Information Session: Lung Cancer and Lung Health

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On July 9, a panel of MSK experts addressed your most pressing concerns and answered your questions about lung cancer, screening, and general lung health.

Show transcript

Operator:  Good afternoon and welcome to the Memorial Sloan Kettering Information Session, Lung Cancer and Lung Health.

Our host and moderator for today's call is Dr. David Jones, Chief of the Thoracic Service, Department of Surgery.

I will now turn the call over to Dr. Jones.  Please go ahead.

David Jones:  Thank you.  I'd like to welcome everyone to this MSK Information Session where today, we're going to talk a little bit about lung cancer, lung cancer screening, general lung health as well as the effects of COVID and its impact on cancer care here at MSK. 

As mentioned, I'm David Jones, chief of Thoracic Surgery at the -- at Memorial Sloan Kettering and a surgeon who specializes in lung and esophageal cancer.  I want to thank all of you for joining the call today.  We here at Memorial are working very hard to try to keep you and your friends and loved ones safe when they come here to an appointment or any one of our regional sites in New Jersey or the Greater New York area. 

I think together with a superb panel of experts, we're going to try to answer some of the many questions that you shared with us in advance of this call today and will try to get to as many of them as possible during this -- during the next hour. 

I do want to remind you too that your MSK doctors and care teams are ready and willing to talk to you directly about any concerns that you may have either after this call or later on if they come to you.  So, I would encourage you to reach out to any of us to discuss next steps in your care and ask questions that you think that are not being answered here today. 

So, with that, I think we'll start off the information session by me maybe first asking Dr. Tobias Hohl, who's our Chief of Infectious Disease Service, to address some of the comments that many of you wrote about with respect to the COVID-19 risk as either lung cancer patients or lung cancer care survivors or those who are just generally concerned with your health -- your lung health. 

So, I want to introduce a Dr. Hohl and then ask him to talk a little bit about what makes somewhat at increased risk for getting COVID-19.  Dr. Hohl? 

Tobias Hohl:  Thank you, Dr. Jones.  So, I'm a part of the Infectious Disease Service and I work with many lung cancer doctors and other physicians at Memorial to treat patients who have COVID-19 and there are obviously -- it's created an enormous amount of uncertainty among all of our cancer patients. 

And I think perhaps the most important thing that I can convey is that the vast majority of our cancer patients, including those with lung cancer, do well with COVID-19.  We have treated over a thousand patients at Memorial for COVID-19 and the vast majority recover and do well.  And we also have facilities in place to take care of those patients who have developed more severe forms of the disease. So, if you're a cancer patient and, God forbid, you developed COVID-19, we, as a center, can take care of you.

Now, for those of you who have lung cancer, this is -- this creates significant uncertainties and worry because the lung is a primary site of COVID-19 disease and we have seen that patients with lung cancer can develop more severe disease than patients in the general population or patients with other forms of cancer. 

But we've learned a lot about how to take care of COVID-19.  We're good at it and getting better and we will take care of you should you develop it. 

Now, with regard to how to move forward, it's really important that your lung cancer is treated and treated effectively because the prognosis of lung cancer, in virtually every circumstance, is far worse than the prognosis of COVID-19. 

So, as infectious disease doctors, we want you to be able to continue your cancer care with the best available therapies and we will -- we can certainly try and minimize your risk of exposure and developing COVID-19 but we've gone to great lengths at Memorial to make sure that this is a safe environment for your care. 

David Jones:  Yes.  I think that's excellent.  Dr. Hohl, what about as things kind of open up more and more, are there any special advice that you could to lung cancer patients and/or survivors?  Should they be extra careful?  Are they at extra risk as we move back out into more -- a new normal? 

Tobias Hohl:  I think caution is still the word of the day and there's a lot that our patients can do to protect themselves.  It's really important for our patients to wear mask if they go outside and we want our patients to wash their hands before they go outside and also after they come back and have perhaps taken their mask back off at home. So, really, social distancing and wearing protective equipment to minimize the risk of COVID-19 remain very, very important. 

I also urge our patients not to travel to areas or states that are now really heavily affected by the virus.  So, I would not a travel for any reason except for the most important ones. 

So, the key here is still to minimize potential exposure and I think our patients are really good at that because they’ve been taught not to expose themselves to germs even before COVID-19.  So, we're seeing that our cancer patients right now, very few of them are coming in with COVID-19 and I think that speaks to their success in maintaining physical separation and hand washing, all these things remain very, very important today. 

