(upbeat music) - [Announcer] The region's premier medical information program, "Call The Doctor."

- There are many different types of lung disease.

There are different ways you can damage your lungs and there are even different types of lung cancer.

We're gonna take a look at some of the more common lung ailments and diseases here in the region.

We'll also take a look at how they're diagnosed and in some cases how they can be treated.

Lung disease and lung cancer in this episode of "Call the Doctor."

Hi, hello, so glad you are with us for this season and this episode of "Call the Doctor" and I'm excited to get right to tonight's panelists.

I would love for you each to introduce yourselves, just tell me a little bit about who you are and maybe where people can find you, we'll start with you.

- I'm Dr. Anthony Cipriano, I'm a lung surgeon at Geisinger Health Network.

I'm from Pennsylvania., I went to University of Pittsburgh for undergrad, I went to Temple for Medical School and I did my thoracic surgery training in Boston at Brigham and Women's Hospital.

- Great, great welcome.

- Thank you.

- My name's Dr. Tom Churilla, I'm a practice and radiation oncologist at Northeast Radiation Oncology Centers.

I grew up in Scranton, went to University of Scranton.

I went to the local medical school, TCMC, now Geissinger Commonwealth School of Medicine.

And I did my radiation oncology training at Fox Chase Cancer Center in Philadelphia.

And I've been with our group now for a little under five years.

- I know you've been on "Call The Doctor" before, so welcome back.

- Thank again for having me.

- Great to have you, what about you?

- I'm Dr. John Sabuto.

I am a pulmonary critical care physician with Geisinger at CMC in Scranton.

I'm a local boy from Old Forge.

I did my college at Penn State Medical School at Pecan in Philadelphia and my residency and fellowship training at Lankenau Medical Center also in Philadelphia, and moved back to the area approximately four years ago, and have been with Geisinger ever since.

- Great, welcome.

It's really great to have you all.

- Thank you.

- So we're talking about lung cancer and lung disease, of course, and I thought before we get into the cancer portion of it, we'll talk about all the various different types of lung disease and damage that one might find.

And I'll throw you, we were talking about maybe perhaps the silliest question of the night, just explain a little bit what lung function really is, what proper lung function looks like from your perspective.

- Yeah, so Dr. Sabuto as a pulmonologist he might be able to go into more depth about this, but basically I try to explain to patients that the lungs are, I mean you have your chest wall, which is a rigid cavity with your ribs muscles, and inside they're the lungs, which are like basically sponges and they're made up of tiny little pockets called alveoli.

So they're just these very delicate sponges really.

And the way they work is just, you have the a muscle called the diaphragm, it goes across your body and your brain stem controls that and that's what allows you to breathe.

So when the diaphragm contracts, it moves down and it lets the lungs fill up with air, like it sucks air into your lungs.

And then in the lungs is where the magic happens, where basically oxygen and carbon dioxides exchanged across the blood through the lungs.

And that's kind of, you know, oxygen's the most important thing to our bodies.

It's how all of our cells work.

They need oxygen to do that.

So, kind of the lungs are the organ that gets the oxygen into your organs.

- I don't think people thought too much about their lungs really perhaps until COVID-19 came about.

What are some of the concerns you started to hear then about lung function?

Dr. Churilla just could send that one to you.

- Yeah, so I mean the pandemic has obviously opened up somewhat of a Pandora's box in terms of people getting CAT scans and presenting with lung disease.

I think one of the things, I know we were talking before the show that we're seeing more in the way of interstitial lung disease that may have went unrecognized beforehand.

Sometimes pulmonary nodules are found when patients get these scans for upper respiratory illness that lead on these paths to find out what those pulmonary nodules are.

So I think we're seeing more in the way of imaging by way of the pandemic and subsequently more in how we manage lung cancers.

- And same question to you, what are some of the things that you are seeing now in the past couple of years where respiratory health is concerned?

- Absolutely, I think people are more attuned to their respiratory status and respiratory health since the pandemic.

And as Tom was saying, more imaging studies of the lungs have led to higher referrals to our centers in our clinic.

Often what I see as a pulmonologist are people that have difficulty breathing after COVID-19 and there are various reasons why, some of them are development of what's called interstitial lung disease, which is an inflammatory disorder of the lungs where scarring and inflammation occur and sometimes go unchecked.

Early recognition of such is important 'cause treatment with supplemental oxygen, pulmonary rehab, and sometimes even referrals to lung transplant programs are really paramount.

- By and large, if you have somehow damaged your lungs are they just damaged?

Is there a way to get back some of that function?

- The lungs are very resilient, is one of the smartest organs of the body.

