Innovation in the Diagnosis of Lung Cancer

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers with
00:08 --> 00:10your host, doctor Anees Chagpar.
00:10 --> 00:11Yale Cancer Answers features
00:11 --> 00:13the latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are in the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:22This week it's a conversation about
00:22 --> 00:24innovations in the diagnosis of
00:24 --> 00:25lung cancer with Doctor Sanket
00:25 --> 00:27Thakore and Kyle Bramley.
00:27 --> 00:28Doctor Bramley is an assistant
00:28 --> 00:30professor of medicine and Doctor
00:30 --> 00:32Thakur as an instructor of medicine
00:32 --> 00:33in the Department of Interventional
00:33 --> 00:36Pulmonology at the Yale School of Medicine,
00:36 --> 00:38where Doctor Chagpar is a
00:38 --> 00:39professor of surgical oncology.
00:42 --> 00:44Kyle, I'm gonna start with you.
00:44 --> 00:45Maybe both of you can tell us
00:45 --> 00:47a little bit about yourselves
00:47 --> 00:49and what it is you do.
00:50 --> 00:52Sure, I'm an interventional
00:52 --> 00:54pulmonologist and critical care doctor.
00:54 --> 00:56I often struggle to
00:56 --> 00:57describe what that means.
00:57 --> 00:59And so I'm a pulmonologist,
00:59 --> 01:01a lung doctor who specializes
01:01 --> 01:03in minimally invasive procedures
01:03 --> 01:05to diagnose cancers and other
01:05 --> 01:07lesions inside the chest.
01:08 --> 01:11And Sanket, how about you?
01:12 --> 01:15I do very similar to what
01:15 --> 01:17Kyle just described as well.
01:17 --> 01:19I'm also an interventional
01:19 --> 01:20pulmonologist and I'm also
01:20 --> 01:21a critical care doctor.
01:21 --> 01:24So we commonly take care of a lot
01:24 --> 01:27of patients with lung cancer.
01:27 --> 01:30So you know it is lung Cancer Awareness
01:30 --> 01:34Month and I think a lot of people know
01:34 --> 01:37that lung cancer is a deadly cancer.
01:37 --> 01:40But what people may not know is that
01:40 --> 01:43we actually have decent screening
01:43 --> 01:44for lung cancer.
01:44 --> 01:46And we know a little bit about the
01:46 --> 01:49risk factors that put people at risk.
01:49 --> 01:50One of the ones that we
01:50 --> 01:51often talk about is smoking.
01:51 --> 01:54But Kyle, do you want to tell us a
01:54 --> 01:56little bit about what's available in
01:56 --> 01:59terms of screening for lung cancer,
01:59 --> 02:02who's eligible for it and why it's important?
02:02 --> 02:04Sure. So as you said,
02:04 --> 02:06lung cancer screening is very important.
02:06 --> 02:08And recently we have some very good
02:08 --> 02:10data that suggests that people who
02:10 --> 02:12are at an increased risk of getting
02:12 --> 02:14lung cancer during their lifetime
02:14 --> 02:16can be screened with a CAT scan
02:16 --> 02:19and so patients who are eligible are
02:19 --> 02:21patients who've had a long smoking
02:21 --> 02:23history and are over the age of 55.
02:23 --> 02:25The way that the screening generally works
02:25 --> 02:27is you have a meeting with a provider to
02:27 --> 02:30talk about what your risk factors are,
02:30 --> 02:33to talk about what the screening may show,
02:33 --> 02:37and then receive an annual CAT scan.
02:37 --> 02:40So it's a low dose of radiation
02:40 --> 02:42cat scan that's performed yearly
02:42 --> 02:45for three years with the idea of
02:45 --> 02:47looking for lung cancers when they're
02:47 --> 02:49still small and more easily treatable.
02:53 --> 02:57Sanket, just to follow up on what Kyle said,
02:59 --> 03:02how much of a
03:02 --> 03:04smoking history do you need
03:04 --> 03:06to have, like if you've smoked one
03:06 --> 03:08cigarette in your entire life does
03:08 --> 03:10that count or do you need to have
03:10 --> 03:12smoked every day for 50 years?
03:12 --> 03:15How does that work and
03:15 --> 03:16my second question,
03:16 --> 03:20why is it annual just for three years?
03:20 --> 03:23So you have your screening for three years,
03:23 --> 03:27but could you not get a lung cancer in
03:27 --> 03:30year 4, 5, 6 if you continue to smoke?
03:30 --> 03:34So let's tackle the first question.
03:34 --> 03:38You're asking how long smoking
03:38 --> 03:40history is indicated, right?