David Jones:  Great.  Thank you so much.  We also had a few questions about how safe it really is to come to Memorial Sloan Kettering now here in the middle of the city kind of the epicenter of COVID-19 initially and patients are wanting to know or potential patients about how safe to see appointment or the treatment. 

And I'd like to maybe ask Helena Yu, who's one of our thoracic specific medical oncologists who specializes in lung cancer here MSK to talk a little bit about some of the precautions that we've put in place and her experience in this.  Helena? 

Helena Yu:  Thanks, David.  Good afternoon, everyone.  I'm glad to be here and chatting with all of you.

I actually think it was quite incredible in March when COVID started to become apparent and how big of an issue it was going to be how quickly we were able to kind of adjust the way that we deliver cancer care from -- in February not having any telemedicine to March and April where we were nearly a hundred percent telemedicine. 

So, telemedicine visits are when we use the phone and the computer to safely and securely connect usually by video with our patients.  And so, I'm able to see them and talk to them and not examine them but sort of see how they're doing.  And we've been utilizing that really since March as a way to care for our patients. 

I think as things open up, we have definitely been seeing patients in person, of course, in Manhattan and in all of our regional sites.  And I think that now we have established a nice mix of in-person and telemedicine visits kind of tailored to the needs of our individual patients with sicker patients, of course, coming in and needing to be assessed but some of our patients who are stable on long-term treatment who can easily be seen by these video visits. 

And so, I think that we can go into a little bit but there had been a lot of kind of safety measures that have been put in place.  I know at the Koch Center and the other places where we practice outpatient medicine where patients are called and screened before visits.  There is limited number of patients that are allowed in the building and we're trying to minimize sort of the time and interaction with other people in the building. 

And so, I think the feedback from my patients is that they actually feel quite comfortable coming in and feeling like we're doing everything we can to help them, protect them against COVID-19.

David Jones:  Yes.  I think just in terms of also ensuring patient's safety, I think specifically before and after surgery, I could comment a little and supplement what you had to say, Helena.  Every patient who now is going to receive any type of procedure whether it's a biopsy of the lung nodule or an operation or even just a simple bronchoscopy to look at the airway tubes has to be tested within 72 hours of that procedure before we're allowed to do the procedure. 

And that testing, which we started back in April, has been huge.  We've identified many patients who are asymptomatic and we did not do their procedure and allowed them to instead be treated by their local physicians and recover and then test negative for COVID and then we're able to do their operations. 

And I think the thing that's probably been meant the most, or one of the things in terms of care after surgery, is that all of our faculty and staff are now being tested routinely for COVID. //  So, the number of employees within the hospital who have turned up to have asymptomatic COVID positive disease is well less than like 0.3 percent.    

So, I think the care after an operation or procedure is very safe as everyone here is being tested.  And, obviously, we're adhering to all of the same safety measures that Dr. Hohl mentioned earlier in terms of masks and social distancing and a lot of hand washing. 

So, I think if someone needs a procedure here at Memorial, there are a lot of things that have been put in place before and after the procedure.  So, I just wanted to comment on that. 

Maybe we'll try to address some of the questions that came about new treatments for lung cancer and I'll ask Bernie Park, Deputy Chief of Clinical Affairs for thoracic surgery here Memorial, also a lung cancer surgeon, to tell us a little bit about the advances in the treatment of lung cancer. 

And then to Helena Yu back again to talk a little bit about clinical trials and even COVID in clinical trials.  But let's start with Bernie. 

Bernie Park:  Yes.  David, thank you for the opportunity and I wanted to thank everybody that’s participating on the call.  I think it is an exciting time for lung cancer treatment in this era in spite of the pandemic that's going on and I say that because there are many new developing both diagnostic and therapeutic opportunities for patients that are really improving our ability to diagnose and treat this very difficult cancer. 

As far as the diagnostic front, one of the major new advances that came about really toward the end of 2019 and beginning of 2020 is a technology called robotic bronchoscopy, which is a kind of variation of an old technique of bronchoscopy but using three-dimensional imaging and it's almost like GPS for your lung where lung nodules now, even smaller ones, once they are being picked up with -- by screening or incidentally can now be biopsied with virtually no threat of lung collapse and spots that perhaps would have been watched because of difficulties of diagnosis can now be sampled and identified much earlier with an essentially outpatient procedure with very little, if any, chance of complication. 

And so, that's rapidly being able to expand our early diagnosis of lung cancer.  And then also it's giving a lot of options for treatment. 