One of the reasons I went into the field itself is just the physiology of the lungs themselves.

They have this intrinsic ability to shunt blood to areas of healthy lung where other areas of lung that are damaged blood moves away from such.

It's amazing local control that the body does on its own.

So if areas of lung are damaged, the more healthy lung gets fed with blood.

Sometimes if extensive areas of the lungs are damaged, that's not possible, and that's often when people need help from me in terms of giving medications to help maximize those areas of lungs.

Sometimes giving medications that are able to shrunk blood further to areas of healthy lungs and sometimes needing things like supplemental oxygen to help replace that, that they can't extract from the air themselves.

- So what are some of the most common types of lung diseases or lung issues that we see?

I mean people have heard of asthma, they've heard of COPD and emphysema, bronchitis, all sorts of respiratory function.

But I know those are very different in the scale of how you can treat them and how dangerous perhaps they are.

What are some of the more common things you see in this area?

- For me, one question I could asked a lot about is COPD.

It's almost once a day where a patient asks me, "Like, doc, do I have COPD?"

Because one doctor told 'em they have COPD, another one says that you don't have it.

Sometimes they'll get a CAT scan for some other reason like a trauma and the radiologist will say COPD on the CAT scan and they're confused like how, like what does that mean?"

And I mean, smoking's pretty prevalent.

I noticed in this kind of region and you know, that is a cause of COPD.

I mean what I often tell 'em is I don't have enough, just asking me that question I don't have enough information to give them an answer.

I mean I'm up there primary care doctor, but it's usually a clinical diagnosis a lot of different factors go into figuring that out.

Like Dr. Sabuto for example, that's kind of like his bread and butter is COPD, but that's one of the more common benign lung diseases.

- Define what that is, tell us a little bit about what it is.

- So COPD stands for chronic obstructive pulmonary disease.

And what that means is our lungs in its very smallest points where we start at the main trachea, which is our largest airway, I came to almost picturing a tree but just upside down, the trachea is like the main trunk of the tree.

And then as you divide into bigger branches into the right and left main stem, bronchi, and then if you picture the tree, the smaller branches and then twigs and then eventually leaves, that's exactly how the lung is structured as it starts with bigger airways and then eventually ends in very tiny small tertiary airways.

Those tiny little airways where the leaves would grow in the tree are where those budding alveoli, as Anthony mentioned before actually live.

Those are tiny microscopic air sacs of which we have millions and that's where air actually goes and interfaces with the blood and where oxygen gets extracted from the air and moves into the blood.

Patients that have COPD have lost a lot of those alveoli.

Those little small budding microscopic air sacs are essentially burned off and damaged and create the radiographic appearance of emphysema as Anthony was mentioning, often radiologists and other physicians that have a misnomer where the presence of emphysema doesn't always equate to COPD 'cause that O portion of the acronym stands for obstructive.

What that means is when anyone, you and I breathe out those small little airways, unlike a tree are not rigid structures, they're actually tubes that have soft tissue that squeeze down as we breathe out and that air then flows from those small little airways to the bigger airways and eventually trachea and then out and we give off carbon dioxide.

When those small airways are damaged, they lose that ability, that elastic recoil ability to breathe air out and air actually gets trapped or obstructed behind small airways.

So, damage to the lungs from things like smoking cause those airways to lose their elastic ability to recoil air gets trapped behind them and it leads to inability to actually get air in on the next breath, and that's what leads to COPD.

In our area smoking is very, very rampant and prevalent.

And even in patients that are elderly exposure to things like asbestos, we see a lot of plural plaquing from asbestos, the plural, the lining of the lung that is the part of the lungs that become most damaged with asbestos exposure leading to things like mesothelioma.

And we also do see a predominance of interstitial lung disease even in the pre COVID area where patients that were often in their prior lives miners, especially in the coal mine region here in northeastern Pennsylvania, had a lot of exposure to dust and silica that caused a lot of damage and then causes a similar sort of disorder to COPD but by a different physiology mechanism.

- So I was kind of rattling off a number of those different issues that are seen.

But it sounds like even if it's not a diagnosed disease, there are lots of different ways you can damage those lungs.

- [Dr Churilla] Oh yeah.

- What other than smoking what are, and you mentioned asbestos and some other chemicals, but Dr. Churilla, I mean do you have any other, how else do people hurt their lungs?

- Yeah, it's a good question.

You know, and specifically I know we're talking about, erythema is lung cancer today.

So radon is another well-recognized cause of lung cancer and ways to damage to the lung that a lot of people might not be aware of.

And we think it might be one of the more leading causes of lung cancer second to smoking.

