Lung Cancer Talk Transcript

Moderator - Tim Wenger: Direct from Roswell Park Comprehensive Cancer Center here in Buffalo, New York, this is Cancer Talk Live. I'm Tim Wenger, and this time on our session, we're going to discuss lung cancer screening. Yes, there is screening for lung cancer. You're going to find out all about it from these three people here we have assembled at Roswell Park, again, here in Buffalo, New York.

Throughout the course of the past several weeks, we have been selecting questions offline, getting them from the RoswellPark.org website. And throughout this webcast, we'll continue to select those questions using the #LCScreening. So if you have a question that does not come up, feel free to use that hashtag and you can reach out to the experts. Any questions we don't get to here tonight, the doctors and the experts will answer them for you directly individually following our webcast. With me here tonight we have three guests from Roswell Park Comprehensive Cancer Center. Dr. Mary Reid is here with us. Dr. Reid, thank you for being here.

Dr. Mary Reid: Thank you very much, Tim.

Tim: You're a Professor of Oncology and a Director of Collaborative Research, and you've been a pivotal leader in the lung cancer screening program here at Roswell Park. That's why you're here. Thank you. And by your side, we have Dr. Samjot Dhillon. Dr. Dhillon is the Chief of Pulmonary Medicine here at Roswell Park. Lots of questions for you tonight, and we appreciate your time in being here.

Dr. Samjot Dhillon: I'm ready for it. Thank you very much for the opportunity.

Tim: And over here next to me we have Pam Germain. Pam, you're the Vice President of Strategic Initiatives here at Roswell Park.

Ms. Pamela Germain: Yes, I am.

Tim: Lots of questions about access and what all this means and how patients or prospective patients or those interested in going through screening can gain access to what we're about to talk about tonight.

Ms. Germain: Thanks.

Tim: So, thank you for your time in being here.

Ms. Germain: Sure.

Tim: Again, that hashtag tonight is #LCScreening. Dr. Reid, let's start with you. When we hear about "lung cancer," we don't hear the word “screening” associated with it an awful lot. There is screening. You've been doing it for some time. But this is an initiative that Roswell has put together. Why is it so important and tell us about it.

Dr. Reid: Well, Tim, up until January 1st of 2015, lung cancer screening was not actually a national standard for the detection of lung cancer. Lung cancer is the biggest cancer killer. More people die of lung cancer than breast, prostate, and colon combined. And worldwide it is definitely the biggest killer. And one of the reasons is that without screening, the majority of lung cancer cases have been diagnosed at a late stage, where cure is really not an option.

There was a very large study completed in 2011 with over 50,000 Americans. And the results of this study showed that if we did an annual CT on people who are considered high risk, we could significantly reduce the mortality from lung cancer. And best yet is that the shift would be to about 70 percent of lung cancer cases being diagnosed when they're early, when surgery is an option, and when you can really get a cure.

Tim: So, who are we talking to here tonight? Who can undergo screening? One of the questions that we collected off of the website leading up to our webcast tonight is, "How do I know if I'm at high risk? And do I need to meet all of the conditions that you're about to tell us about to qualify for the screening that we're here to talk about?"

Dr. Reid: Well, to qualify for screening, you have to be between the ages of 55 and 80. You have to have an exposure to cigarette smoke that we call 30 pack years, which means you smoked an equivalent of one pack a day for 30 years; two packs a day for 15 years. And you have to have actively smoked in the last 15 years. You can be a current smoker. You can have quit smoking, but you have to have been an active smoker within the last 15 years. Those three requirements you do have to meet. Those are the minimum. But, of course, people are concerned because they have other risk factors for lung cancer, which we'll talk about more tonight, that plug into some of our surveillance during the course of screening.

Tim: The good thing is that the screening is initially done via telephone. So it's simply picking up that phone, calling Roswell Park. What can I expect when I make that phone call? And you're going to answer some of those questions that may determine whether I'm someone that would move forth, right?

Dr. Reid: Right. So, you can call and self-refer. You don't need a physician to refer you for screening. You can call in and they'll ask you, "Do you meet the age criteria, 55 through 80? Do you have that significant smoking exposure of equivalent to 30 pack years? And have you actively smoked in the last 15 years?" They'll also ask you questions like if you've ever had a history of throat, head and neck, esophageal, or lung cancer, because again we're very interested in monitoring you by CT to prevent extensive recurrence. We'll also ask you about whether you have any obstructive lung disease like COPD, emphysema, or chronic bronchitis. It's not a requirement to get into the screening program, but it is a risk factor for lung cancer. We will also ask you about significant asbestos exposure. Have you ever been diagnosed with asbestosis? Again, because that is a risk factor for lung cancer. And if you qualify with those minimum requirements of age, smoking, and active smoking within the last 15 years, they'll refer you on to schedule an appointment in our clinic.