03:40 --> 03:42And we generally
03:42 --> 03:43describe smoking history
03:43 --> 03:46by pack years smoking history.
03:46 --> 03:49So according to the
03:49 --> 03:50lung cancer screening guidelines,
03:50 --> 03:53we look for at least 20 pack
03:53 --> 03:55years of smoking history.
03:55 --> 03:58What that means is that if
03:58 --> 04:00somebody smokes about a pack
04:00 --> 04:02a day for straight 20 years,
04:02 --> 04:05they would qualify for lung cancer screening,
04:05 --> 04:08Or similarly if they smoked half
04:08 --> 04:10a pack a day for 40 years or two
04:10 --> 04:13packs a day for 10 years, right.
04:13 --> 04:16That is correct. So accumulatively,
04:16 --> 04:19it has to be 20 packs a year for smoking
04:19 --> 04:22history, and they would qualify for that.
04:22 --> 04:24OK. And Kyle, maybe you can
04:24 --> 04:26pick up on the question of why
04:26 --> 04:28is it annual for three years,
04:28 --> 04:30what happens after year three?
04:30 --> 04:31The biggest part of that I would
04:31 --> 04:33say is just that that's what the
04:33 --> 04:34research has shown and that's what
04:34 --> 04:35the research projects have done.
04:35 --> 04:37I think a lot of us would continue
04:37 --> 04:39to advocate for ongoing screening
04:39 --> 04:41through the course of the lifetime
04:41 --> 04:43depending on risk factors and
04:43 --> 04:44their other health issues.
04:44 --> 04:47Sanket, when we talk
04:47 --> 04:49about screening, oftentimes the
04:49 --> 04:52whole idea behind screening is
04:52 --> 04:55to pick up these cancers
04:55 --> 04:57before they are symptomatic.
04:57 --> 04:59Oftentimes this is when these
04:59 --> 05:01cancers are really small and
05:01 --> 05:03presumably the most treatable.
05:03 --> 05:04We know, however,
05:04 --> 05:07that lung cancer is the leading cause of
05:07 --> 05:10death both in men and women in this country.
05:10 --> 05:12So does screening really work?
05:12 --> 05:14I mean, are we picking up lung
05:14 --> 05:15cancers when they're smaller?
05:15 --> 05:17And if so,
05:17 --> 05:19is there really good treatment for
05:19 --> 05:21lung cancer when they're small
05:21 --> 05:23such that we can actually improve
05:23 --> 05:24survival rates?
05:26 --> 05:29Do think that there is enough data to
05:29 --> 05:31suggest that everyone who qualifies
05:31 --> 05:34for the lung cancer screening and if
05:34 --> 05:37they do not have any other medical
05:37 --> 05:40problem that's going to kill them
05:40 --> 05:42sooner than that lung cancer itself,
05:42 --> 05:44then it is highly recommended that they
05:44 --> 05:47do get the yearly lung cancer screening.
05:47 --> 05:50Because if we catch it early, there is a
05:50 --> 05:52definitive therapy like a surgical
05:52 --> 05:55therapy when they can just
05:55 --> 05:57go in and take it out.
05:57 --> 05:58Part of the lung out.
05:58 --> 06:00I will also add to that that
06:00 --> 06:01we often think about,
06:01 --> 06:03do we need to make this lung
06:03 --> 06:04cancer screening change?
06:04 --> 06:06Do we need to change criteria,
06:06 --> 06:09do we need to make any fancy screening?
06:09 --> 06:12That's not the point here.
06:12 --> 06:15The point really being is that we
06:15 --> 06:17have good lung cancer screening and
06:17 --> 06:20let's see if we can get everyone
06:20 --> 06:21who qualifies for that.
06:21 --> 06:25Can we get them do the lung cancer screening?
06:25 --> 06:27That's where the key is because
06:27 --> 06:29if you look now at all the people
06:29 --> 06:33who qualify for the lung cancer screening,
06:33 --> 06:35even after having the lung cancer
06:35 --> 06:38screening for close to 7-8 years
06:38 --> 06:40now a very small percentage of those
06:43 --> 06:45will get the lung cancer screening and
06:45 --> 06:49this is where we can get the
06:49 --> 06:51biggest advantage, if we can get
06:51 --> 06:53all those patients to come and
06:53 --> 06:55get the lung cancer screening.
06:55 --> 06:57I mean it certainly sounds like
06:57 --> 06:59it would be something that people who
06:59 --> 07:02have more than a 20 pack year history of
07:02 --> 07:04smoking should talk to their doctor about,
07:04 --> 07:06especially if they can find these
07:06 --> 07:09cancers at an earlier stage and
07:09 --> 07:11potentially improve their outcomes.