So radon is an odorless gas that's radioactive, it's emitted from uranium typically in the ground and it can seep up and if there's cracks in basements or lower floors can infiltrate places where we live and where we work and we're breathing it in and not really aware of it, but it could be silently damaging their lungs.

So I always encourage folks to get radon home test kits for their home or places of work to see if they have any radon and things can be done to mitigate that and help reduce that.

But that's another kind of exposure that we don't commonly think about.

- I have one in my basement.

Radon detector and a system.

It's actually more common in our area than we think, especially in the mountains reasons.

- Radon would never have thought of that.

I saw you nodding your head.

- No was I was gonna say like one of the questions I would be asking if I was watching is should I buy a radon detector?

'Cause I don't have one.

- Don't forge it, I think you're probably okay.

- And Clark summit at Waverly and you know, in the Moscow area as well, it is quite prevalent so it isn't a bad idea, pretty cheap.

They're on Amazon I think they're like 20 bucks.

- Well as we get from some common lung diseases into lung cancer and how we screen for lung cancer, we wanted to mention there's a doctor who wanted to be with us tonight who was unable to be, Dr. Brian Matt from Commonwealth Health and he invited us to take a look at some of the diagnostic tools he is using.

Let's take a look at that.

(gentle music) - So in the past, before this technology was available, getting those diagnoses at an earlier stage was very difficult 'cause there wasn't a good tool to go and biopsy those small nodules anywhere in the lung.

If a patient had a big nodule somewhere, they may be amenable to having a CT guided needle biopsy, which is not a great procedure, can cause a collapsed lung and cause bleeding.

So we were looking for something that was minimally invasive, that was highly accurate to diagnose lung cancer with small nodules and this tool fits that niche that we're looking for.

If we can diagnose people with lung cancer earlier, we can get them to surgery earlier and they have a earlier stage diagnosis and their treatment and their post-op survival is gonna be much better than if they come in with a later stage diagnosis.

So this tool that we use, once we've identified somebody who has a high risk module that we think needs to be biopsied that potentially is a lung cancer, this tool is a robotic navigational system.

And what that means is, is we take the patient's CT scans and we feed it into the computer that's part of the robot and we get a three-dimensional map of the patient's airways and we're the tumor that we're looking for is located.

And the computer will then generate a GPS like map for me to follow with the robot in order to get to the part of the lung that has this nodule or tumor that we're looking for.

I can get anywhere in the lung fields from top to bottom from the middle to far out in the periphery and we can chase nodules as small as eight millimeters.

When I find the nodule on the CAT scan and we get this map, then we use this catheter that's gonna be driven by me to navigate down through the airways and there'll be a GPS style cartoon map with a pathway to follow that I follow that's supposed to take me right to where the nodule is.

Once we get to that point where the nodule is and we're confirmed, then we lock the catheter in that's position and we can go down with brushes or needles or forceps and biopsy the tissue that we suspect is part of the nodule or part of the tumor and we get rapid on-site evaluation of that material rate in the operating room with a pathologist in the room and we can diagnose somebody with early stage lung cancer within five minutes of getting a good biopsy.

(gentle music) - Now I know a lot of what we wanted to talk about tonight had to do with screening.

So let's get into that, what happens, say you have now determined that maybe someone does have something, who knows what that thing might be on their lung.

What's step number one?

We'll start with you.

What do you do in that case where you think there might be something to check out in there?

- Sure, I think one of the things even before patients get to that point are identifying those that are the at-risk population, who should get a CAT scan?

So oftentimes if patients do come to us, they already may have an abnormality on their CAT scan that should be further investigated.

But before we even get to that point, a lot of patients just come to us for the respiratory disorders.

We just spoke about COPD asthma and we identify them as those at-risk populations for development of lung cancer.

And that's defined as patients that are 55 years of age or older and have smoked for at least 30 years or equivalent of what's called 30 pack years.

So even if someone didn't smoke for quite 30 years, but smoked two packs of cigarettes a day for 15 years, that equates to 30 pack years.

And then are either actively smoking or quit within the last 15 years.

So those patients should be screened what's called a low dose CT of the chest for lung cancer screening purposes to identify these small nodules where cancers start in its earliest stages.

When they do, when they are present on CAT scan then the size of the nodule, the weight appears radiographically, whether it's round and smoothed, whether it's speculated, meaning appearing like a spider's web or if it grows over the course of time, which is usually followed, by a short interval CAT scan not long after you've seen the patient initially, then based on a consolation of those behaviors, then it's at the discretion of the physicians to decide whether or not to pursue a biopsy of some kind.