Tim: All right. And there's a lot more information I know you're going to pass along throughout our webcast — different factors that are involved and what would advance someone through that screening process. Thank you.

Dr. Dhillon, I want to turn to you right now, because once we've gotten through that point, where we've talked to the experts at Roswell Park and we've determined that we're going to move on and go through this screening process, one of the questions logically submitted prior to tonight's webcast was, "What tests are done? How much time is needed?" This person is really asking the questions I think we're all asking. "What do I expect once I undergo this process?"

Dr. Dhillon: I think the first and foremost thing is to meet one of our health care experts, one of our health care providers. So, this will be a visit with a health care provider who will take a detailed history of the patient, try to understand all the risk factors for lung cancer, and then answer all the questions the patients have. The patients have a lot of questions, and everybody's history and risk factors are unique. So, we try to do our best to answer those questions.

And before scheduling anyone for the screening test, which is a low-dose CT scan of the chest, we want to answer all the questions that the patient has, tell them about the noninvasive nature of this test, update the patient about what are unexpected findings, that there could be nodules, how we can watch them, and prepare the patient for any findings that we can find on the CT scan.

The patient will be subsequently scheduled for a CT scan. This CT scan is without any dye, and therefore it's totally noninvasive. It's done with a low-radiation dose. And then, a few days later, once the patient has the CT scan, they meet the health care provider, one of our experts, again. And at this time, we review the CT scan with the patient in great detail, and then make a plan for further management.

The further management will depend on what we find on the CT scan. For example, if there are nodules, we may decide to do another CT scan in a few months or in a year. Or if we find something that merits a biopsy, we'll discuss what's the best way to approach that abnormal finding. Subsequent appointments will be based on the findings of the CT scan. Additional tests, including breathing tests, can be performed if the patient meets the criteria. We expect to see the patient within a week of the CT scan to discuss the results.

Tim: You mentioned something that I think is key — this is a noninvasive procedure. The CT scan is noninvasive — no pain.

Dr. Dhillon: Absolutely.

Tim: Not that anything like that should stop you for being screened for anything, but it's an important thing to note that if you do get to the point where you think that someone should be screened, it is noninvasive.

Dr. Dhillon: Absolutely. And I also want to state that this is a very quick CT scan. It's not an MRI. So please do not hesitate to have a CT scan with low-dose if you have claustrophobia or any of those concerns.

Tim: And then I know the fact that this is low-dose is also a concern, a concern in the reading of it. It's a very specific test, and it needs to be read by people who are used to reading this.

Dr. Dhillon: Absolutely. The reason the CT scan did not become a screening test for so many years was because of the radiation concerns. In the last 10 or 20 years, the technology has advanced to the point that we can now perform CT scans with very low-dose radiation.

Obviously, the centers performing these scans should have the expertise to do these tests properly. On top of that, these scans are not as crisp as the usual CAT scans, because you're using low-dose radiation. So, you need radiologists who are experts in interpreting these CT scans.

Tim: We have been collecting a lot of questions in the days, the weeks leading up to our webcast tonight using the #LCScreening, lung cancer screening, and also RoswellPark.org/highrisklung. One of the questions, Dr. Dhillon, that came from our audience, as most of these questions did and are coming from the audience - you mentioned nodules that can be detected in this screen. "Are small nodules on the lung a sign of upcoming lung cancer?"

Dr. Dhillon: Well, most of the nodules are not lung cancer. Unfortunately a lung cancer also starts as a nodule, so it's hard to tell which nodule is a cancer and which is not. We have to study the various characteristics of the nodule, the size, the risk factors, and then we make further decisions about whether a nodule has higher chances of being benign, and that just needs to be watched with more CT scans, or whether a nodule needs a biopsy.

Tim: All right. A lot more from this side. We want to move over here to Pam Germain. And, Pam, it's slow-down time, okay, because we all have questions about what can we do, what will our providers allow us to do, and what kind of coverage do we have. How does that all work in and fit in with lung cancer screening?

