Chapters Transcript Video Advances in Lung Cancer Treatment: Navigating Toward a Solution Welcome to the Baptist Health Doc to Doc podcast. A conversation for physicians by physicians, providing insight on the latest in medical practice, research, technology and innovation in health care on the Doc to Doc podcast. Even with the success to reduce smoking, lung cancer remains the leading cause of cancer deaths worldwide. For both men and women. In 2023 there were approximately 238,000 new lung cancers and 100 and 25,000 deaths in the United States alone. Efforts to improve outcomes have not only led to greater understanding of biology and genetics of lung cancer, but also the individual lung tumors. In recent decades, the evolution of robotic assisted thoracic surgery has enhanced primary lung cancer treatment and post operative outcomes. That in combination with advances in immunotherapy and our understanding of the cancers molecular biology, bring many tools to the battle against leading the leading cause of lung cancer deaths in the United States. I'm Doctor Paul Kan. I am a thoracic medical oncologist at the Miami Cancer Institute, also a part of Baptist Health South Florida. Uh sitting next to me is Doctor Mark Deloy, uh who will introduce himself. Hello. I'm, uh, uh, the Chief of Thoracic Surgery at, uh, Baptist Health Systems. Yes. So, Mark, maybe we can chat a little bit about our approach to, uh, managing and diagnosing and treating lung cancer at Miami Cancer Institute. Uh, what are your thoughts when you first see a patient? Well, that's a very interesting question. I think that we should start a little bit about how things have changed in a very short period of time. I think in the last uh 3 to 5 years, um there's been dramatic advancements, not only in the surgical fields, but also in the medical oncology fields and in radiation oncology fields. And we'll go through that today. But just to, to point out in the past, um many patients who presented with lung cancer, despite the uh various stages um would generally be seen by an individual, either a surgeon or a medical oncologist. And often there wasn't collaboration between the specialties and we've made it a very important point or part of our treatment algorithm that virtually every patient that presents to MC I is handled in a multidisciplinary fashion where the experts within the field of treating lung cancer have an input in every individual case. Yeah, I I agree completely. I think uh multi disc plenary is really the key, the key word here and we collaborate very closely together also with our radiation oncology colleagues. Um And a big part of that is our uh thoracic uh tumor board that we have uh once a week. So Paul, let me ask you, what do you think is the importance and why treat patients who present with complicated lung cancers in a multidisciplinary fashion? What does that bring to the value of the treatment? Well, each patient's journey with lung cancer is very individual. Every cancer is somewhat different. And our philosophy at Miami Cancer Institute is to guide treatments. We often use the word precision medicine, we guide treatments to want to know what is their type of lung cancer, what are their stage of lung cancer? Um And what are the specific about their, about their cancer? Um And then we conference together to make the best decision. Is this a patient that it's best treated with initial surgery or is it a patient that's best treated with initial medication treatment or with radiation or a combination? So, it's very diff important that the three disciplines talk to each other and evaluate each patient individually. So when I was in medical school and residency, I was taught that there were basically four types of lung cancer. So earlier in your statement, you said every patient is different. So how is everybody, everybody different. It's uh um what explains the, the variety of tumors and how every patient should be treated as an individual and not as a group. Yeah. So yeah, when, when we were first in training, the uh basic decisions about cancer, lung cancer treatment were based on histology, the type. So we know there are subtypes of lung cancer, broadly small cell, non small cell and then within non small cell histologically, the main types being adenocarcinoma, and squamous carcinoma. And that guides us in terms of different treatments, especially from a medical oncology. Point of view, certain medicines are better for one histology or the other. But what's transformed the treatment from a medical oncologist point of view uh To answer your question more specifically is basic research that's been done um to get more information about each person's type of cancer. So in year 2000, the human genome was sequenced um DNA sequenced and a particular technique called Sanger. But by 2004, what was called, what is now called next generation sequencing became available, which made the ability to quickly and cheaply um sequence DNA. So we can now take everybody's lung cancer either by a specimen from a biopsy which you may have done or some cancer, shed their DNA in the blood. Um And we can sequence the DNA of that cancer to detect mutations. Um And we know that lung cancers have many mutations, but some mutations are what we call actionable mutations. These are not genetic mutations that are inherited, they're spontaneous mutations that develop in normal lung cells to sort of make them or drive them to be cancer cells. So