As far as treatments, one of the other advances going on right now is we recognize particularly with earlier stage cancers that are diagnosed based on screening or based on other tests that we don't have to -- surgery has always been the mainstay of treatment of early lung cancer but we -- in the past, we've removed half a lung to treat even small cancers and now, we're innovating new techniques to not only perform surgeries less invasively without spreading the ribs or making big cuts.

But we can also -- there's a real focus on lung sparing techniques, what we call sublobar or (lessen) a lobe surgery such as removal of a segment of the lung to really preserve lung function, reduce complications. 

And then lastly and probably most excitingly, there had been many inroads in new therapies for lung cancer based on the characteristics of the tumors.

 We're now in an era, and I think Dr. Yu can take the ball from here and maybe discus in a little bit more detail, but we're in an era now where every individual patient that gets diagnosed with lung cancer can now get a genetic personalized workup of their tumor to really characterize it on up on a gene and a molecular level so that we can really tailor treatments to the characteristics of the tumor.   

And there are many new therapies that have been created what we call targeted therapies as well as I'm sure many of our participants have been aware of things like immune therapy that are now becoming increasingly available for patients based on the molecular characteristics or the biology of their tumor.  And so, it's really exciting because we can now tailor treatments.  It's not just the generalized chemotherapy but it's often a combination of chemotherapy, immune therapies or single targeted pills where you could just take a pill every day that will basically halt your cancer right in its footsteps.

So, I think right now, it's a really exciting time and perhaps Helena can discuss a little bit about -- more about the targeted and immune therapy options for patients. 

Helena Yu:  Sure.  I think to put a number on what Dr. Park was saying, really over the last kind of two in change years, there's been more than 20 different drugs approved for lung cancer either oral drugs that are used for new indications or brand-new drugs that have been // sort of approved.

So, I think that really just speaks to the fast pace of drug development and clinical trials and getting -- from identifying a drug to getting it approved.  And to patients, we've been able to really shorten that time period, which has really been great. 

I think just agreeing with everything that Bernie said, I think that MSK has been really a forerunner in not only in one changing the standard of care.  So, I think if -- for people that were diagnosed with lung cancer that I saw three or four years ago, the treatment recommendations that I provide today are actually completely different than they were three or four years ago.  So, I think that's how quickly and dramatically things have changed.

And I think just to reiterate what he was saying about these targeted therapies, I think we're really able to personalize treatments.  So, someone comes in to see me, we have that MSK impact test which looks at hundreds of genes and helps me sort of provide sort of a roadmap of the cancer and then really being able to personalize treatments for individual patients based on those mutations. 

And I think what's neat about what we do at MSK is once something's approved, we're already on to how do we make that better. So, I think for all of these different mutation subsets of lung cancer, we're designing and participating in clinical trials that are looking to take things to the next level.  So, never being satisfied with -- happy about new approvals but really always looking to see how can we make outcomes for our patients even better. 

And I think one other area that I think is going to be a new emerging area in the next couple of years is //at our big cancer conference called ASCO that we had this year, one of the exciting findings was the use of targeted therapy after surgery.  And so, there was a study of an EGFR inhibitor after surgery and it really did show sort of really significant delays in cancer recurrence.  And so, I think that’s going to be a future area where we're going to see nice advances of being able to take things that we use when people have incurable cancers and moving them to the early stage setting and hopefully curing more patients.

David Jones:  Great.  I agree.  That's very exciting, Helena.  Let's turn to some of just the general kind of signs and symptoms that many of our listeners ask about as it relates to lung cancer and here, I'd like to ask Jessica Marcus who's an amazing nurse who works on our service and maybe, Jessica, can you share with our listeners what they should be on the lookout if they have any concern about potentially having a lung cancer from a symptom or sign perspective. 

Jessica Marcus:  Hi.  My name is Jessica.  Thank you so much for having me.  Perhaps frustratingly, lung cancer often does not start with any telltale signs.  The cough that you had this winter is most likely an upper respiratory infection or infectious and not a lung cancer.  

Our greatest number of patients that we see in the clinic are largely asymptomatic when they are diagnosed with their early lung cancer especially and they're often found incidentally. 

They were getting a workout for an elective procedure like a hip replacement or something like that or they were in a car accident and had a workup for that trauma and that’s how the lung nodule was found. 