07:11 --> 07:13So that really brings us,
07:13 --> 07:16Kyle to the next question which is,
07:16 --> 07:19what happens next for a patient?
07:20 --> 07:22Let's suppose that somebody who is
07:22 --> 07:24listening to our show today listens
07:24 --> 07:26to what Sanket says and goes and
07:26 --> 07:28talks to their doctor.
07:28 --> 07:31They get their low dose CT,
07:31 --> 07:32and lo and behold,
07:32 --> 07:34there's a lesion found.
07:34 --> 07:35What happens then?
07:36 --> 07:37So that's a great question.
07:37 --> 07:39So it's always important to remember
07:39 --> 07:41that a lot of the lesions that we find
07:41 --> 07:43on these scans may not be cancerous.
07:43 --> 07:46And so it's very important to meet
07:46 --> 07:48with someone who has an expertise in
07:48 --> 07:50this area to talk about what the risk
07:50 --> 07:52of that lesion being a cancer is.
07:52 --> 07:55In some patients there may be
07:55 --> 07:56some characteristics on the
07:56 --> 07:58scan that make us think that
07:58 --> 08:00it's actually not a cancer and we
08:00 --> 08:02may elect to just watch those.
08:02 --> 08:05Over time, things like a small size
08:05 --> 08:07or a location may be suggestive
08:07 --> 08:09and some of those patients,
08:09 --> 08:10those nodules are going to
08:10 --> 08:11be concerning for cancer.
08:11 --> 08:15And so additional workup will be necessary.
08:15 --> 08:16And a lot of those cases,
08:16 --> 08:18the patients may end up getting a biopsy,
08:18 --> 08:21which can be done a variety of
08:21 --> 08:22different ways where we actually
08:22 --> 08:23go in and get a piece of that
08:23 --> 08:26tissue to get a sample and then the
08:26 --> 08:27pathologists will look at it under
08:27 --> 08:29a microscope and be able to tell
08:29 --> 08:31us exactly what we're dealing with.
08:32 --> 08:34And so Sanket, do you want to walk
08:34 --> 08:37us through some of the ways in
08:37 --> 08:39which biopsies are done these days?
08:39 --> 08:41I mean I would presume that many of
08:41 --> 08:44them are are done simply with a needle
08:44 --> 08:45and the CAT scan, is that right?
08:47 --> 08:49Correct, but can I also add one
08:49 --> 08:51thing, before we go to biopsy,
08:51 --> 08:53when we look at the nodule,
08:53 --> 08:54we generally like to think
08:54 --> 08:55about three things.
08:55 --> 08:57Whether that could be really,
08:57 --> 08:59really low risk or that could be really,
08:59 --> 09:01really high risk or that
09:01 --> 09:02could be somewhere in between.
09:02 --> 09:04So the very, very low risk are simple.
09:04 --> 09:06We're just going to repeat a CT
09:06 --> 09:08scan at a future time and see that
09:08 --> 09:10nodule, what's its behavior, right.
09:10 --> 09:13On the flip side, the very,
09:13 --> 09:15very high risk are many
09:15 --> 09:16times also straightforward.
09:16 --> 09:18Sometimes we also choose
09:18 --> 09:19hey, you know what,
09:19 --> 09:21here biopsy is not even needed.
09:21 --> 09:23So surgeons might just decide that
09:23 --> 09:26this is such a high risk that even
09:26 --> 09:28the biopsy doesn't give us an answer.
09:29 --> 09:30I'm not going to be able to have
09:30 --> 09:32a good night's sleep with that.
09:32 --> 09:34So in that case is what we surgeons
09:34 --> 09:35decide that we are just
09:35 --> 09:37going to go and take it out and
09:37 --> 09:38that's a very common approach.
09:38 --> 09:41It's important for patients to know
09:41 --> 09:43that then the challenging patient
09:43 --> 09:46populations are the one we just follow.
09:46 --> 09:47In between,
09:47 --> 09:48to be honest,
09:48 --> 09:50most of them fit right in
09:50 --> 09:53between though and that's the time
09:53 --> 09:55that we think about the biopsy part of it.
09:56 --> 09:59And so Kyle, one would think that
09:59 --> 10:02the decision between which way to
10:02 --> 10:04biopsy this nodule really might depend
10:04 --> 10:07on where exactly the nodule was.
10:07 --> 10:10I mean is this something that's
10:10 --> 10:12amenable to a needle biopsy
10:12 --> 10:14under CT guidance or whether it's
10:14 --> 10:17more amenable to a bronchoscopy?