these are driver mutations and it's very, very important. Now, every person with lung cancer that's diagnosed at Miami Cancer Institute gets next generation DNA sequencing to see if they have particular driver mutations because that would guide me as a medical oncologist as to what specific type of treatment may be best. In addition to these driver mutations, we can pick up a test called a PDL. One that gives me information as to whether the cancer or may respond to immune therapy. So the weapons that I have to treat cancers with medicines, chemotherapy, immune therapy and targeted biological therapy are available. And what I need to do as a medical oncologist and what we do multidisciplinary wise is to take that into consideration to say what would be the best medical treatment for that person. Now, from your point of view, there have certainly been huge changes during your career about techniques for surgery. So tell me a little bit about how your journey, how you got into robotic surgery. And you're one of the country's leading teachers for robotic surgery, you train other doctors. Um What's that all about? So, yes, there's been, you're absolutely correct. I've been practicing a little over 20 years now, but things have changed so dramatic since I originally uh went through residency program. Um in the early days, we used to do these surgical procedures through a very invasive open approach, uh through big incisions, spreading the rib cage, cutting all the muscles so that we could actually put our hands inside the chest and do what we were tasked to do throughout the operation, for instance, doing a lobectomy for lung cancer. And then about 15 years ago, we started toiling around with um small instruments, handheld uh instruments on lung shafts where we put them through uh small ports and try to replicate what we do um as an open surgeon, but it wasn't always adaptable to most surgeons. In fact, only very small percentage, about 30% of surgeons were able to accomplish the same level of surgery through uh what we call a video assisted approach uh that you could do through an open approach. But what has happened in the last decade or so is many of you have probably heard about robotics. It's happening in all aspects of our human life and building automobiles and, and um all kinds of uh robotic assisted uh procedures. Well, it has entered the field of surgery. It's uh basically a system that we control as the surgeon, but we're actually external to the operative field. We sit at a chair like this, sit in an immersed field using a, a video headset and some glove like hand instruments that we put our fingers in. And we're able to actually control instruments that are placed through small pencil size ports inside the rib cage. And those the tips of those instruments function just like a human hand. So you can have a grasper in there and you can have uh seven degrees of rotation and flexion and you can grab and cauterize and cut and do all kinds of delicate maneuvers in very tiny, tiny spaces. And we've learned that this technology allows us to essentially replicate what we do through an open approach, but through a completely minimally invasive approach, which has had a dramatic effect on the um early recovery of patients, the complications associated with uh post surgical patients. And it has made AAA big improvement in how we operate on patients, how what risk factors um apply to surgical patients nowadays. And when I mentioned risk factors, um you can remember we've been working together for 20 years and you can remember patients who present with very advanced stages, stage three disease with very large tumors, bulky lymph nodes in the mediastinum. And those folks, we, we used to treat with a multi modality approach with chemotherapy and radiation and then offer them surgery. And those folks um would often go to surgery through an open approach and had a very difficult time in the hospital recovering for several weeks. And then after they've left the hospital, they'd have many more weeks of recovery and they'd be debilitated after the complex surgery and chemo and radiation therapies that we offer them. I believe you've witnessed the changes that have occurred with respect to how these patients respond to surgery. They do very well after surgery, it's usually an overnight stay in the hospital nowadays and we send them home after the patient has received um their upfront therapy. Now, nowadays, we don't utilize radiation as much. And it would be interesting to tell the audience why we've made that change and how the immunotherapies and the targeted therapies have sort of altered our methodology of treating these patients. Yeah. And just by the way, did so when you're doing your robotic surgery compared to the old days, do you see things better? Does it give you actually uh better, you're looking at a TV screen where things are magnified? Absolutely. You see 3d vision and it's magnified by 10 fold. So in fact, you can see even, you know, small layers of tissue through the robotic camera that you would never be able to see with your own eyes, you'd have to wear a headset to magnify it. So you can see very precisely the tissue layers that you're dissecting through. There's also augmented type of adjunctive um devices on the robot that allow you to say I the vaske, we can pull up a CD AC T rendition of three dimensional reconstruction of the vessels inside the camera that we can sort of set off to