New Lung Cancer Screening Tool

In this episode, Dr. Rami Zebian, a pulmonary and critical care specialist and Chief Medical Officer of MUSC Health Florence and Marion Medical Centers talks about lung cancer screening and the shape-sensing robotic-assisted bronchoscope tool that is helping them detect and stage lung cancer sooner.

"(With robotic bronchoscopy) by the end of the procedure, we can tell someone if they have lung cancer, what stage it is, and we have already made some calls. We have oncologists, we have radiation oncologists, we have CT surgeons, we already have arranged that plan for them so that there will not be a delay. Every day matters, right? If someone has lung cancer and if we can decrease that time, get a diagnosis early on, do staging at the same time, that's a big game changer for us."
- Rami Zebian, M.D.

Topics covered in this show

• Lung cancer is very common and is the leading cause of cancer deaths, mostly because it is often diagnosed at a later stage when interventions are not as successful. Zebian wantsto find ways to diagnose lung cancer sooner, to help improve outcomes for patients.
• Lung cancer screening is more difficult to achieve as compared to mammograms for breast cancer screening or PSA tests for prostate cancer. Zebian’s team has found that with low dose CT scans, they can detect lung nodules that could cause cancer. They are doing these screenings for patients who are asymptomatic, but at higher risk for developing lung cancer. If they spot a lung nodule, it doesn’t necessarily mean a cancer diagnosis, but it gives the doctors an indication that they should watch it and look for issues down the road, hopefully, resulting in earlier lung cancer diagnosis.
• Smoking is by far the leading cause of lung cancer, but family history and exposure to secondhand smoke, radon, pollution and asbestos can cause lung cancer as well.
• Lung cancer has been rising in women, possibly due to ad campaigns promoting weight loss for women through smoking.
• Zebian has never had a patient who said quitting smoking was easy, but every patient said they wish they had quit sooner once they do. MUSC Health offers smoking cessation programs for patients trying to quit.
• Nationwide smokers account for about 14% of the population, but in South Carolina they are at about 20% of the population. Zebian has heard from patients that higher smoking rates in South Carolina may be related to tobacco farming in the area, and how it has offered financial success for many people living there. Moreover, the weather is nice in South Carolina, which allows people to step outside for a cigarette more easily.
• Robotic bronchoscopy is a minimally invasive procedure that allows for specialists to see deeper in the lung. If they find cancer, they can sample the lymph nodes to find out what stage it is and immediately get a team of doctors in place to treat the cancer. This is a game changer for doctors.
• Patients who receive a robotic bronchoscopy can arrive in the morning and leave the same day, and have an immediate answer about a lung cancer diagnosis. This allows doctors at MUSC Heath to deliver the best, local care that they can.
• Zebian stresses the importance of confronting a possible lung cancer diagnosis head on, instead of putting it off, as earlier detection of the cancer leads to better outcomes for the patient.

Read the show transcript below

Erin Spain: [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Every year, more people die from lung cancer than colon, breast and prostate cancers combined. Doctors and researchers at the Florence Medical Center at MUSC Health are working hard to change this statistic. And now they have new technology that will allow them to diagnose lung cancer at earlier stages in a less invasive way with fewer complications. MUSC Health Florence Medical Center is the first in the state of South Carolina to use this technology called shape sensing robotic assisted bronchoscopy. Dr. Rami Zebian, a pulmonary and critical care specialist and Chief Medical Officer of MUSC Health Florence and Marion Medical Centers is here to talk about lung cancer and this game changing new tool he and his colleagues are using. Welcome to the show, Dr. Zebian.

Rami Zebian, M.D.: [00:01:04] Thank you, Erin. Thanks for having me today.

Erin Spain: [00:01:06] Can you describe lung cancer to me? Describe it in its common forms?

Rami Zebian, M.D.: [00:01:10] Yes. Unfortunately, lung cancer is very, very common, very prevalent in our community. And lung cancer is often because of a sad story. Lung cancer is the reason why we have a lot of empty seats on dinner tables, and it is sad that we are not able to cure everybody with lung cancer. Lung cancer patients need a lot of support from families, but there is more that we can do to impact their lives and the lives of their family members or people who had loved ones who have had lung cancer.

Erin Spain: [00:01:42] It is such a deadly cancer. Lung cancer is the leading cause of cancer death by far making up almost 25% of all cancer deaths. Why is it so deadly?