Ms. Germain: Yeah, that's a very key question. So, as Mary described the beginning of the process at Roswell Park, when you first phone in to ASK Roswell Park, and you're asked several questions to determine your eligibility, as Dr. Dhillon said, that is at no cost. If, however, it is determined that you meet eligibility requirements, and depending on your age, if you're in the eligibility age that Mary had described, then the insurance company issues start to come up. So, if you are under 65 and not a Medicare member, the regulation through Affordable Care Act, as of January 1st of 2015, makes you eligible and benefits would be covered for the consultation with the physician. And also for the low-dose CT, if that is what is determined by the physician that you need, that would be a covered benefit. Where we're still waiting to hear, of course, is Medicare eligibility is still to be determined. And we can talk more about that later. But for a person who is under a commercial insurance plan, you would have coverage with your normal deductibles for both a physician visit and for the low-dose CT if that is recommended for you.

Tim: I would think that it's important to note — I think you're going to agree here — that making that phone call to Roswell Park and going through the initial screening on the phone, we don't need anyone's permission to do that.

Ms. Germain: That is correct. It is self-referral, as Mary had said. It's definitely something that we would encourage. And I want to add that at Roswell Park we have been doing lung cancer screening for many years. There wasn't the regulation that now exists that encourages our whole population of citizens to seek this screening, but we have developed the infrastructure at Roswell Park to be able to do this intake very professionally, very quickly, very well-organized, and to really understand who it is who meets eligibility requirements that are now well-defined under the recommendations of the U.S. Preventive Services Task Force that the Affordable Care Act is now supporting.

Tim: We can't let us slow that down, though. We at least have to get to the point of asking.

Ms. Germain: Yes. Absolutely.

Tim: If we don't ask, we don't know.

Ms. Germain: Correct.

Tim: So thank you for that. Mary, one of the questions that was submitted is this: "I was an on-and-off smoker for 55 years and finally was able to quit six and a half years ago. Should I be screened for anything at my now-age of 75? So many of the people out there were products of the 50s, when smoking was considered okay."

Dr. Reid: The first thing to say is that you quit smoking, which is the best thing you can do to decrease your risk of lung cancer. And while we know that your risk never goes back to normal, quitting smoking brings about a significant 20–90 percent decrease in risk for lung cancer. And those benefits happen immediately.

But if you smoked on and off for 55 years, we would need to calculate your actual exposure. And we know that people who smoke don't always smoke the same amount throughout their lifetime. And if you meet the criteria of 30 pack years, you're over the age of 55, and you smoked within the last 15 years, you would be eligible to come in and go through the process of evaluation. I think it's important to say that you can get into the clinical appointment and know what the risks of having follow-up procedures are, learn about the CT, and you may decide that you don't want to have it. Although for someone who has a substantial smoking history, who's older, and who's smoked within the last 15 years, we know that there is a benefit to being screened with CT.

Tim: Dr. Reid, we’re here talking about lung cancer screening tonight, which I think is maybe not a surprise, but it's certainly not something common. We're used to hearing about breast cancer screening. We're used to hearing about ovarian screening. We're used to hearing about colon screening. We're here talking about lung cancer screening, which I think is exciting. And it brings up part of what this question is, submitted by one of our webcast viewers. And that is this: "Could I already be in the early stages of lung cancer, even though I have yet to encounter any symptoms?" It's really asking the question about how important early detection is.

Dr. Reid: Well, it's critical. Lung cancer doesn't really have a lot of symptoms until it's a rapid onset. And that, again, has led to, historically, late-stage lung cancers being diagnosed. That's what's very insidious about this cancer. You know, we would love to be able to take a scrape of the inside of your mouth or draw a blood sample and know who's going to be at risk for lung cancer from people who've smoked and haven't smoked. That would be the ideal, and from a research perspective, that is what we're hoping we'll find - a biomarker for lung cancer in the future. But since we don't have that, our CT offers the best option. And, again, we're focusing on high-risk people because the majority of nodules that are found, even in this high-risk group, will not be cancer. But this particular high-risk group offers us the best chance of finding tumors.

Fifty percent of lung cancer cases are now among people who quit smoking, especially within that first 15 years of quitting. And so we know that quitting smoking is not the only way. It's not a surefire way to decrease risk of lung cancer. But clearly we have a lot of emphasis on people stopping smoking. The longer you're exposed, the higher your risk for lung cancer is, and the higher the risk is for people who are around you when you smoke. And so we do have a big emphasis on cessation, but that's not going to solve the whole problem.