So, often, our patients are surprised when they come in and find out they have a lung cancer and their first comment is, but I don't even have a cough, I'm not coughing up any blood.  But these are not symptoms that are specific to lung cancer and oftentimes not seen in our early lung cancer patients. 

I think that we're going to touch a little bit later on lung cancer screening and how we can capture a good amount of asymptomatic patients with lung cancer, that specific risk criteria.  But I would say that, by and large, our patients don't walk in with a telltale lung cancer symptom that brings them into our office. 

David Jones:  I think that's a very good -- a good summary of that.  What about if a patient -- someone wrote in, Jessica, if a patient comes in and has excessive coughing, do you think that that's -- and they've had a history of lung cancer, does that new coughing, does that tend to make that their cancer is getting worse and how do they kind of workup this coughing? 

Jessica Marcus:  Yes.  So, I mean, I think the number one thing that we're going to do is get some imaging and be able to talk with real data about why you have this cough.  Certainly, there are types of lung cancer, stages of lung cancer that can cause a cough.  There's also treatments that we could have put the patient through, for instance, surgery that can cause a cough not because of the cancer but because of the treatment and we're certainly equipped to handle this symptom. 

We now actually have symptom clinics not only in Manhattan but in our regional sites where a patient can be seen very quickly for a symptom and get whatever necessary treatment or medication or intervention that they need.  Obviously, our offices are available by phone 24/7 and we can handle this. 

And then there's just excessive cough in a lung cancer patient that has nothing to do with lung cancer and we see that often.  So, if you have lung cancer, you have a history of lung cancer or you have no lung cancer history, usually the first thing I do is take a deep breath and get some imaging before we start talking about lung cancer or progression of lung cancer something like that. 

David Jones:  Yes, I agree.  I think that’s very good advice. 

Let's switch it up a little bit here and ask Dr. Hohl and also Jamie Ostroff, who's our Director of Tobacco Treatment Program and a valued member of our thoracic disease management team, to comment first about what do we know about COVID-19 and smoking. Maybe Dr. Hohl could do that and then ask Jamie to weigh in as well. 

Tobias Hohl:  Well, I think this is a very important and timely question.  We know now that individuals who smoke clearly have a higher risk of developing complications and more severe COVID disease.  

So, if there's one thing -- that’s clearly one thing, if you are thinking of quitting, now would be a fantastic time to do so.  So, not only is smoking associated with more severe disease and there's some interesting data that suggest, for example, that nicotine may increase the amount of the receptor on lung epithelial cells that binds to the virus.  So, that may be one reason for it.

But also, the question of whether if you're a smoker, does that increase your risk of acquiring the disease in the first place and I think that when you're smoking a cigarette or if you're vaping, you can't wear a mask if you're outside and you frequently touch your face or your lips with your hands. 

And so, I'm also concerned that the act of smoking may make it more likely that an individual in an environment contracts COVID-19 and we know that COVID-19 is more likely to be severe in individuals who smoke or vape or use marijuana for the reasons I outlined.  So, it's a fantastic time to take advantage of our resources and to help you stop smoking and to do this for your health and to prevent COVID and its complications. 

David Jones:  So, Jamie, any additional thoughts on this? 

Jamie Ostroff:  Yes.  I wholeheartedly agree.  It's now more than ever there are even more reason to consider quitting smoking and I'll just say that so much about both lung cancer and COVID-19 involves disruption and loss of personal control and quitting smoking is something that an individual can do to gain control and to protect themselves.  And certainly, now more than ever, seeking opportunities for safety is now more than ever important.

David Jones:  Great.  What about -- Jamie, we've heard a lot about trying to quit smoking.  What are we doing here at Memorial and what are you doing specifically with your program that can help people stop smoking which we know is probably one of the best things we could do to prevent developing a lung cancer and maybe why is it really important right now.  You touched a little bit on this already. 

Jamie Ostroff:  Yes.  No.  Thank you.  It's a really good question and I'm really glad to particularly answer it for our participants today because individuals are going to be asked about smoking and I know that this question often feels like it's irritating. 

And I want to say the reason that we ask about smoking is obviously not to make people feel badly but in fact we -- smoking remains the single most preventable cause, not the only cause but the single most preventable cause of lung cancer and we know that -- so, that factor is one thing.   

But even more importantly is that there is ample research that patients who -- patients with lung cancer who quit smoking at the time of diagnosis have reduced treatment side effects, they have reduced risk of recurrence, progression of their disease.  They have better pain control.  They have better quality of life.