the side and utilize that to sort of identify the anatomy while we're working. And the advancements in that, you know, development is, is ongoing every other six months or so. They come up with a new adjunctive therapy. So it, it's made our ability to do surgery on much higher risk patients, much older patients very safely with very low complication rates. Yeah. And I would definitely agree. Um, and I remember the old days where someone would come to see me post operatively from surgery and they'd have a huge incision across their thorax and now they come and they have a few small little incisions and they've had surgery a week before and they're up and around. So it's quite, quite amazing. I would definitely agree. So, um to answer your question from before, as we talked about, um multidisciplinary is sort of the watchword. And um with the treatments that I have as a medical oncologist, as I mentioned, chemotherapy, immunotherapy targeted therapy. Those treatments were developed in people with advanced lung cancer is what we call stage four. And in those cancers, uh these treatments are not curative if someone has an advanced lung cancer, stage four, metastatic lung cancer, we these treatments can be very effective to induce a remission to control the cancer, uh often times for many years, but they're not necessarily curative. So the thought process then in terms of the research for lung cancer is well, well, if you have treatments that are effective in the advanced setting, what about moving them earlier to earlier stage lung cancers? And we know that even in pay people that are operated on for early stage lung cancer, the curability relates to the stage. So a small stage one lung cancer, for example, has a high crate just with surgery alone. And those people we often just observe. But as the stage gets higher, larger stage one stage two, stage three, there's significant risk for those people to have a recurrence of their cancer even after surgery. So now we know through clinical trials that have been done over the years that post operative treatments um with targeted therapy, if their cancer has a mutation or immune therapy or chemotherapy or sometimes a combination after surgery can improve the cure rates. And there's ongoing clinical trials to try to do even better. So then the thought process says, well, if we have treatments that we know can achieve remissions in the advanced stage and we have treatments that can improve the cure rate in the post operative setting. What about putting those treatments before surgery? And the term that we use is neoadjuvant before the surgery and clinical trials have been done? And now you and I discuss patients all the time and tumor board where they may present with a cancer that is potentially receptible. Um but that it makes sense to consider giving them initial treatment with chemotherapy and immunotherapy that may help to downsize or downstage of the cancer that may make your surgery easier. But more important. What's been shown is that in many of those people after surgery is done and the specimens are looked at when they've had chemotherapy and immunotherapy ahead of time that some of those um cancers have achieved what we call a pathologic complete remission where under the microscope, it just doesn't look like there's any living viable cancer. Um And in those people, we certainly hope that having this neoadjuvant this upfront chemotherapy immunotherapy um may be successful to even improve the cure rate above and beyond just the surgery alone. So these are the issues that we talk about and discuss all the time at, at our uh tumor boards and our radiation colleagues are not here today, but they also play a big role um in making this, in making these some of these decisions as to um what would be the best, uh what would be the best cancer treatment. So what I'd like to talk a little bit about is, you know, it's easy to, to address patients that present to us with a tumor in the lung that's been discovered for whatever reason they developed symptoms or they received a, a chest X ray for another reason and was found to have a large mass within it. But what about talking about the patients at risk? I mean, how, how do we educate our referring physicians, our medical community, the patients at large as to what would be appropriate um screening modalities uh to encourage patients to have in order to catch them in their earliest of phases. I I think you would agree that the earlier you catch the tumors the bigger impact that you'll have on improving their survival and long term cure. Um And so how do we go about educating our referring physicians, our medical community and the patients out there? Yeah. And you've been a big part of the initiative that we have and Baptist Health, um, along with our radiologist to set up what we call lung cancer screening program. Um, and so certainly we know 85% or so of uh lung cancers are related to cigarette smoking. So that clearly is our target population. And there have been a series of worldwide clinical trials done um showing that doing a low dose uh CT scan in people at risk, people, 50 years older, who have had a s a significant smoking uh history, um if they're screened um that we can detect these cancers earlier um and uh may and then increase the uh the cure for that. Absolutely, you're absolutely correct. And what's so insightful in the national uh and the international trials with respect to lung screening is