10:17 --> 10:19Guided biopsy, is that right?
10:20 --> 10:22Yeah. It really does depend a lot
10:22 --> 10:23on the location and where it's
10:23 --> 10:25located relative to the airways and
10:25 --> 10:27the other structures in the chest.
10:27 --> 10:29And so nodules that are further out
10:29 --> 10:30into the periphery of the lung,
10:30 --> 10:32closer to the chest wall are usually
10:32 --> 10:34more amenable to a CT guided approach
10:34 --> 10:35or even possibly an ultrasound
10:35 --> 10:36guided approach if it's really
10:36 --> 10:38right at the edge of the lung.
10:38 --> 10:40Whereas things that are more centrally
10:40 --> 10:41located and especially if they're
10:41 --> 10:43located in closer proximity to one of
10:43 --> 10:45the larger airways or branches of the
10:45 --> 10:47windpipe that go out into the lungs,
10:47 --> 10:49we often think about taking a more
10:49 --> 10:50bronchoscopic approach because we'll be
10:50 --> 10:53able to sample it with a higher efficiency.
10:53 --> 10:58And so you know Sanket, when we think
10:58 --> 11:00about these different techniques,
11:00 --> 11:04are there risks and
11:04 --> 11:06benefits associated with
11:06 --> 11:08these and
11:08 --> 11:10can you talk a little bit more about
11:10 --> 11:13what do you talk to patients about
11:13 --> 11:15when they're undergoing these biopsies
11:15 --> 11:17in terms of risks and benefits?
11:18 --> 11:19Yeah. And and there are two
11:19 --> 11:20ways to think about that.
11:20 --> 11:23One would be overall
11:23 --> 11:25in terms of in general how are we
11:25 --> 11:27going to find these overall not
11:27 --> 11:29just diagnosis but the staging
11:29 --> 11:32as well and how are we going to
11:32 --> 11:34soon get them to the treatment
11:34 --> 11:35because that's the ultimate goal.
11:35 --> 11:37And then also we have to think
11:37 --> 11:39about risk and benefit of that and
11:39 --> 11:41then on the day of the procedure
11:41 --> 11:43and risk and benefit of
11:43 --> 11:45those individual procedures.
11:45 --> 11:47So when you do a CT guided biopsy,
11:47 --> 11:48the risk
11:48 --> 11:50that we think about the most
11:50 --> 11:52common one would be lung collapse
11:52 --> 11:55and that risk can be as high as
11:55 --> 11:57about 20 to 30% depending on what
11:57 --> 11:59literature that you're looking at.
11:59 --> 12:01And there is a fair number of those
12:01 --> 12:03patients that end up having a chest tube
12:03 --> 12:06which is a treatment of those lung
12:06 --> 12:08collapse and a fair number of those
12:08 --> 12:11spaces and might end up spending a few
12:11 --> 12:14days in the hospital because of that.
12:14 --> 12:16And then the other risk factors
12:16 --> 12:18would be bleeding from that.
12:18 --> 12:19And the same way when we do
12:19 --> 12:21those with the bronchoscopy,
12:21 --> 12:25then the risk of lung cholestatic is
12:25 --> 12:27significantly low under 2% and
12:27 --> 12:29then there is risk of bleeding
12:29 --> 12:32as well which is under 1 to 2%.
12:32 --> 12:33And these are the most common risks
12:33 --> 12:35that risk we think about,
12:35 --> 12:37but at the same time we also think
12:37 --> 12:39about the diagnostic success,
12:39 --> 12:43because there is always a benefit versus risk ratio.
12:43 --> 12:45So when you think about the CT
12:45 --> 12:48guided biopsy as of today what we know
12:48 --> 12:51is that on an average the success
12:51 --> 12:53is around 85 to 90%,
12:53 --> 12:56that depends on the size of the nodule,
12:56 --> 12:58characteristic of the nodule.
12:58 --> 12:59And on the flip side,
12:59 --> 13:03when we go with the bronchoscope, as of now,
13:03 --> 13:05the diagnostic success is
13:05 --> 13:07somewhere in a range of around 70%.
13:07 --> 13:09So there is a trade off there
13:09 --> 13:11when you think about an approach.
13:11 --> 13:14We're going to take a
13:14 --> 13:16short break for a medical minute.
13:16 --> 13:18When we come back, we'll learn more about
13:18 --> 13:21lung cancer diagnosis with my guests,
13:21 --> 13:23Drs. Sanket Thakore and Kyle Bramley.