So, I and other colleagues in our Tobacco Treatment Program, we see smoking cessation as an opportunity for patients to be active partners in their cancer care.  And just like we think about our molecular, our biologic colleagues, our medical oncology colleagues, treating the whole person means understanding what does somebody bring to the table if you will and if you have struggled with tobacco dependence, we have treatments and we are there to support and help patients and their family members. 

David Jones:  Great.  What about vaping or e-cigarettes? I mean, they're very popular now and sometimes adult smokers are using them to try to quit and how safe is vaping or these e-cigarettes and is there any data out there that suggest that they're linked to developing lung cancer or maybe if not lung cancer, other diseases of the lung that over time could perhaps develop into or are associated with lung cancer? 

Jamie Ostroff:  David, such a good question.  I think the best way I can answer that is to think -- is think of this question as this is -- vaping and electronic cigarettes, for those that may not be aware, are relatively new type of tobacco product and in fact, they are vaporizers, vaping pens, hookah pens, e-pipes and they're all battery-powered devices that often look and feel like cigarettes.  But instead of burning tobacco like regular cigarettes, electronic cigarettes use cartridges filled with a liquid and that liquid contains nicotine flavoring and other chemicals. 

And so, the key here and I should also say that while they are considered to be tobacco products, they are not regulated by the FDA and much of the challenge about electronic cigarettes has been that we are still learning about the potential risks and benefits of these products. 

But to specifically answer your question, I have to do it in two parts.  The first is that for adolescents and young adult never smokers, we used to think that these products were certainly safer forms of nicotine delivery.  We also recognize that they contribute to nicotine addiction and make no mistake, JUUL, which is the most common electronic cigarette device used among adolescents and youth, packs quite a nicotine punch and there is no doubt that adolescents and young adults are finding themselves casually experimenting with vaping and then finding themselves just as, if not, more addicted than individuals with cigarettes.

So, JUUL use is common and addiction is certainly the name of the game.  Last fall, some of you may remember that there was a health crisis around electronic cigarettes and serious life-threatening lung injury was observed particularly among young adult vapers and much of this was related to the chemicals that were in the electronic cigarettes, which had been hacked and tampered with.

But we don't consider them safe.  We consider them to be safer than traditional cigarettes.  But as a parent, I certainly would recommend non-use.   

The question -- the answer for adult smokers is a little bit more nuanced.  So, first, I want to say, there is no compelling evidence that vaping helps smokers quit.  That said, adult smokers who are concerned about their tobacco do use vapes to manage nicotine withdrawal, to reduce their exposure to harmful chemicals in regular tobacco smoke, to cut down and sometimes even to keep from starting to smoke again or prevent smoking relapse. 

What I typically will say to our patients is we have a wheelhouse of safe and effective cessation behavioral strategies and medications and we want to recommend what we know as safe and effective.  So, there is not a strong recommendation for -- we do not recommend electronic cigarettes as cessation tools.

David Jones:  Great.  What about -- Jamie, I hear this often, the spouse is there with the patient and is trying to encourage them to quit smoking.  What are kind of some of the dos and don'ts for trying to support patients as they try to initiate smoking cessation programs? 

Jamie Ostroff:  Right.  Thank you.  This is really one of my favorite questions because it is so common and let me first start with the don'ts.  I'm sure you can imagine if -- that nagging and criticizing just don’t work. 

All smokers, all individuals that struggle with nicotine dependence know that it is risky and dangerous.  And so, nagging only tends to make people feel more demoralized and feel inclined to hide or not [fair] that they're struggling or not seek help. 

So, the dos are to first start with really a heartfelt sit-down that always begins with something like, I care about you, I know that you're scared, I know it's hard to quit but I and -- I will help you get assistance in quitting smoking.  So, always start from that well-intended place. 

The other things that a loved one can do is to be empathic.  This is a bear of an addiction to nicotine and a psychological dependence.  I often tell people, imagine for 40 years, you practiced something 20 times a day, that’s the number of cigarettes in a pack of cigarettes.  How much of an expert you'd be? 

So, being empathic about the challenge of becoming smoke-free is really important.  And the last thing I would say is that if somebody is a loved one that also struggles with tobacco to really work together to have a smoke-free home and a smoke-free car and be your smoker's best cheerleader and your most heartfelt support because that's what they really need from you more than -- probably more than anything. 