We know from research that you do damage to the inside of your lungs when you smoke. Some people can repair that damage. Only one in nine smokers actually gets lung cancer. The other nine get other diseases like cardiovascular disease, kidney disease, other cancers, peripheral vascular disease. There's a myriad of other ailments. Having smoked is not a guarantee for lung cancer, but, again, there is some damage that you do that your body cannot repair, and you can go 15 years of quitting and still develop lung cancer.

Tim: Dr. Dhillon, Dr. Reid has been talking about early detection. In all of my years involved with all of you great experts here at Roswell Park, never has one said it's better to wait than it is to find out something early.

Dr. Dhillon: Absolutely.

Tim: Early detection is key. And from a clinical standpoint, can you talk about how important early detection is? And obviously that plays right into why someone who qualifies for this would undergo the screening.

Dr. Dhillon: As we already know, lung cancer is not a good cancer to have. The prognosis, or the survival, depends on the stage at the time of diagnosis. Unfortunately, more than two-thirds of lung cancers are diagnosed in the late stage. The late-stage lung cancers do not do very well. Our goal is to try to diagnose lung cancer in the early stages. So, by doing screening, we want to shift the stage from stage 3 and 4 to stage 1 or 2 by diagnosing lung cancer early, where it can be treated in a better way and where prognosis is good. Therefore, early detection of lung cancer is very important.

We also know that lung cancer does not come within a day or two. It slowly grows. It starts as a nodule or a premalignant lesion, and it grows slowly over months. And therefore we do have time to detect it. And the sooner you detect it, the better it is. And low-dose CT is the most promising technology to date to diagnose these growing lung cancers in the earliest stages, the stages where this is curable. And that's why it's so important to diagnose at the early stages with screening.

Tim: Dr. Reid brought this up in her response to the previous question. And someone follows up and asks this question a different way and quite simply, "Can your lungs recover after you quit?" So, that last person that we just referred to their question, I think they had quit six and a half years ago. Do the lungs recover after quitting?

Dr. Dhillon: The best thing to do is never to smoke. But if somebody has smoked, it's always important to quit. And the sooner you quit, the better it is. People who quit before age 50, their chances of getting lung cancer goes down significantly.

In fact, the beneficial effects of smoking cessation are immediate. Within 20 minutes of stopping smoking, people start having slight dilation of the blood vessels, which are tightened because of smoking. And within 24 hours, the carbon monoxide level starts going down. Within one to nine months, often shortness of breath symptoms start to improve and the lung functions may show some improvement also. In addition to that, within the first one to five years after quitting, the risk of heart attack goes down, the risk of cancers of the esophagus/throat cuts down into half, and after 10 years or so, the risk of lung cancer goes down to half. After smoking cessation for around 15 years, the risk of lung cancer goes down by 70–90 percent.

So, the answer is it never goes down to 0 percent. There is always a slightly high risk of lung cancer in those who have smoked, but there is significant reduction as time passes after cessation of smoking. So, the earlier you can quit, the better it is.

Tim: All right. We have been asking for questions out there in Twitter world, using #LCScreening, lung cancer screening. And a couple have come in so far during our webcast this evening. One question that we have before us right now coming in is in regard to radon exposure. For those out there in the web world watching us right now in the Western New York area, radon is a concern locally, and I know in other parts of the country, as well. Talk to me about radon exposure. Is it a factor?

Dr. Reid: It is a factor. If you look at the areas of the country with the highest radon levels, we are definitely in it. It stretches across the U.S. through Montana and Idaho up to Washington state. Radon is the second-leading cause of lung cancer. If you smoke, you see about a tenfold increase in risk of lung cancer with a significant radon exposure.

It's a gas that's produced naturally from the degrading of uranium in our soil. And the gas comes into our house when our cellars flood, which also is a very common occurrence in our region. Preceding the water is the radon gas, if you've bought a house, if you have an eradication system put into your home, if your levels are above the levels that are deemed safe. But we do see a lot of variation from house to house and neighborhood to neighborhood. And I think one thing - I know there was a question about someone who had lived in their house for 30 years, which is also not uncommon here - is that you can call the Erie County Health Department, where you can order from Home Depot a kit to put in your cellar for 24 hours and then mail it in. And they'll give you an idea of what your radon levels are like. But, again, the risk of lung cancer is greatly enhanced when you're exposed to radon and you smoke.

Tim: The next question that we received via Twitter comes from a 54-year-old woman, and I'm not so sure that there are risks, but she's asking: "Discuss weighing the risks versus the benefits of screening." Dr. Dhillon, do you want to take that for us?