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14:46 --> 14:48Welcome back to Yale Cancer Answers.
14:48 --> 14:50This is doctor Anees Chagpar and
14:50 --> 14:52I'm joined tonight by my guests,
14:52 --> 14:54Dr. Sanket Thakore and Kyle Bramley.
14:54 --> 14:56We're talking about advances in
14:56 --> 14:59diagnosis of lung cancer in honor
14:59 --> 15:01of Lung Cancer Awareness Month.
15:01 --> 15:03Now right before the break,
15:03 --> 15:05we were talking about kind of
15:05 --> 15:07the two different ways lung
15:07 --> 15:09cancer is often diagnosed.
15:09 --> 15:13One is with a CT guided needle biopsy,
15:13 --> 15:15the other is
15:15 --> 15:16with the bronchoscopic approach.
15:16 --> 15:20Kyle, before the break
15:20 --> 15:23you were telling us that a lot of
15:23 --> 15:26this really depends on where the
15:26 --> 15:29tumor is located and one would
15:29 --> 15:32think that if you had a peripheral
15:32 --> 15:35lesion and you didn't want to get
15:35 --> 15:37a CT guided biopsy because you were
15:37 --> 15:40afraid of the risk of of lung collapse,
15:41 --> 15:44is there a way that bronchoscopy can
15:44 --> 15:47get to those lesions or is that
15:47 --> 15:50completely not amenable given the
15:50 --> 15:52fact that it's not centrally located?
15:53 --> 15:54That's a great question.
15:54 --> 15:55So traditionally, we were very
15:55 --> 15:57limited by the tools that we had to
15:57 --> 15:58bronchoscopically work ourselves
15:58 --> 16:00out into the periphery of the lung.
16:00 --> 16:03We were using a lot of electromagnetic
16:03 --> 16:05navigation where we essentially put
16:05 --> 16:07an electromagnetic field around the
16:07 --> 16:10patient and then we correlate that
16:10 --> 16:12electromagnetic field to the CAT scan that
16:12 --> 16:14diagnosed the nodule and then we would
16:14 --> 16:15essentially
16:15 --> 16:18use a computer to make a GPS
16:18 --> 16:20like signal that would allow us
16:20 --> 16:22to drive out into the lungs.
16:22 --> 16:24And that increased our yield some,
16:24 --> 16:27but we were still very limited by the tools,
16:27 --> 16:28by the size of the instruments
16:28 --> 16:31and also by our ability to make
16:31 --> 16:33small adjustments in our navigation
16:33 --> 16:35when we drove out to that nodule.
16:35 --> 16:37One of the biggest advances
16:37 --> 16:38for our field as interventional
16:38 --> 16:40pulmonologists and NOTE Confidence: 0.858700948
16:40 --> 16:43the people interested in
16:43 --> 16:45thoracic cancers in general has been
16:45 --> 16:50the new tool that we've all started using,
16:50 --> 16:53which is the robotic bronchoscopy.
16:53 --> 16:54And so it's different than a regular
16:54 --> 16:56bronchoscopy in that I'm not standing
16:56 --> 16:57there driving it with my hands.
16:57 --> 17:00There's actually a robot arm that
17:00 --> 17:02will drive out into the periphery.
17:02 --> 17:04It has the advantage of its much
17:04 --> 17:06smaller than our standard bronchoscopes.
17:06 --> 17:08It's also much stiffer,
17:08 --> 17:10much more navigable into the airways.
17:10 --> 17:12And so we can drive out much further
17:12 --> 17:14into the airways than we used to.
17:14 --> 17:17We were also very limited by our
17:17 --> 17:19ability to biopsy things that didn't
17:19 --> 17:21have an airway that went directly
17:21 --> 17:23to them in the past and with
17:23 --> 17:24the robotic bronchoscopy,
17:24 --> 17:26we can essentially know where
17:26 --> 17:28we are in space,
17:28 --> 17:31drive out to the lesion or
17:31 --> 17:33next to the lesion and now pass
17:33 --> 17:35instruments across the airway
17:35 --> 17:37wall into the lung tissue itself.
17:37 --> 17:41So it's a very new
17:41 --> 17:43instrument that we're using,
17:43 --> 17:45but the preliminary literature
17:45 --> 17:47suggests that the diagnostic yield
17:47 --> 17:49is much higher and certainly
17:49 --> 17:51approaching the diagnostic rates
17:51 --> 17:54that we've classically seen with
17:54 --> 17:56Transthoracic CT guided biopsies.