QUESTIONS AND ANSWERS

David Jones:  Great.  Thank you.  Thank you very much, Jamie.  I'm looking at the questions here and one question that probably would go to Jessica again, what -- one of the writers asked, what are some of the basic things that we could do to keep our lungs healthy and maybe specifically, are there any breathing exercises that are recommended following surgery or treatment if they're concerned about their lung health?  Jessica, any thoughts on this? 

Jessica Marcus:  Yes.  So, we do use a machine called an incentive spirometer to help give our -- give patient's lungs after surgery some additional exercises to help build up their strength and their stamina after a surgery. 

This can be helpful even preoperatively.  So, we do give it to patients a few weeks ahead of time so they can start.  But I think the surgeons would agree that the number one thing you can do preoperatively and postoperatively is some exercise, some walking.

Really, getting your heart rate up and therefore giving your lungs a work out and it's as easy as walking around your neighborhood, walking around your house if you have to, and just getting your lungs in the best shape that they can be in before we have to give them any treatment and then helping you bounce back from surgery and prevent a whole slew of side effects that you don't want can be as specific as just walking. 

I think the basics of keeping our lungs healthy, which is the question, is also, as Jamie touched upon, not using any tobacco, exercise and also just making sure that if you do end up in our offices, you're in the best shape that you can be in from a lung standpoint but also from a health standpoint and that is before you have to walk into our offices, keeping up with your health with any chronic conditions that you have. 

When you walk into our office and we schedule you for surgery, it's not the time to start getting your blood pressure or your blood sugar under control.  If you could do that now and show up as optimized as possible, it will be to your benefit as making you a candidate for whatever treatment we need and also helping you recover from whatever treatment that we can give you. 

So, the basics, no tobacco, exercise and just keeping up with all your normal health markers. 

David Jones:  OK.  Terrific.  Terrific.  Helena, I -- we had a couple questions about natural health aids and in particular, one listener asked, does vitamin A have any positive role in lung cancer prevention?  So, even preventing lung cancer.  I know there is some data on that from an older trial.  Can you comment on that, Helena? 

Helena Yu:  Sure.  It's a question that I get all the time with my new patients, I think, of course, people want to do whatever they can either to prevent cancer, lung cancer, or if they end up developing lung cancer, what can I do to help increase my odds of sort of successful treatment. 

I think that there are older association studies where we look to see in different populations what is the likelihood of getting lung cancer.  And so, there were some kind of decades-old studies that looked at potentially people who eat more fruits and vegetables and had higher beta-carotene levels, which is the vitamin -- essentially vitamin A, did that decrease their risk of lung cancer. 

And in those association studies, it actually did, but then there was a study called the CARET study, clever name, that looked at beta-carotene and vitamin A and whether there was -- by giving patients vitamin A, where they able -- randomizing patients to receiving vitamin A or not where they able to improve or prevent lung cancer and actually was a negative study where it was stopped early because there really was no benefit to the vitamin A supplementation. 

So, I usually counsel my patients, I think, a normal, healthy balanced diet.  Of course, full of fruits and vegetables is always recommended and I think the stronger and cleaner your body is, the better it is going to withstand whatever treatments are required to treat the lung cancer. 

And then I echo what Jessica said about exercise.  I think the more kind of functional and strong you are, really the better that you're going to do.  And I guess I would use this opportunity to also plug our Integrative Medicine colleagues.  Any time patients are interested in herbs or supplements, there's always a concern that those might interact with cancer treatments. 

And so, in that case, I always refer them to our Integrative Medicine department and they're really skillfully able to kind of see -- instruct the patients as to what supplements could be really helpful and where there's data that they're safe to use and then, obviously, sometimes they say, no, not the supplement.  And their website is about herbs, you can Google it and that also has some information but they're a great resource. 

David Jones:  Great.  Great.  Let's talk a little bit now perhaps about lung cancer screening.  Over the past few weeks, we had some updated guidelines and there's been some recent publications regarding the NELSON trial. 

So, maybe I'll start with Dr. Park and ask him what these new guidelines suggest and who's really eligible for lung cancer screening.  Bernie? 

Bernie Park:  Yes.  Thanks, David.  Really timely question and excellent question.  So, for the audience, the NELSON trial was sort of the European equivalent of our National Lung Screening Trial that was done here in the United States and both trials were looked at whether screening patients that were felt to be higher risk for lung cancer reduced the lung cancer-related death rate and both studies did show that routine screening of patients that did not have symptoms and that were felt to be high risk reduced the death rate from lung cancer in the group of patients that were randomly assigned to have screening. 

