plan after surgery is just some follow-up
scans and no therapy needed. We’re now entering into a
different era of medicine where there’s a lot of new
drugs that are addressing these sort of in-between cancers, stage twos, stage threes, to really maximize their outcomes. And that’s where you start
seeing blended treatments of old technology, new technology, or you see medical oncology
working with radiation oncology. – And Sarasota Memorial
has a very large program that handles many
different aspects of this, I mean, including wellness, right? – Yeah, absolutely. We have a wonderful collection
of wellness professionals that intervene on sort of the
social aspect of lung cancer. And, also, educate the
patients about nutrition and exercise and alternative therapies that may not move the
cancer survival needle, but what they do move is
that individual’s perspective on their cancer, their perspective on their self, and improves their overall wellbeing. – Is there anything patients can do to improve their outcomes? What would you advise? – Well, I think what’s
critical is adequate nutrition, adequate activity, and we start that from the
first day after surgery for the early stage cancers, and we start that beforehand. So it’s important for you to recover. It’s important for you to
build your protein stores. It’s important for you to
be active in terms of that. What we’ll find is some
of these early stage lung cancer patients, we’ll actually find
some microscopic spread in the lymph nodes. And that is a surprise, because usually the testing ahead of time didn’t suggest that, but
there’s always a probability. The value of that is,
now, we’ve identified that the patient’s
actually a different stage. And in our teamwork approach,
we now have the ability to, in a very quick timeframe,
implement some type of systemic cancer therapy or combinations of systemic cancer therapy, immunotherapy, maybe
even radiation therapy, where otherwise we wouldn’t know that. So that’s the whole value
of working as a team. – And as a team approach before, during, and even after the
person has been treated, tell us about that. – Yeah. So the important of knowing where to send the patient to get
the best possible outcome, it takes a lot of communication. So talking to the patient, talking to the other
medical professionals, and putting them in the
smallest circle possible so that everybody knows what’s going on is gonna lead to better outcomes and better communication
amongst team members. – Dr. Joe Seaman and Dr. Paul Chomiak, thank you so much for your time today. – [Dr. Seaman] Thank you.
– [Dr. Chomiak] Thank you. – [Heidi] All right. Time
now for today’s takeaways. One is that Sarasota Memorial
takes a team approach to lung cancer treatment with an army of healthcare professionals. Two is that advances in
technology and surgery are paving the way for better
outcomes in cancer treatment. And three is that the Sarasota
Memorial Cancer Institute has the nation’s highest
level of accreditation from the American College
of Surgeon’s Commission on cancer. And if you’d like more information, just call 941-917-7777. (upbeat music) – [Announcer] Thank you
for joining us today! For more information,
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