17:56 --> 17:58One of the things that we can do is
17:58 --> 18:01now that we can actually make small
18:01 --> 18:03changes because the catheter is much
18:03 --> 18:05stiffer and more easy to navigate.
18:05 --> 18:06We can actually incorporate that
18:06 --> 18:08with a live image guidance as well.
18:08 --> 18:10And so we can actually take a CT scan
18:10 --> 18:12while the patient is having a bronchoscopy.
18:12 --> 18:14Make sure that we're in the lesion.
18:14 --> 18:16Make sure that we're getting a
18:16 --> 18:18sample and can make small adjustments
18:18 --> 18:20if we're not inside the lesion.
18:20 --> 18:23So Sanket, that sounds really
18:23 --> 18:26quite great that you'd be able to
18:26 --> 18:28get a higher diagnostic yield.
18:28 --> 18:31But it also sounds like,
18:31 --> 18:34especially if you're taking
18:34 --> 18:36these stiffer tubes and going
18:36 --> 18:39across the actual parenchyma or
18:39 --> 18:41the actual tissue of the lung,
18:41 --> 18:43that you might actually see
18:43 --> 18:44higher rates of bleeding.
18:44 --> 18:47So have have you seen an increase in
18:47 --> 18:50complication rates with robotics as well?
18:51 --> 18:53No. In fact, if anything,
18:53 --> 18:56the risk of bleeding is less than
18:56 --> 18:58the traditional bronchoscopy because
18:58 --> 19:00in general when those nodules
19:00 --> 19:02are in a peripheral of the lung,
19:02 --> 19:05your vessels starts to get smaller.
19:05 --> 19:07So that kind of decreases
19:07 --> 19:09the risk of the bleeding.
19:09 --> 19:11And I will add to that, one
19:11 --> 19:13of the other advantage of the
19:13 --> 19:15bronchoscopic biopsy is that
19:15 --> 19:17if someone was going to bleed
19:17 --> 19:18you're already in the airways,
19:18 --> 19:20so you can kind of fix it
19:20 --> 19:21right then and there.
19:21 --> 19:23By fix it you mean that you can
19:23 --> 19:25coagulate the vessels on the inside
19:25 --> 19:28because you have the tools to do that?
19:28 --> 19:31Correct. And we can tamponade that area.
19:31 --> 19:33So they would not have any
19:33 --> 19:35complications from that bleeding, that
19:35 --> 19:37takes care of the stopping part,
19:37 --> 19:40but we help them not
19:40 --> 19:42develop any complications.
19:42 --> 19:45And so Kyle, it sounds like
19:45 --> 19:47this is new technology.
19:47 --> 19:49Is this widely available and
19:49 --> 19:51is it covered by insurance?
19:51 --> 19:54Bronchoscopic biopsies in
19:54 --> 19:56truth have always been covered
19:56 --> 19:59by most insurances.
19:59 --> 20:00Essentially all insurances,
20:00 --> 20:01they certainly want patients
20:01 --> 20:03to get their lung
20:03 --> 20:05cancer diagnosed and treated.
20:06 --> 20:08The other part of the question,
20:08 --> 20:10is it widely available.
20:10 --> 20:12I mean one would think that
20:12 --> 20:14bronchoscopy is pretty widely available.
20:14 --> 20:16I think most most people know
20:16 --> 20:18that their pulmonary doctor
20:18 --> 20:21can can do bronchoscopy,
20:21 --> 20:24but this whole concept of adding
20:24 --> 20:26a robot,
20:26 --> 20:28it sounds like that's a little
20:28 --> 20:31avant-garde and may not be
20:31 --> 20:33necessarily available at
20:33 --> 20:36the local pulmonologist.
20:40 --> 20:42Is that right or is this
20:42 --> 20:44something that is more ubiquitous?
20:44 --> 20:47No. At the current time it's really
20:47 --> 20:48centralized around large hospitals
20:48 --> 20:51and large academic centers and
20:51 --> 20:53certainly large hospital systems.
20:53 --> 20:55It's certainly not a procedure that
20:55 --> 20:58at least I don't think will be widely
20:58 --> 20:59adopted by pulmonologists universally.
20:59 --> 21:03It really does require some extra
21:03 --> 21:05training and expertise and obviously
21:05 --> 21:09the bronchoscopic skills to do it.
21:09 --> 21:12There's definitely a learning
21:12 --> 21:15curve associated with it and so I don't
21:15 --> 21:16think it will be universally adopted.
21:16 --> 21:18And so it's really just in large
21:18 --> 21:20hospital systems right now.
21:21 --> 21:22And second,
21:22 --> 21:24when we think about robotics
21:24 --> 21:27it certainly has started to really make
21:27 --> 21:31its foray into the surgical subspecialty.