Dr. Dhillon: I think the biggest benefit is the early detection of lung cancer. As I said earlier, the prognosis of advanced lung cancer is not as good as when you detect it in the early stages. Early stage is when you can completely take it out with surgery, which could be cured of itself. The sooner you can diagnose it, the better it is. And therefore low-dose CAT scan offers us that opportunity to diagnose lung cancer early and save lives. In fact, the National Lung Cancer Screening Trial in 2011, which recruited 53,000 patients, clearly showed 20 percent reduction in mortality in the group that had low-dose CT scans. So, I think saving lives is an immense benefit of screening.

The risks, on the other hand, which you have to weigh is exposure to radiation from a low-dose CT scan. However, as compared to the regular CT scan, the low-dose CT scan has a significantly lower level of radiation. There is no clear answer to whether the low-dose CT scan significantly increases the risk of cancer, but most of the calculations show that the risk is fairly low.

In addition to that, you have to weigh the possibility of finding nodules. And a lot of these nodules could be benign. Almost 25 percent of patients who undergo the first round of screening will have nodules that are more than 4 millimeters. And some patients can be anxious about the finding of a nodule. And then they need to talk to a health care provider, and that could be one of the downsides. But, overall, if you select patients who are at the highest risk of lung cancer, I think screening and early detection by far outweighs the risks.

Tim: Can a parallel be drawn to the colonoscopy that so many people are familiar with in our society today where polyps are found? Polyps detected in a colonoscopy don't mean that they're cancerous. Is a nodule similar in nature?

Dr. Dhillon: Yes, a nodule is similar in nature, except that you need to have a team of experts that watches those scans and those nodules and makes sure you're not missing a cancer.

Tim: All right. But the benefits of being screened far outweigh the potential of what would happen if you . . .

Dr. Dhillon: Absolutely. Detecting lung cancer early is so, so, so important that the risk of a small amount of radiation - and by the way, we get exposed to radiation every day we live - there is so much radiation outdoors, too. So, the benefits in the selected population outweigh the risks.

Tim: Okay. Back over to you, Pam. It sounds great in a perfect world. We all want to get screened for whatever it is we should get screened for. We know that, for example, maybe it's every five years that you'll get a colonoscopy over the age of 50; a mammogram every year for many women; a prostate exam for men. How often will insurance providers allow me to come back and be tested for something like this?

Ms. Germain: That's a good question. So, if you meet the eligibility criteria set by the taskforce and adapted under the Affordable Care Act, I believe that you're eligible for a screening annually if you meet the high-risk criteria. Of course, if nodules are found or if other evidence of concerns are found, then it would become a more therapeutic visit, not just a screening visit. And I will defer to my colleagues on the clinical side in these matters. But if you meet the eligibility criteria, you're eligible for an annual lung cancer screening, and we would encourage that.

Tim: Dr. Reid, a question coming in using #LCScreening tonight out on Twitter. This one just came in, and it's pretty simple. The question is simple. I don't think the answer will be. Is lung cancer genetic?

Dr. Reid: There is a genetic component to lung cancer. For people who developed lung cancer earlier, in their 40s, under the age of 50, we know that there is a stronger familial component. We have isolated through family studies of lung cancer cases and their families that there are at least two areas on Chromosome 6 and on Chromosome 15 that carry many genes that promote lung cancer or promote cancer. Those influence your susceptibility to cancer and to lung cancer, specifically. There are also areas that are associated with addiction to nicotine, which, again, links to the risk of lung cancer. So, if you're an earlier lung cancer case, the feeling is that more of the causes of lung cancer are associated with your familial risk.

If you're in your 60s or 65, the majority of what drove that lung cancer is associated with the exposures that you accumulated during your life, either from smoking, from air pollution, or from radon. And so it plays a less important role in actually driving your lung cancer if you develop lung cancer late in life.

Many of the people who wrote in talked about their family history. And that really is an important thing that we evaluate during your clinical visit. It certainly influences the exposure to smoke you may have had during your lifetime. It will influence how you metabolize drugs, including nicotine and other drugs that are found in cigarettes. And that also leads into how your family genetics influences your risk for lung cancer.

Tim: I didn't think it would be long before we would get to this question, and it's come in live here off the Twitter feed, #LCScreening. And this also came in in advance as well. And this concerns secondhand smoke. "Should someone who lived with a smoker for 45 years be screened?" And kind of a different way of asking the same question just came in: "I was exposed to secondhand smoke every day most of my childhood. I've never smoked myself." So, really the same question. Let's talk about secondhand smoke.