So, both studies really showed that lung cancer screening is effective in identifying cancers at an earlier stage and saving more people's lives from lung cancer. 

With this information and some other recently discovered information, the United States Preventative Services Task Force just drafted a revised set of recommendations.  So, after the National Lung Screening Trial results several years ago, they recommended that patients that were between the ages of 55 and 80 and that had smoked the equivalent of a pack a day for at least 30 years and quit -- either not quit or quit less than 15 years prior benefited from screening, and so, they recommended screening in those patients.   

Well, really literally, just a day ago, the task -- the U.S. task force revised its recommendations to lower the age range.  So, now, they're recommending patients between the ages of 50 to 80 and they also lowered the amount of tobacco exposure.  So, they reduced the smoking -- the tobacco exposure requirement to the equivalent of one pack per day for 20 years.

And what that -- that was based on not only the results of the NELSON trial but they also had commissioned a systematic review of the literature of other published trials as well as they also commissioned actually an analysis to look at the potential reduction in lung cancer mortality if these new guidelines were adopted. 

And really, the significance of these amended recommendations is that it's going to make a lot more people eligible for screening and interestingly, it also will increase the number of minorities such as African-Americans and Latin-Americans as well as women that would be eligible for screening because it's well recognized that in some of these populations, actually lung cancer rates are higher at a lower tobacco exposure.

So, in theory, it is going to really expand the patients that we can identify early lung cancers and be able to intervene and save more lives.  So, really the next hurdle with the screening is getting the Centers for Medicare and Medicaid Services to and then the private insurers to reimburse for these new expanded indications, number one; and number two is actually getting patients to go get screened because that’s actually our biggest -- one of our biggest hurdles is getting people actually -- that fit the criteria to actually go get screened. 

David Jones:  Bernie, could you tell the audience kind of how long a screening CT last and kind of what the equivalent kind of radiation dose is.  A lot of patients I find are uncertain about the radiation exposure and do they have time -- enough time in the day to get this done.

Bernie Park:  Sure.  That's really a great question.  Basically, lung cancer screening is very easy.  Actually, at Memorial, we have some digital tools that allow patients to find out if they're eligible within just like three questions basically online and it does require a basically a five-minute visit with a practitioner just to make sure that they're eligible. 

But now, in the era of -- one of the silver linings of the pandemic is that we recognize that that could be done as a telehealth visit because it does not require physical examination, just a couple of questions and then discussing what the risks of and benefits of screening are.

And then the CT scan actually is a non-contrast five-minute scan.  So, actually, if you added up the entire time that it would take to do screening, it amounts about 15 minutes plus travel and the nice thing about Memorial is that we have -- all the screening scans can be done as well in the regionals.   

So, odds are that most of our patients in the tri-state area probably live within 20 minutes of one of our centers.  So, I would say conservatively, if we add it all up, it might take an hour for the entire process. 

And so, it's very convenient and there's really no reason not to be screened.  And insurance, if you are eligible, will cover it and so there will be no out-of-pocket cost to that.  So, very easy and simple to do it particularly through our MSK lung screening program.  

David Jones:  Yes.  I think this is just terrific.  It's very underutilized and probably it's the single most thing that we've seen to date in terms of saving patients' lives from lung cancer. 

We're going to move on and address a question someone asked about proton therapy here at Memorial Sloan Kettering and do we do much proton therapy at Memorial Sloan Kettering specifically as it relates to treating lung cancer. 

And I would say the answer is yes and as an institution, we've made a huge commitment to open up our very own New York Proton Center which we did in August 2019 and this is fully operational now here in Manhattan and we can actually treat upwards of about 110 patients a day.

And we're increasingly using proton therapy, which is a type of radiation therapy, because the damage from -- to normal adjacent tissues that are adjacent to the tumor is minimized because the amount of exit energy, if you will, from the protons to the normal healthy tissue is minimized significantly. 

So, in lung cancer patients, we treat tumors often with proton therapy when they’re near important structures, things like the aorta or the heart or the spinal cord and we've had a really amazing successes.   And part of that is through a commitment to excellence by hiring Dr. Charles Simone who we recruited from the University of Maryland a few years ago and now leads the New York Proton Center from Memorial Sloane Kettering.  So, we actually have probably one of the, if not, the world's experts leading that center and I think we'll see more proton therapy for lung cancer for sure. 

Let's see some of the other questions.  One of the listeners asked, what is respiratory therapy and is this offered at Memorial Sloan Kettering.  Jessica, could you answer that, please? 