21:31 --> 21:33So certainly we've talked on
21:33 --> 21:36this show about how robotics have
21:36 --> 21:38entered the operating room for
21:38 --> 21:40cancers like prostate cancer,
21:40 --> 21:43gynecologic cancers, et cetera.
21:43 --> 21:47But that technology has a cost, right.
21:51 --> 21:52I realize that this is newer
21:52 --> 21:55technology in terms of bronchoscopy,
21:55 --> 21:58but have people looked at the cost of
21:58 --> 22:00robotic bronchoscopy and compared it
22:00 --> 22:02to standard bronchoscopy?
22:02 --> 22:06A cost effectiveness analysis to see
22:06 --> 22:10whether or not this actually does
22:10 --> 22:14add value and if it is more expensive,
22:14 --> 22:17who bears the brunt of that cost?
22:17 --> 22:19Is it the patient or is that really
22:19 --> 22:22something that is being covered by insurance?
22:28 --> 22:31Yeah. So when we we are comparing the
22:31 --> 22:35robotic with the traditional bronchoscopy,
22:35 --> 22:38I would also add that the navigational
22:38 --> 22:41bronchoscopy part of that
22:41 --> 22:43already has been there for several years now.
22:43 --> 22:46It was just not as good as
22:46 --> 22:47the robotic bronchoscopy.
22:47 --> 22:49So when you think about switching
22:49 --> 22:51from the traditional approaches
22:51 --> 22:53to the robotic bronchoscopy,
22:53 --> 22:56yes, a hospital has to
22:56 --> 22:57make some investment up front
22:57 --> 23:00to get this kind of technology.
23:00 --> 23:02But the cause that drips down
23:02 --> 23:04to the patient that has not,
23:04 --> 23:06it's not going to change compared
23:06 --> 23:09to what we are already doing with
23:09 --> 23:11the navigational bronchoscopy.
23:11 --> 23:14So that's an important part to note.
23:14 --> 23:16The second part to that question
23:16 --> 23:18is that is it adding any value?
23:18 --> 23:21And I do think that it does add
23:21 --> 23:23value in two ways.
23:23 --> 23:25You're going to improve
23:25 --> 23:27the diagnostic success.
23:27 --> 23:27And two,
23:27 --> 23:30when we do the robotic bronchoscopy,
23:30 --> 23:36it also allows us to do a second procedure
23:36 --> 23:39what we call endobronchial ultrasound,
23:39 --> 23:40which is really important for
23:40 --> 23:42those lung cancer patients.
23:42 --> 23:45Because that allows us to take
23:45 --> 23:47samples of those lymph nodes in
23:47 --> 23:50the chest, in the mediastinum,
23:50 --> 23:52which helps us with the lung cancer staging.
23:52 --> 23:54Because when we think about
23:54 --> 23:55lung cancer diagnosis,
23:55 --> 23:58we're thinking about the diagnosis
23:58 --> 24:00and staging simultaneously.
24:00 --> 24:03Those are not two separate things.
24:03 --> 24:05When you look at national data,
24:05 --> 24:07every time a person who has a nodule
24:07 --> 24:11that is suspected to be a lung cancer,
24:11 --> 24:12the number of biopsy
24:12 --> 24:15that you do on separate days,
24:15 --> 24:17that delays their care by on
24:17 --> 24:19an average about 17 days.
24:19 --> 24:24So what you want to focus on is to not
24:24 --> 24:26just improve the diagnostic success,
24:26 --> 24:28but you also want to minimize
24:28 --> 24:31the number of boxes that they go
24:31 --> 24:33through on a separate occasion.
24:33 --> 24:35Because what that's going to allow you
24:35 --> 24:38is to not just finish the diagnosis
24:38 --> 24:40but also the lung cancer staging.
24:40 --> 24:43You're going to get them all the information
24:43 --> 24:45that you need sooner and they can
24:45 --> 24:47get the therapy sooner and that's
24:47 --> 24:49the real value of this technology.
24:51 --> 24:53And so Kyle picking up on that,
24:53 --> 24:55I mean before the robot came
24:55 --> 24:58along in terms of staging,
24:58 --> 25:01was that done on a different day
25:01 --> 25:03because a different test was required?
25:03 --> 25:05In other words, you would need to
25:05 --> 25:07do a mediastinoscopy or something
25:07 --> 25:10different than a standard bronchoscopy.