And the modality of biopsy changes depending on what's available to you.

As Dr. Matt alluded to, there are more now advanced techniques for smaller nodules and earlier intervention and the ability to do this without any kind of surgical intervention and essentially a same day procedure to basically diagnose and maybe immediately treat your early stage lung cancer.

- So Dr. Cipriano, what did that used to be?

How did it used to be found or screened for how much...

I mean we mentioned earlier that it was getting a lot better and a lot faster, can you explain or tell people what that used to be like versus what it is today?

- About detection?

- To screen and detect, yeah.

- I mean, I kind of grew up in the world with all these kind of newer technologies, even the screening.

But historically I remember basically it'd be symptoms but which are, I mean not many people with lung cancer have symptoms until it's almost too late in like coughs kind of the most common symptom.

But I mean you'd have your symptoms and then screening usually with an x-ray or sometimes they would do sputum, like they'd make patients cough and test the sputum to see if there's cancer cells in it.

But there have been multiple studies that have kind of debunked that like they've like trying to screen or detect with x-ray or sputum, like wasn't kind of significant or it didn't really work.

But when Dr. Churilla was talking about this, this lung screening, there was a big trial that looked at this and they compared screening of the CAT scan versus x-rays and we actually, people screened with CAT scans have improved survival.

I think that study showed we can save about three people per every thousand people that we screen.

- Three per every thousand that you screen.

- Yeah, that's the number that I remember from that paper.

- What are you seeing now?

I know this is kind of getting into your area here, the detection and the and treatment of what has, it seems like it's come a long way, what have you seen?

- Yeah, it's really interesting because you know, as Dr. Sabuto and Cipriano had mentioned, the best time to treat a lung cancer is when it's small.

The survival rate for early stage small tumors is much higher for those that have spread in the neighborhood of the lung and is much greater than those cancers that have spread beyond the lung, which are basically incurable.

If you look at national trends around the time the US PSTF started endorsing lung cancer screening, we started to see a pretty sharp fall in the amount of cancers that have spread.

And we started to see a subsequent rise in cancers that are earlier stage.

So, that's kind of the holy grail of screening when you shift cancers that would have came to attention because patients had symptoms by the time they were incurable.

Now suddenly finding them when they're smaller, not causing symptoms and we can do different types of interventions like surgery or radiation therapy to help try to cure those patients at an earlier stage.

So we're definitely seeing a shift from less advanced, less cancers that have spread to earlier stage tumors that are more readily curable.

- But typically you would only screen, as you said, if someone is considered in that high risk category.

- Exactly.

- Yeah.

- Or if they've had a CAT scan for some other reason and we happen to fund something that's concerning.

- What about the radiation on something like this, Dr. Churilla, you've mentioned several, you have mentioned targeted, did it used to be that it was a little bit more all over and more toxic and now you can pinpoint?

Explain what you meant by that?

- Sure, yeah.

So our radiation techniques have really evolved.

So radiation therapy, what we deal with is basically use of high energy x-rays to treat tumors.

And we used to be limited by the technology and that would be able to treat broader areas to lower doses, and you started running into side effects earlier.

And our ability to know where the radiation was going was also limited by the technology.

With the advent of more modern machines, we're able to do CAT scans right before patients are treated to make sure they're lining up well, that we have a good sense of the anatomy.

And because of that we're able to treat smaller and smaller areas.

And you know, a really nice example of that is the evolution of something called stereotactic body radiation therapy or SBRT, and that's a technique where we give very high doses of ablative radiation to very small areas by pinpointing it.

So basically a radiation coming from 360 degrees all converging on where that tumor is with the goal of ablating it.

So our technology, just like our systemic therapies, our medical oncologists use and our surgical techniques and our interventional pulmonology techniques have improved so to have our radiation techniques.

- What about surgery surgically?

- How has it improved?

- The techniques, yeah.

- Oh yeah.

- Or I, maybe I'll even go a little step further, how would you then go about treating various types of lung cancers?

- So once you diagnose it, the important thing initially it's called staging.

Like most can, you've probably heard of, like almost every cancer has a staging algorithm.

So lung cancer is no different.

We have stages one through four.

So the important thing up front is like we'll all tell you is we try to assign the patient a stage like whether they're one, two, three or four.

And surgery is kind of a cornerstone for stage one and two for sure.

So for stage one and two patients, kind of surgery still is kind of the standard of care.

And surgery itself's evolved.

I mean, early on it was taking out a whole lung, then they showed your lungs have different lobes.

So like your right lung for example has three lobes, three parts, and they showed taking out a lobe is the equivalent of taking out the lung.