Jessica Marcus:  Sure.  Respiratory therapy, I think what this patient is asking would be a professional, a respiratory therapist that would visit the patient after surgery, help them utilize that incentive spirometer, that lung exercise, make sure that they're breathing easily if they need oxygen or any type of inhalers or nebulizers, this should be the person that would help them.  Any type of chest PT or anything like that, this would be the person. 

We also have an occupational therapy and physical therapist that would come and visit you in the hospital, make sure that by the time that you leave the hospital you're able to walk around, do everything that you need to do at home and be relatively independent. 

To talk about the Integrative Medicine Program at Sloan Kettering, when you leave the hospital, if you were having any symptoms, there are exercise programs, there's also pulmonary medicine, lung medical doctors if you need any type of medications or help with your breathing after surgery. 

But just so very briefly say that a very common fear that I deal with with patients that are going to have lung surgery is in what condition we're going to leave them with -- in after the surgery and most of our patients do not require oxygen.  They are up and about the day after surgery, walking around and are independent, maybe a little sore but independent when they go home just as a general rule. 

So, your surgeon could, of course, based on your particular case and what lung function you're bringing to the table, help you understand how you would anticipate feeling and what your breathing would be like after surgery.  But I think the fear that lung surgery leaves you debilitated is real and, yes, that’s not how our patients end up after surgery.  So, just to give that. 

David Jones:  Great.  Great.  Maybe finally, Helena, one listener asked and lung cancer still is the leading cause of cancer deaths in both men and women here in North America and around the world but the numbers have decreased over the past several years.  So, what's really caused this decrease in dying from lung cancer?  What do you think, Helena? 

Helena Yu:  Yes.  I think it was really exciting when this came out and it's why I love my job and I'm sure all of you guys love your job is that we are making a difference and to see something tangible like that was really exciting. 

I think it was -- the main reason for that decline I think we talked about earlier, I think it really is in the last 10 years the advent of both targeted therapies and immunotherapies have really revolutionized the way that we treat lung cancer and they impact survival.  Both of these types of treatments are so effective.  We are both curing more people but also helping people that have lung cancer that's incurable to live longer with their disease. 

And so, I think it really is just chipping away at, for targeted therapy, really identifying the drivers to people's cancer and being a little more elegant about figuring out what makes each person's cancer tick and addressing that versus kind of a one-size-fits-all treatment. 

And then I think immunotherapies are so neat in the way that we're really harnessing the body’s -- our patient's own body's power that using our own immune system and white blood cells and finding a way to activate our body cells to kill the cancer. So, I think that's just really such a novel way to treat cancer that we weren’t able to do five years ago, 10 years ago and I think that it's just a testament to sort of development of new treatments. 

And I think with all of the clinical trials that we have ongoing at MSK like I mentioned before, I think we're not just satisfied with those improvements, we really are kind of seeking for what's the next step, how can we move the needle even further. 

So, I think it's a really exciting time to be caring for patients with lung cancer and if someone's unfortunate enough to develop lung cancer, I think we have more treatments than ever to try to help them during their journey. 

David Jones:  I agree, Helena.  I think lot of advances in targeted therapy and immunotherapy and on the surgery side, we certainly have seen a lot of compelling data that getting these operations done minimally invasively either robotically or with VATS or thoracoscopic approach actually decreases their likelihood the tumor would come back and improves overall survival as well. So, I think a lot of improvements on all aspects of how we treat and diagnose lung cancer

Helena Yu:  Definitely. 

David Jones:  I think we're just about done.  I'd probably like to thank everyone who's with us today on the call and particularly those who submitted questions.  We really appreciated that. 

I think on behalf of my colleagues, I think we all hope that you found this session to be informative and helpful.  And I really want to thank the speakers who took time out of their really busy clinical day to spend time with you, trying to answer your questions and who gave a great conference. 

We'll certainly be hosting more calls like this in the future.  A replay of this call will be available on our website shortly and would urge you to visit it often for the latest updates.  Again, that mskcc.org. 

So, with that, I'll just remind you, we're dedicated here at Memorial, all the clinicians here on the call and everyone else, to moving your cancer care forward and encourage you to be in touch with your MSK doctors, nurses and care teams. 

So, with that, be safe, take care of yourself and your loved ones.  And thank you again for joining us today for this session on lung cancer and lung cancer health. 

Operator:  This concludes today's call.  Thank you for joining Information Session for Patients and Caregivers.  Have a good evening.