25:10 --> 25:13Yeah, in patients who we have
25:13 --> 25:15any concern that the cancer
25:15 --> 25:17may have spread to the lymph nodes
25:19 --> 25:20they need their mediastinum staged,
25:20 --> 25:22and there's two ways to do that.
25:22 --> 25:24One is with a mediastinoscopy,
25:24 --> 25:26which is an older technique that's still
25:26 --> 25:29in use for patients who need confirmation.
25:29 --> 25:31But because we can do it minimally
25:31 --> 25:33invasive with endobronchial ultrasound
25:33 --> 25:35as Sanket was talking about,
25:35 --> 25:37that's really become the first
25:37 --> 25:39choice for mediastinal staging.
25:39 --> 25:41And so we have lots of patients
25:41 --> 25:43who undergo that procedure.
25:43 --> 25:45But if a diagnosis is not made, well,
25:45 --> 25:47it's good news because it means that the
25:47 --> 25:49cancer hasn't spread to the lymph nodes.
25:49 --> 25:51But a lot of those patients end up
25:51 --> 25:53going on for a second test to get a
25:53 --> 25:54biopsy of the actual nodule if they
25:54 --> 25:56needed that before they underwent their
25:56 --> 25:58definitive treatment for their cancer.
25:58 --> 26:00And so in terms of cost,
26:00 --> 26:03certainly there's a time cost
26:03 --> 26:06that's going to be improved by
26:06 --> 26:09having two procedures done at once,
26:09 --> 26:12but also the just the cost of the procedures,
26:12 --> 26:13I think too having two procedures
26:13 --> 26:16is going to be more expensive and
26:16 --> 26:17especially if there's complications
26:17 --> 26:19from those procedures then that's
26:19 --> 26:20going to add to the patients healthcare costs.
26:24 --> 26:27Sanket, where do you see the
26:27 --> 26:30field going now that you have the
26:30 --> 26:33robot and this ability to do
26:33 --> 26:35a bronchial ultrasound and biopsy
26:35 --> 26:38these lymph nodes at the same time?
26:38 --> 26:40It sounds like that certainly
26:40 --> 26:41has been one of the,
26:41 --> 26:44if not the major advance in terms
26:44 --> 26:47of diagnosis of lung cancer.
26:47 --> 26:49Are there other things coming down on
26:49 --> 26:51the horizon that you're particularly
26:51 --> 26:53excited about in terms of lung cancer?
26:56 --> 27:00Yes. So there there are a lot of things
27:00 --> 27:03coming down the pipeline I would think and
27:03 --> 27:05our expertise is more on the diagnosis
27:05 --> 27:08part of that, but on the therapeutic part
27:08 --> 27:11a lot of exciting development coming up,
27:11 --> 27:13down the pipeline as well.
27:13 --> 27:16In terms of newer targeted therapies,
27:16 --> 27:19there are new targeted therapies every
27:19 --> 27:22other month when you look up literature.
27:22 --> 27:25So those things going to continue to improve.
27:25 --> 27:27When we focus on the robotic
27:27 --> 27:29bronchoscopy and all generally
27:29 --> 27:31we're thinking about the early
27:31 --> 27:33stage diagnosis and one of the
27:33 --> 27:35important things that we
27:35 --> 27:37need to focus on moving forward
27:37 --> 27:40would be how can we cut down on
27:40 --> 27:42the time from the nodule was found
27:42 --> 27:46to the time when we treat them?
27:46 --> 27:49And I think that's going to have a
27:49 --> 27:51significant impact on an outcome here
27:51 --> 27:54and try to get that cancer early
27:54 --> 27:56because we are focusing on something
27:56 --> 27:58called a stage shift.
27:58 --> 28:01We know that when lung cancer
28:01 --> 28:03is diagnosed in a late stage
28:03 --> 28:07it has an outcome and
28:07 --> 28:09identified survival under 10%
28:09 --> 28:12compared to when you diagnose lung
28:12 --> 28:15cancer early in stage one or two,
28:15 --> 28:18then that survival is
28:18 --> 28:20well above 70%.
28:20 --> 28:21So that's our focus.
28:21 --> 28:24We want to diagnose them as early
28:24 --> 28:26as possible so that we can treat
28:26 --> 28:28them as well as possible.
28:28 --> 28:30Doctor Sanket Thakore is an instructor
28:30 --> 28:32of medicine and doctor Kyle Bramley
28:32 --> 28:34is an assistant professor of medicine
28:34 --> 28:36in the Department of Interventional
28:36 --> 28:39Pulmonology at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu,
28:43 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Innovation in the Diagnosis of Lung Cancer with guests Drs. Sanket Thakore and Kyle Bramley November 27, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095