So you could just get away with taking out part of the lung.

And now it's even evolved to the point for certain small cancers like less than two centimeters for example, we can even get away with doing a segment, it's called like part of the lobe.

So, we're kind of getting smaller and smaller in terms of surgery.

And the techniques evolved it used to be a big incision called a thoracotomy, then it evolved to VATS meeting with a camera.

And now we have the robot, which is kind of a VATS on steroids.

It's you're actually using a machine with four different arms on it and a surgeon's use kind of controlling all these arms at a console.

So technology's advancing quickly.

- And are you seeing cancers that are not quite as far gone?

I mean, to their point that the screening is better or are you still seeing people coming in who had no idea until it was very late?

- So the people that make it to my office, usually they've kind of made it past a lot of different barriers, like Dr. Sabuto, Dr. Churilla, the lung cancer team.

Usually the people that are seeing me they're people think are surgical candidates.

So I'm not seeing usually the oncologists who are seeing the more advanced staged patients 'cause they know they're not gonna get surgery, but... - 'Do you usually see still, unfortunately I do advanced stage patients, Tom and I care for them quite often usually with a medical oncologist as well.

- Several of you mentioned having a team type approach to these types of cancers.

Do you wanna explain a little more about that as well?

- Well, there's just been, so like the technology's advancing so quickly, that the different treatments things like chemotherapies in immunotherapies, surgery, radiation, these are all different treatments for lung cancer.

So it involves a big team.

So we have pulmonologists, the surgeons, the radiation oncologists, the oncologist, other surgeons who weigh in kind of the cancer coordinators.

At our campus we meet on Mondays with the team and we review the patient's history, their films, we talk about the patient and we kind of come up with a plan.

- It's one of the program program, in fact- - It's almost a standard of care to have a team based approach.

- A multidisciplinary lung cancer team, which includes our pathologists as well that help review the pathology for us.

So it's, the nice thing about our program that we have at Geisinger is we discuss their cases around 12 o'clock on lunchtime, and then by one o'clock they're seeing Dr. Cipriano in the office and Dr. Churilla usually and our medical oncologist as well as kind of a joint visit, it helps reduce the amount of time that patients have to spend at multiple different sites and multiple different visits.

- And their anxiety too.

Because it helps to know that it's scary to be diagnosed with something like this obviously, but it helps to know that this was reviewed by a team and this was a team opinion that's not just coming from me, that you need surgery.

It's kinda like a team decided on this and we all wanna do what's best for you.

So it kind of helps like soothe their anxiety a little bit.

- Helps with a second opinion maybe, yeah.

- Of course.

- What would you like people to know most about this Dr. Churilla?

- Yeah, I mean, I wanna just echo with Dr. Cipriano and Dr. Sibuto had mentioned, I mean, I think in 2023, the care of the lung cancer patient is really a multidisciplinary endeavor.

It sounds a little bit cliche, but every case really is unique and not everyone fits into, a well described box.

So having multiple specialists give their perspective to optimize a treatment plan for any one patient, which sometimes can be approached in very reasonable ways, I think is how we get optimal outcomes for patients.

But on a broader theme I think we're making great strides, great progress in the management of lung cancer.

The progress had been stagnant for many years leading up to say the past decade with the advent of more effective systemic therapies, whole body therapies like immunotherapies with the advent of better surgical radiation, pulmonology, medical oncology procedures and techniques.

I think we're seeing better outcomes earlier detection is shifting kind of what would be incurable patients to more curable patients.

So I think the diagnosis, the staging, shifting stages to earlier and the treatments have all improved.

And I think we're certain to see the fruits of those labors.

- And your final thoughts, I know you were very big on making sure people understand that there is screening available out there.

- Absolutely.

There's a still a vast majority of our population that never make it to our offices because they're just unaware that they're able to be screened.

So, anyone with any smoking history that's over the age of 55, I would have that discussion with your doctor.

It doesn't have to be a specialist or primary doctor or your primary care provider of any kind and be appropriately referred if if you're eligible.

- Well, thank you all of you, I appreciate.

And I know that we have barely even scratched the surface of this giant topic, but maybe someone at least got a little bit of direction and can ask their own doctors the questions they might have about lung disease.

That's gonna do it for this episode of "Call the Doctor."

We are, as always, glad that you've joined us.

If by chance there's something you missed, something you wanna listen to again, you'll find this entire show at our website, wvia.org, as well as episodes from the past to check out.

Click on Watch and then "Call the Doctor."

You can also find us on the WVIA mobile app.

I'm Julie Sidoni, Thanks again for watching for all of us here at WVIA.

We'll see you next time.

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