Rami Zebian, M.D.: [00:01:52] I think that is one of the biggest reasons why we're doing things differently about lung cancer. Lung cancer is often diagnosed in a later stage. Stage three and stage four. And when you get patients in stage three or stage four and it has already spread, then I'm not saying we don't have treatments; we can still offer treatments for people with advanced lung cancer. We still have we have newer technologies. We have newer tools. However, the best chance at cure is that early diagnosis of lung cancer. We talk a lot about stage shifting and lung cancer, and that's really important. How can we diagnose patients with lung cancer at an earlier stage? See, because the lungs as organs, they live inside our chest cavity. They're protected by the bones, by the rib cage. It's the inside. If somebody has a tumor in their lung, you can't see it. And most of the time, at early stages of lung cancer, there's really minimal symptoms. It's different with breast cancer where somebody may feel, hey, I was taking a shower, I felt a lump. And every woman knows that at a certain age we're going to do a yearly mammogram, and it becomes part of a natural thing that that we do. We do our yearly mammograms. Women are encouraged and educate on self-examination, and people can tell. But that's why we're doing things a little bit differently. So we talk about lung cancer screening and trying to diagnose lung cancer early on to impact that mortality and decrease the chance of people dying from lung cancer.

Erin Spain: [00:03:21] So who is getting screened for lung cancer these days and how do these people come to you?

Rami Zebian, M.D.: [00:03:26] So lung cancer screening is relatively newer in the medical literature. We know that everybody knows, hey, when you come by a certain age, you may get a mammogram to diagnose breast cancer. People get a colonoscopy for screening for colon cancer. And there has been a lot of research and study about what are the tests that can be used for screening. And people tried X-rays and that trial did not show a benefit. And then people talked about CT scans and said, well, what about the dose of radiation? And now there's a new protocol with what's called low dose CT scan. And by low dose, I mean low dose radiation. Right? Because everything that we do in medicine has risks and benefits. And when we do, a seat has a higher dose of radiation. But we found that we can detect lung nodules with a low dose C.T. scan. So we have criteria and they just changed that and it is people used to be above the age of 65, now above the age of 55, people who are active smokers or have smoked in the last 15 years and people who have smoked for a long time, 30 pack year smokers. And I think it's important to differentiate screening from diagnosis. And we use those terms medically and they're very different. So when I say screening, that means someone who does not have any symptoms. I'm not saying, hey, I need to find out, do a test to find out why someone has a cough or why someone as short as a breath. Screening is for patients who are asymptomatic or do not have any symptoms, but they're high risk, right.? And we find a lung nodule. And that is a very common term that we use a lung nodule. And I've seen people that are colleagues or family that they get alarmed or I have a lung nodule, I'm scared and it is very scary. And we that's why we try to expedite seeing those patients. Most of the time we do reassurance. I think of a lung nodule as a spot on the lung. If I take 100 people off the street right now and do scans maybe close, a little bit less than half of those folks would have a lung nodule. If you think about the lungs that are filter and anything you inhale ends up in your lungs. So it could be particles and all the infection. So majority of lung nodules are not lung cancer and will never be lung cancers, but majority of lung cancers start as a lung nodule. And that's why it's important when we have a nodule or a spot on the lung that we follow it up. We see what we need to do, diagnose it, try to get diagnosis of lung cancers early on, which offers the best chance of cure.

Erin Spain: [00:06:02] You know, you mentioned smokers and of course, smoking puts you at risk for lung cancer. What are some of the other demographics that you see in people who are diagnosed with lung cancer?

Rami Zebian, M.D.: [00:06:12] So smoking is by far the number one risk factor for lung cancer. And smoking can be first hand smoking or secondhand smoking. So if you live with someone that is a chain smoker, you know, there are some people that say, hey, my grandpa lit his first cigarette in 1970 and has not turned it off; they do chain smoking. So if you live with someone who smokes that much, you're exposed and you're at risk for lung cancer. There are some other environmental factors like radon, there's pollution, and there is one subtype of lung cancer, which is called adenocarcinoma that is not specifically associated with smoking. Some genetic factors may play a role in that. So definitely smoking, family history of lung cancer, or other risk factors. Or if we live in an area where there is a lot of lung cancer. So we think about is there environmental factors or is there some pollution going on that is causing it. Asbestos is also a risk factor for lung cancer, although it's more known to be a study with mesothelioma that you hear that on TV, but asbestos can cause lung cancer as well.

