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Not Just a Smoker’s Disease: Rethinking Lung Cancer Risk · Meaningful Medicine with Novant Health

• 0:03
  Joey Wahler (Host): It's the second most common cancer in the United States
• 0:07
  and the leading cause of cancer deaths.
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  So, we're discussing lung cancer.
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  Our guest is Dr.
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  Garrett Sherwood.
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  He's a medical oncologist specializing in lung cancer and thoracic malignancies.
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  This is Meaningful Medicine, a Novant Health podcast bringing you
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  access to leading doctors who answer questions they wish you would ask.
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  From routine care to rare conditions, our physicians offer tips to navigate medical
• 0:32
  decisions and build a healthier future.
• 0:34
  Thanks so much for joining us.
• 0:36
  I'm Joey Wahler.
• 0:37
  Hi there, Doctor.
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  Welcome.
• 0:39
  Garrett Sherwood, MD: Hi, Joey.
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  Thanks for having me.
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  Host: Great to have you aboard.
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  We appreciate the time.
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  By the way, only skin cancer is more prevalent than lung cancer in the US.
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  And so, first, what is lung cancer?
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  What happens when cancer hits our lungs, and what are the most common types of it?
• 0:58
  Garrett Sherwood, MD: Thanks for that.
• 0:58
  Lung cancer is incredibly common, like you said.
• 1:01
  There's multiple different environmental exposures that can transform the DNA or
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  the code of a normal lung cancer cell into a cell that grows out of control.
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  And at that point, a cell has transformed from a normal cell into
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  what we consider a cancer cell.
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  Those cells grow in groups that we call tumors, and then over time try to
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  spread through the blood or the lymph system to other parts of the body.
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  Lung cancer comes in two primary types.
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  The most common type is called non-small cell lung cancer.
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  It's also the more treatable of the two types.
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  The second type is called small cell lung cancer.
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  The primary difference is in the aggressive nature
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  of the latter of these two.
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  Small cell lung cancer often spreads through the body very quickly; and thus,
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  it's very hard to find at an earlier stage like we find many other cancers at.
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  Host: Gotcha.
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  So as you well know, Doctor, one of the biggest misconceptions
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  is that only smokers get lung cancer, but that's not true, right?
• 1:56
  Garrett Sherwood, MD: Absolutely.
• 1:56
  I'm glad you brought that up.
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  Anyone with lungs can get lung cancer.
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  It's true that we've spent in the medical profession quite a bit of time
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  and effort identifying the patients that are at risk of lung cancer and
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  making sure patients are aware of the link between smoking and lung cancer,
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  but that's been somewhat of a detriment in modern times of not emphasizing
• 2:15
  enough that anybody can get lung cancer.
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  There's multiple environmental factors that can predispose people to lung cancer.
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  Radon and asbestos exposure have been well described, but there's
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  also genetic or hereditary factors lung cancer can occur in patients
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  without any significant environmental, exposures, without a smoking history.
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  And sometimes these lung cancers run in families just the way
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  breast cancers and others do.
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  Host: Understood.
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  So, people often assume as well that lung cancer always comes with obvious symptoms
• 2:48
  like a persistent cough, for instance.
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  But what are the early signs people might overlook or dismiss from your experience?
• 2:55
  Garrett Sherwood, MD: Well, that's one of the problems with finding
• 2:57
  lung cancer as early as we want.
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  We have a much more lung tissue than we do have tumor in the lungs, even in
• 3:02
  somebody with an early-stage lung cancer.
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  So, early-stage lung cancer is often clinically silent, and that's
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  why we need to do a better job of emphasizing screening for those
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  that are at risk and following up on incidental nodules in those that have
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  scans done that detect tiny spots in the lungs that we call nodules.
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  But like you mentioned, persistent cough is one important symptom
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  that should trigger a patient to be concerned about lung cancer.
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  If that cough comes with weight loss, if that cough comes with blood mixed
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  in with the sputum, or if that cough comes with persistent hoarseness, those
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  would be other clinical signs that I would strongly encourage patients to
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  advocate for themselves for, to ask their doctor, "Do you think this is something
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  more than bronchitis or pneumonia?
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  Should I be worried about something like lung cancer?
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  And do I need to do an additional test beyond just a chest X-ray, like
• 3:49
  a CT scan, in order to help rule out whether cancer could be there?"
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  Host: Gotcha.
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  So, there's still a stigma around lung cancer, right?
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  That can affect how patients seek care.
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  So, how does that impact patient outcomes, and what do you want people joining
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  us to understand about that stigma?
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  Garrett Sherwood, MD: Yeah.
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  Unfortunately, that's absolutely true.