how the survival and the curability is improved when a tumor is caught in its earlier stages on a lung screening. As opposed to um the data that would suggest that the curability after someone presents with a symptom and are undergoing screening CT scans at that point and are still found to have an early stage lesion in a symptomatic patient that's found to have stage one cancer compared to someone who's incidentally found to have a stage one cancer on lung screening, the survival almost increases by 10% when they're treated appropriately. So that's, that's really important to convey to our medical community and the patients at large that if you have those risk factors, um you should undergo an appropriate screening CT scan and maintain that on an annual basis. Because if you're unfortunate enough to be discovered to have a pulmonary nodule, the impact that a lung screening study will have on the ability to cure that patient is going to be significantly higher than if you present when you develop symptoms. It also has the benefit of reducing the overall cost of society in treating patients with lung cancer. Because you can imagine if patient, a patient who's a smoker that doesn't seek out lung screening and eventually present with stage two or stage three disease, talk a little bit about the, the cost to society compared to someone who we treat with early stage disease. Yeah. Yeah. I mean, it's, it's uh absolutely. Um a very important point. Um not only, not only in terms of screening but at in, at um our institution, Baptist Health and Miami Cancer Institute, uh we have lung screening programs that our listeners, if there are physicians listening to this podcast, uh should avail themselves uh any doctor can send a patient for a lung cancer screening and we also have smoking cessation programs uh that are available. Uh for people since we know that smoking is such a risk factor. You know, back before the 19 hundreds, lung cancer was rare. It's only been really since cigarette smoking that the lung cancer has exploded. Uh, it kinda peaked in the 19 eighties. Remember the surgeon general report linking cigarettes to lung cancer? Uh was in 1964. Um, and after that society jumped in to try and really, um, make public, the public aware of the risks of cigarette smoking, cigarette commercials were taken off the air on TV. Shows, for example, in 1970. So lung cancer incidence has been trailing lower since the 19 eighties, but it still remains the number one cause of cancer deaths uh as well. Um So looking ahead, um, what do you see as uh possibly some of the advances that might be coming along in terms of from the surgical point of view that you might be interested in letting our, our listeners know about. Well, that's a, that's a very, um intriguing question and there's a number of advances in the field of surgery. Um I think those advances are sort of dovetailing into what people believe or physicians or researchers believe the future treatment of lung cancer is going to amount to and take, for instance, a patient with early stage lung cancer, those patients would typically undergo surgery done in a minimal invasive fashion, usually with robotics nowadays. But there's some thought process that with the advancements of targeted therapy with the advancements of genetic analysis of the tumor, um perhaps maybe just a biopsy to get enough tissue to do the genetic testing. And then if we discover that the patient's tumor has a particular marker, it may be readily treated with a targeted um therapy and not require any type of surgical intervention or maybe add radiation to that following upfront immunotherapy. And that's the sort of the thought process as to where the science going with respect to invasive treatments of, of lung cancer. I think surgery is always gonna be around. We always see those tumors that just don't get a complete pathological response with upfront therapy and those patients are ultimately gonna need surgery. But I, I do believe that moving away from more invasive uh procedures and treatments is going to be where we're heading with the treatment of lung cancer. Yeah. And um you know, looking ahead from my perspective, uh and certainly the initiatives at the Miami Cancer Institute in terms of clinical trials for medical oncology are very important. Um That's how we make advances. Uh science is real and uh the basic science research or what, where we make some of our biggest advances in terms of understanding uh lung cancer treatments. Um and putting up putting some of the treatments that are available or newer ones that are being developed to target uh cancers and to find many of the lung cancers that we see uh have mutations, but the mutations don't yet have an a treatment. So we're looking forward to more research to be able to target those mutations as well. So uh wrapping up a little bit, um maybe we can uh summarize um where, where we stand um that uh the field of innovation and research continues and with it, the hope for millions in the future, as these proven advances come into view, we will continue to bring the best treatments for all of our patients and advance the knowledge based for our colleagues. So mark, it was a pleasure talking to you today on this podcast. Thank you for the opportunity to participate in the podcast. I really enjoyed it to find out more about the topics covered on the doc to doc podcast. Please visit physician resources dot Baptist health.net. Created by