Dr. Reid: The general consensus is that if you had a greater or equal to 25 years of passive smoking exposure, that's considered a significant exposure. And we do know that that increases your risk of lung cancer. It's not enough to get you into a high-risk category to be eligible for CT screening. But we do know that it contributes to airway disease, to infections, to inflammation, that it definitely contributes to disease in the lungs. And we do evaluate it.

The one thing I can say is that lung cancer screening really is in its infancy. We've never as a nation, and actually around the world, made a concerted effort to screen people and pick up lung cancer early. And we are going to learn more about the influence of things like secondhand smoke and family history and actually the formation of lung cancers. And so the regulations that we have now as national standards may change as we learn more about how important or how to detect those really high-risk secondhand exposures and how those will predict lung cancer.

Tim: Okay. We're about halfway through this session. It goes quickly, doesn't it? There's an awful lot of information, though, I still know the three of you want to offer. And the questions, they are streaming in here off of the Twitter feed out there, as well.

This is Cancer Talk Live, and we are at Roswell Park Comprehensive Cancer Center in Buffalo, New York. That last voice you heard was Dr. Mary Reid. She is a Professor of Oncology here at Roswell Park, pivotal in the lung cancer screening program here at Roswell Park. Dr. Samjot Dhillon is with us, as well, Chief of Pulmonary Medicine, and Pam Germain over here, Vice President of Strategic Initiatives here at Roswell Park.

I am Tim Wenger. And we continue with the questions again coming in on the Twitter feed right now with the #LCScreening. The next one: "Why this 15-year-limit? What if you haven't smoked for 15 years?" Can one of you explain to us the 15-year-limit?

Dr. Dhillon: Looking at all the previous studies and data, it has been determined that the longer you've quit, the risk of lung cancer starts decreasing. And it decreases by 70–90 percent after 15 years. So, somebody who has quit smoking for more than 15 years, the risk goes down significantly. At this point in time, because they're no longer high risk, it's not justified to put them through a CT scan screening, because at this time, the risks of the screening may outweigh the benefits, because the risk of lung cancer itself is so low.

Tim: Pam, there are so many insurance providers and ways that we gain access to our coverage these days. And one of the questions that just came in on the Twitter feed: "How soon to know Medicare eligibility for cost coverage?" And, really, I kind of want to expand on that. This person is asking specifically about Medicare. There's Medicare, there's Medicaid, and then there is the plethora of different providers that are out there. I know it's a confusing world that you live in.

Ms. Germain: Yes, it is. So, we have Medicare. Then we have the Medicare Advantage insurance plans that are sold by many insurance companies, including our local insurance companies, HealthNow, Blue Cross, Independent Health, Univera, and others. At this point in time, it's expected that Medicare will decide in mid-February as to what their position is for Medicare-eligible people in our population in terms of screening under this program. So, today we are working with our commercial insurance companies here in Western New York. And they're all actively allowing screening for their commercial members who are under 65. And we're all waiting to see what Medicare announces. Probably we're expecting mid-February for eligibility for the Medicare population.

Tim: I think it's important. You and I have talked about this with regard to this program and others. I said that the world that you live in is very confusing, but you and your department at Roswell Park are dealing with these providers on a daily basis. So, when I reach out to Roswell Park, for example, with this lung cancer screening program, you've done a lot of this legwork already.

Ms. Germain: We have actually, I think, with the help of the clinical team here, we've been talking about lung cancer screening with our insurance companies who cover the Medicaid, Medicare, and commercial populations at least since 2006, and have really been strong advocates for each of them in our Western New York market to cover lung cancer screening well in advance and to pay for the low-dose CTs when our doctors say the patient really should be getting that service. They've really worked with us and trusted us. And they know that in our center we're really focused on our patients. And we really want to make sure that we're providing the best possible care.

And also we think it's very important to keep the data and to do the research to really lead to better information. And so some of the national studies and some of the work that's going on around the country, there's been many contributions from centers like Roswell Park, who have really added to the body of literature. And the payers are very respectful of that, and I think so is the government. So, as I say, we have been doing screening at Roswell Park for many years and have always had good relationships with the insurance companies. And they have been authorizing the care even before these standards.

Tim: I do like that fact that Pam has done a lot of the legwork and the folks here at Roswell Park have reached out to most of those providers. So, they'll have some answers for you in that prescreening process. A question that came to us in advance to our webinar tonight, Dr. Reid: "Do people with asthma have greater risk of lung cancer?"