Erin Spain: [00:07:26] A really interesting statistic from the American Lung Association: lung cancer diagnoses have been rising dramatically and women in the past several decades while dropping and men over the same period. Why is that happening? Why are more women being diagnosed with lung cancer?

Rami Zebian, M.D.: [00:07:41] Unfortunately, smoking was more common in men previously, and the good thing is not recently, but before it was more hip or more cool for women to smoke. You see advertisements. I remember I went to a museum and they had an auction and some of the older magazines were still there that you can buy them. And you can see at the cover of the magazine how it's an advertisement for smoking, allowing weight loss for women. And, you know, this is the most common cigarette for women. So that is an unfortunate thing. Women started smoking and had more incidence of lung cancer. People know the risk factors and it is hard, right? I have never had a patient that quit smoking that has shared with me that this has been the easiest thing they've done. Or somebody told me, "Oh, quitting smoking was so easy. I've been doing it for years and it was so simple." But all of those patients, all of them have told me, I wish I quit sooner. And although it's never too late to quit, quitting sooner will be a game changer in a lot of things decreasing the chances of COPD, lung cancer, heart disease, stroke. I've become friends with a lot of my patients and one of them shared with me that she still has one of the prescriptions that I gave her years ago, and I wrote on a prescription pad at the time, "Stop Smoking." And I gave it to her and she said she still has it on her fridge and that's how she quit smoking and it worked for her. I don't think that will work for everybody. We have some medications that can help with smoking cessation, but we share a laugh every time I see her in clinic.

Erin Spain: [00:09:22] And smoking is still very common in South Carolina as compared to other states?

Rami Zebian, M.D.: [00:09:26] That's correct. Partly related to tobacco farms. I hear a lot of people that say, "hey, I put my kids through college from tobacco farming." South Carolina also is a state where the weather is pretty today. People can go outside and people can need to be outside for smoking. But I have hope. I think that there is more education. I see the younger crowd really moving away from cigarette smoking. It's not the cool thing anymore, which I'm not saying that people who smoke are bad people, but it is an influence piece, right? If you're among a group of people that all smoke, you're more inclined to pick up a cigarette. So we're hopefully moving away from that. You know, when we look at hospitalized patients that are smokers, nationwide about 14% and we looked at the number of smokers and our hospitals across the MUSC, at least in our division, Florence and Marion was higher than 20%. So we have work to do in decreasing the chances of smoking.

Erin Spain: [00:10:29] Well, another reason to be optimistic is this new technology that you've been able to bring to Florence, and it's called robotic assisted bronchoscopy technology. Tell me about this, how it works and why this is a game changer for you when it comes to not only screening, but diagnosing lung cancer and staging lung cancer?

Rami Zebian, M.D.: [00:10:48] It definitely is a game changer. So the lungs are, it's like a puzzle or you have airways that start very large and then become very, very smaller airways. And traditionally, when we have bronchoscopy or traditional bronchoscopy, which is a small fiber optic scope that just travels in the lungs, that traditional one cannot go further. And when you have a lung cancer that is early stage, it may be further deep down in the lung. And when you have a robotic bronchoscopy that can travel much further in the software, we mapped the CT scan that was done for the patient and it creates like a GPS route and will guide which way to go the catheter because it's shape sensing and it it will stay in that location. We can travel much further to almost the edge of the lung. And when we do that, we find out what it is. If it is lung cancer, then we go ahead and do staging at the same time. So if we find out that someone has lung cancer, we can sample the lymph nodes in the chest and find out what stage this is. And if we can find out that someone has lung cancer early on, find out what stage it is in the same session because our pathologists read the samples that we get immediately while we're doing the procedure. So by the end of the procedure, we can tell someone if they had lung cancer, what stage it is, and we have already made some calls. So we have oncologists, we have radiation oncologists, we have CT surgery. We already have arranged that plan for them so that there will not be a delay. Every day matters, right? If someone has lung cancer and if we can decrease that time, get a diagnosis early on, do staging at the same time, that's a big game changer for us.

Erin Spain: [00:12:33] Because in the past, as you mentioned, the old way was much more invasive and it was a bigger procedure. Tell me about that.