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  And I think what a lot of people don't realize is that the patients
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  that are getting lung cancer that are coming to my clinic today started
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  smoking in the 1960s and 1970s.
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  The vast majority of those patients have quit smoking.
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  And at that time, many doctors were smoking.
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  And I think we tend to take the lens of what we know today and apply it to the
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  decisions that people made in the past.
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  And so, it's important that we recognize that any cancer patient, whether they
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  have lung cancer or any other type, all of those patients deserve our compassion,
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  and they all deserve the best the medical profession can deliver to them.
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  Host: Yeah.
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  Oftentimes when it comes to skin cancer as well, you can get it later
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  in life from exposure that happened when you were just a kid, right?
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  Garrett Sherwood, MD: Absolutely, yes.
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  And again, the majority of people diagnosed with lung cancer today have
• 4:54
  quit smoking, years and years ago.
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  Host: Of course.
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  We should point out, right, Doc, that that doesn't mean you shouldn't quit in
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  order to avoid cancer and, of course, to be healthier in many other ways as well.
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  But I guess what we're saying is if you were a smoker and you've quit and
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  you've quit for a while, you don't really know whether or not you're
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  going to still get cancer, right?
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  It's really pretty arbitrary, isn't it?
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  Garrett Sherwood, MD: Absolutely.
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  And we've tried to simplify the screening guidelines to make sure
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  that patients that are eligible for screening are able to go to their primary
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  care provider and encourage them to consider a low-dose CT screening study.
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  These screening studies are for patients ages 50 to 80, and for anyone that
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  has smoked 20 pack years, meaning an average one pack a day for 20 years,
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  regardless of whether they've quit or not.
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  Host: Speaking of which, you led me beautifully there into my next
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  question when we talk about screening.
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  It can save lives literally, right?
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  But many people don't realize they qualify for it.
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  So, who should be getting screened here for lung cancer, and what does
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  that process actually look like?
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  Garrett Sherwood, MD: Screening absolutely can save lives.
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  We know that less than 10% of patients that are eligible for lung cancer
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  screening get screened, which is unfortunate, and that is a major
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  contributor to why the success rates for lung cancer treatment often fall far below
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  that that we see for things like breast and colon cancers, where 60% and 70% of
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  patients that are eligible get screened.
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  Screening is very simple.
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  It's a CT scan.
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  But we intentionally use a low dose of radiation so as not to expose
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  the patients to too much radiation.
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  It should begin at age 50.
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  And again, these are in patients that have smoked for at least 20
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  pack years, regardless of whether they have quit smoking or not.
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  The screening's designed to be annual, meaning that each year you should have
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  a follow-up CT scan to either follow up on any spots that we call nodules that
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  were seen on the prior scan, and to rule out the presence of any new nodules.
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  Host: Before we go any further, let me ask you to just touch a little bit more
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  on what you mentioned a moment ago, that only a fraction of people go for cancer
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  screenings and it pales in comparison to some of the other major cancers.
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  Why do you think that is?
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  Garrett Sherwood, MD: I think there's multiple factors.
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  I think unfortunately, some of the bias towards lung cancer patients
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  still exists within the healthcare system, and you have providers that
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  aren't as apt to push a patient to get a lung cancer screening study.
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  The guidelines have actually been out since 2013.
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  So, these aren't necessarily new.
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  And despite these being close to 15 years old, we've not seen a dramatic
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  increase or uptake in screening really in any part across the country.
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  I think, as you mentioned, lung cancer patients are also a little bit less
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  likely to advocate for themselves.
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  And so, even those that may identify that they could benefit from a screening
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  are less likely to go to a primary care provider or their doctor's office and say,
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  "Hey, I think I qualify for screening.
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  Will you screen me?"
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  And then, lastly, I think the lung cancer community can do a
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  better job of publicizing the need for lung cancer screening.
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  You know, we're all well aware of, you know, Breast Cancer Awareness
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  Month and the pink ribbons that you see people proudly wearing.
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  We don't really have that sense of pride or ownership in the
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  lung cancer, you know, patient community and their support givers.
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  Host: I can't help but ask then, Doctor, how frustrating is that for someone
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  like you that's trying to fight this and is to some degree, as the saying
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  goes, pushing the boulder uphill?
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  You want the word to get out.
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  Obviously, conversations like this certainly help, but it would be so
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  much easier for providers and mainly patients easier and better if they
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  would just heed these warnings, right?
• 8:37
  Garrett Sherwood, MD: It would.
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  Unfortunately, there's multiple different obstacles within the
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  system that make this challenging.
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  And so, I think for a system that's serious about tackling this
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  problem, you have to engage all of the various different stakeholders
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  that touch these patients.
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  It starts with the patients themselves and their family, their community.