Dr. Reid: That's a really good question. Asthma is kind of an acute inflammation in the lung, and we know that inflammation, at least chronic inflammation, contributes to the risk of lung cancer. I have done a few studies recently looking at very large cohorts of 50,000 to 120,000 people prospectively and relating asthma with lung cancer. And I think the findings show that if you, at your initial diagnosis of lung cancer, have asthma, you may be evaluated for lung cancer, especially if you're within this age group.

But if you've had well-controlled asthma for three to five years or more, your risk for lung cancer actually goes down. And that's because the control of asthma actually contributes to the control of inflammation. That leads to less disruption of the cells in the lining of the lung and it actually decreases your risk.

Those people who fall into that more recent diagnosis or who are poorly controlled, there is some suggestion that their risk goes up initially. And that's why it's so important both with asthma and with COPD to keep going to your clinician to get it under control so that you don't suffer some long-term effects related to lung cancer.

Tim: All right. I'm trying to give out that hashtag as much as I can. The questions continue to stream in at #LCScreening. And we've got another one in just a moment. Dr. Dhillon, first to you, though, this question was presubmitted to us via the website, www.RoswellPark.org: "How do you address what could show on a CT or an MRI lung cancer scan as false positives? What steps are taken from that point so that you and the patient know with 100 percent accuracy whether it's cancerous or not?"

Dr. Dhillon: Some of the answers are not immediate. It requires close observation and careful decision-making. A typical CAT scan that will show a nodule, we will look at the risk factors of the patient and try to define them into a high-risk category or low-risk category. Then we carefully look at the nodule or nodules and see what kind they look like. Either they are ground glass or solid nodules. And what's the size of the nodules? Is it spiculated? Does it have calcium in it? What's the pattern of calcification and all those factors?

Depending on all those risk factors and the findings of the CAT scan, we may recommend a biopsy if there is significant concern. And if the risk is intermediate or low, we may ask for a repeat CT scan in three to six months. Within three to six months, when we get the next CAT scan, if we see any growth in any of those nodules, we either remove them or biopsy them. And if they stay stable, we continue to watch them. Mostly if a nodule does not change over a two-year period, it's benign.

So, it's important not to biopsy every nodule you see, because then the rate of complications will be significant and it will outweigh the benefits of screening. So, we have to make some very complicated decisions. The most important thing is not to miss a cancer - get an early biopsy, but at the same time, not to do unnecessary biopsies, and monitor the nodules that don't look high risk.

Tim: I know it would vary from patient to patient, case to case, situation to situation, but ballpark, what are we talking once someone goes through this, has the CT scan, and perhaps a nodule is detected and you decide to do a biopsy. What kind of timeframe are we talking about?

Dr. Dhillon: So, we try to see the patient within a week of the CT scan and discuss the results. And within a week or two, we get a biopsy done and then we see the patient again. And depending on the results of the biopsy, further management is planned.

Now, the decision to do a biopsy or not to do a biopsy or what kind of biopsy to do is the most complicated one. For example, a nodule could be situated in a location that you can do a biopsy of by CT guidance. It could be hidden deep inside the lung where you may need a GPS bronchoscopy. Or a nodule may be in a location where you feel that the best way to take it out is surgery without putting the patient through an unnecessary biopsy, because with surgery, you're also curing the lesion at the same time. So, it becomes important to have a multidisciplinary team of experts that can give their opinion, people who can do the most complicated biopsies, and at the same time, provide the best care to the patient by making the best decision for that particular patient.

Tim: You're mentioning GPS bronchoscopy. It's amazing the different types of things and tools that you have available to you. But what I'm hearing is that you can come in, you can have a CT scan, you can have it read, and find out that there is nothing to be concerned with right now. You may need to come back. Or you could find out that there's something you might be concerned with. It really is, I think, a no-brainer. You really should be considering this if you fit within the high-risk categories.

Dr. Dhillon: Absolutely. As I said earlier, the low-dose CT scan is noninvasive, painless, and a quick test. And it gives us a lot of information. As a good screening program, it's very important first not to do biopsy on something that doesn't need it. And at the same time, if you need to do a biopsy, do it in the most appropriate way, where a strong multidisciplinary team plays a very vital role. And that's where we are very proud of our multidisciplinary teams of surgeons, radiation oncologists, interventional pulmonologists, and medical oncologists.

Tim: It matters who reads that test?

Dr. Dhillon: It matters a lot.

Tim: Okay. Pam, we did strike a nerve with all the questions about coverage and insurance, as I assumed that we would. And one of our hashtag viewers out there in the webcast world has chimed in with, "Is there a flat fee cost for the lung screening for the uninsured person?" So, no insurance - what are my options and is there a flat fee?