Rami Zebian, M.D.: [00:12:40] Absolutely. So in the past, the way to do a diagnosis of lung cancer was surgical resection, where the surgeon will do an incision in the chest, get a sample of that, and then send it to pathology. It's usually in the hospital 3 to 5 days with some chest tube. And then we had radiology or radiology partners, which they still do; they do what's called a CT guided biopsy. So it's insertion of a needle from outside the chest to get that sample. Although it is less invasive, the chances of a lung collapse is about 20 to 40%. And we know how to treat it, we know how to fix it. But if we can try to prevent that with a chance of less than 1% when we do a robotic bronchoscopy plus doing staging at the same time, it's definitely a game changer for patients.

Erin Spain: [00:13:27] Now, you haven't had this technology for too long. Tell me what it's been like to use it and have you had any success stories so far?

Rami Zebian, M.D.: [00:13:34] We've been very pleasantly surprised how easy it has been. Patients come in in the morning, they leave the same day. There's no complications. We've been able to find a diagnosis early on and get patients connected with the system. And sometimes the diagnosis is that we confirmed lung cancer. Sometimes we had confirmation that this is not lung cancer and we had a few patients that we weren't able to get that diagnosis without this technology, sometimes the location of that nodule does not allow us to diagnosis with another technology. I think we've been happy that we have it. I believe that the community and the PD deserve the best. Whatever newer technology that we have, we have an obligation with MUSC to bring the best and latest technology here, locally. The best care is local and we want to do local care whenever possible.

Erin Spain: [00:14:26] So how are you combining this technology with your existing lung cancer screening program?

Rami Zebian, M.D.: [00:14:31] Yes. So we've had this lung cancer screening program and now it's across all MUSC sites. Started in Charleston. We have in Florence, Lancaster, are now in the Midlands Division. And with the eligibility criteria that we talked about before, people who are high risk for lung cancer smokers or previous smokers, age group and other criteria; when those patients have a CT scan, if we find a nodule that's suspicious enough that we need to find out what the diagnosis is, then we use this technology to find that out. The biggest thing is stage shifting. We can diagnose early, get patients at stage one or stage two. The biggest success stories we've had with lung cancer is when we find out lung cancer, when people have no symptoms, and if we wait till someone has cough that is not going away or coughing up blood or losing weight or having chest pain, those are usually signs of late lung cancer. Some of my patients had shoulder pain and went through a shoulder X-ray. And oh, by the way, we found out that you have a small nodule. So things that are found accidentally are the highest chance of success, or we have a higher cure rate. So we have surgery that can remove it. And we partner with radiation oncology where they do focused smaller dose radiation that can also cure early stage lung cancer. So it's all about stage shifting, early diagnosis, finding it early and offering the best chance of cure rate.

Erin Spain: [00:16:03] What would you like people to know? People who are listening, maybe their family member or someone who is at risk themselves. What would you like to say to them about lung cancer screening and what is offered at MUSC Health?

Rami Zebian, M.D.: [00:16:15] I would say that the most important thing is to face things head on. A lot of times people say, Well, if I don't know about it, it doesn't exist, and that is not the way to go about it. I've seen a lot of family members that say, well, they just didn't want to go to the doctor, didn't didn't want to get this addressed. I would say let's find out about it as early as possible to have the best chance for cure. I would like for patients to get screening if they're eligible for it. Let's talk about smoking cessation. We're not going to judge you for it, but we're going to help you. And if you have lung cancer, we're going to try to find it early. We're going to try to stage it and give the best possible chance of cure for lung cancer. We want them to get care locally. We have a team that's going to help them from the beginning to the end. Lung cancer journey can be hard, can be difficult. And we have a team that can do complicated procedures, the latest technology and adding clinical trials here in MUSC Florence. We owe it to the community and we're going to be here for them.

Erin Spain: [00:17:16] What do you do to optimize your health and live well?

Rami Zebian, M.D.: [00:17:22] I'm intentional about exercise. I schedule my classes or exercise and I have it on my calendar every day because otherwise I would not do it. It goes a long way. I feel more energetic. Already burned 800 calories this morning and I'm ready to go. I'm pumped and it will be a good day.

Erin Spain: [00:17:40] Thank you so much for coming on the show, talking about lung cancer in this new technology. And we really appreciate your expertise today.

Rami Zebian, M.D.: [00:17:48] Absolutely. Thanks for having me.

Erin Spain: [00:17:54] For more information on this podcast, check out advance.muschealth.org.