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  I'm hoping that this podcast will reach not necessarily
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  just the lung cancer patients.
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  You know, many of my patients are in their 70s and 80s, but their children,
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  their friends, their families who can then, you know, turn to someone that they
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  recognize might be eligible for screening.
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  We need to do a better job engaging with the primary care providers
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  and understanding what are their obstacles and what are their barriers
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  to getting patients screened.
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  Many of these doctors and APPs are overworked, and they're practicing in
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  communities where they don't have access to as many resources as they would like.
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  And that certainly limits their ability to screen everybody
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  as much as they would like.
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  And then, health systems need to do a better job of following
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  up on abnormal findings.
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  We know that many patients that ultimately get diagnosed with lung cancer have
• 9:41
  a spot or a nodule that was seen on a prior scan that was done for a different
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  reason, but these number in the tens of thousands in our community every year.
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  Almost 50% of patients that have a CAT scan done of their chest for
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  any reason will have a lung nodule.
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  And so, it's incredibly challenging to pick out the needles in the haystack,
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  so to speak, of which of these nodules are concerning and may be a precursor to
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  what ultimately becomes a lung cancer.
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  Host: And it takes a village, as they say, and very well said by you indeed.
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  Couple of other questions for you.
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  Lung cancer treatment has evolved rapidly in recent years.
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  That's part of the real good news, of course.
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  So, what are some of the biggest advances that are changing survival
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  and quality of life for these patients?
• 10:26
  Garrett Sherwood, MD: Yeah.
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  Thankfully, that's been the number one thing that I think has contributed to
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  some of the improved statistics about how our patients are doing with lung cancer.
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  I can't tell you the number of times I've had a patient come to my clinic
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  with the understanding that they have a lung cancer that is advanced and has
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  started to spread, but they also come in with the belief that there's nothing
• 10:43
  that can be done for them, and that couldn't be further from the truth.
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  We have seen the advent of a group of treatments that we call immune therapies.
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  These are medications that work with the patient's own immune system
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  to help get the immune system to attack and eradicate the cancer.
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  And when these treatments work, they can work incredibly well to the
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  point where patients that show up to clinic with metastatic or stage
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  IV cancers can go into remission.
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  And I have a growing group of patients that have not only gone into remission
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  on these treatments but have been able to stop their treatment and remain in
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  remission for years and years, even after the end of their course of treatment.
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  Host: And speaking of which, for years there was a belief that lung cancer
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  was always a death sentence, right?
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  But those survival rates have now changed.
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  So off what you just said, any numbers you can give us that illustrate just how
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  much the picture has gotten brighter here?
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  Garrett Sherwood, MD: Yeah, absolutely.
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  The numbers aren't as good as we want them to be, but like
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  you said, they're improving.
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  With access to the latest drugs, we can now quote people about a one in
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  four chance that even with a metastatic cancer, again, a cancer that we would
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  previously considered to be incurable and one with almost no chance of
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  surviving five years, about 20% of those patients are living five years today.
• 11:56
  Host: And then, in summary here, Doctor, what gives you the most
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  hope on a daily basis when you're treating these lung cancer patients?
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  What's most rewarding about what you do?
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  Garrett Sherwood, MD: The most rewarding thing is the sense of gratitude
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  that patients get and demonstrate when they get into my clinic.
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  I think many of these patients feel like they've battled the healthcare
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  system, and it's been an uphill climb to get to an oncologist's office
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  to get to that final diagnosis.
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  But we're doing a better job of creating streamlined systems that allow every
• 12:26
  patient to get evaluated quickly and efficiently, and we're giving more
• 12:30
  patients the chance to have these dramatic outcomes by getting patients
• 12:35
  started on treatment before the symptoms of the disease progress to the point
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  where they're no longer treatable.
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  Host: Sort of wrap things up here.
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  You're saying that the treatment options are getting better all
• 12:45
  the time, but it all starts with that screening, doesn't it?
• 12:48
  Garrett Sherwood, MD: Absolutely, yes.
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  The number one thing we can do to improve the cure rate for lung cancer is to
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  make sure that the patients that are eligible to be screened get screened,
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  and those that have an incidental finding get that followed up on.
• 13:01
  Host: Well, folks, we trust you are now more familiar with lung cancer
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  and the importance of screening.
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  Doctor, keep up all your good work, and thanks so much again.
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  Garrett Sherwood, MD: Thanks so much for having me.
• 13:12
  Host: Absolutely.
• 13:13
  And to find a physician, please do visit novanthealth.org.
• 13:17
  For more health and wellness information from our experts,
• 13:20
  please visit healthyheadlines.org.
• 13:22
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• 13:26
  Thanks so much again for being part of Meaningful Medicine,
• 13:29
  a Novant Health podcast.