Ms. Germain: Roswell Park has a policy. If you come to Roswell Park and you have financial need, there is financial assistance available. There's criteria and policies. If you pay full charges, and let's say you have an initial visit with a provider and it's determined that you need a CT and then you need a follow-up visit, our charges right now are about $1,700, but you could be eligible for a discount off those charges. So, there is financial need available. As a hospital-based service, we really have some latitude in terms of offering for patients in need of discounts.

Tim: Dr. Reid, this one I think is pointed at you. "My mother and grandmother both died of lung cancer. They were both heavy smokers. What is my chance of getting lung cancer, even though I don't smoke?"

Dr. Reid: For the general population, the overall risk for lung cancer is 1 in 14. You probably were exposed to some secondhand smoke that may increase your risk a bit. But not being a smoker really is the biggest preventable action by you for preventing lung cancer.

I want to add this caveat. We know that over the years that I've been doing lung cancer research that the proportion of lung cancers that we find in people who've never smoked has increased. Between 12–15 percent of all lung cancers are never-smokers. This screening test will not address the risk of never-smokers in developing lung cancer. But going forward, screening smokers for lung cancer will help us to understand the genesis of this cancer and may help us develop a marker that we could then apply to people who have a significant history in their family - may have been exposed to passive smoking and whatnot. So, there is hope going forward that we're going to learn a lot more about who's at risk for lung cancer, even though you don't smoke. But bravo for never having picked up a cigarette.

Tim: That's where it all starts. But for anybody who's in this position, it's nice to know that this screening program is available to anyone out there. And, again, you can find out a lot more at RoswellPark.org.

This next question I think involves everybody on the panel. And it came in prior to the session tonight. And it also comes a little bit, I guess, from me. There is not a colonoscopy, so to speak, for lung cancer. There is not a mammogram or a prostate exam. But there is screening for lung cancer that is available, and it's available for those with high risk. I guess I'll start with you, Dr. Reid. Do you see us going down the road where this will become more and more commonplace?

Dr. Reid: Actually, there's probably 40 million Americans who are eligible for lung cancer screening on these criteria. So, it really does impact a lot of people. We know there's a significant amount of smoking and smoking history in Buffalo. And so there is a significant portion of our population here who's eligible on these current guidelines.

The thing with other screening, say, colonoscopy - it didn't start out that way. You really had to have more of a significant risk. We do tailor colonoscopy to the general public. If you don't have a polyp, you can go for five to ten years between scopes. But where we are with lung cancer screening is we are focusing on the highest risk people, the people who will benefit the most, where we're most likely to find tumors, where we're most likely not to do any harm by biopsying nodules or lesions that are not cancer. And so, for now, focusing on this high risk is more than appropriate. We've gotten used to screening in the general public, between cervical, prostate, colon, and breast. Focusing on high-risk people we know is going to make a significant difference in the mortality. In 10 years from now, who we choose into this program may look different. Some of these restrictions may go away. But for right now, we know we can do the most good and really save the most lives by focusing on this high-risk group.

Tim: Pam, I would think that when some of those other screens that Dr. Reid referenced and I referenced, when they first came out there on the stage, they were new, too. And there were probably a lot of questions by the insurance industry that were asked.

Ms. Germain: There were. Absolutely.

Tim: And look where we are today where they're commonplace.

Ms. Germain: Absolutely. I think everyone is so excited when we can really show in a population of patients - and let's use breast cancer as an example. When you're finding so many cases at an early stage and you see such success in terms of treatment and long lives and happy lives, even when patients have a cancer diagnosis, we're all hoping that with lung cancer, we can continue on the path of learning, starting with the screening program.

The high-risk population, we really urge you to come and have the screening. Call Roswell. Call ASK Roswell Park. Be screened. See if you're eligible. And if you are, please be screened because there's nothing better than finding cancer at an early stage other than not having cancer. But if you're going to have a diagnosis, and you find it early, there's such a hope for a good life. The late-stage cancers, especially in the area of lung cancer, have proven so perplexing for all of us. And so if we can encourage people to come and really take the chance to see, in fact, if you have an early-stage cancer or need monitoring, I think it's the important first step.

Tim: That is the key, that whole early detection. And that's what this screening offers, early detection. If there is something obviously to detect to begin with. This could all be for naught, and certainly we all hope it is. We are going to volley it back over to Dr. Reid for this one. This came in via Twitter tonight: "Is risk higher if you have COPD?"

Dr. Reid: COPD is an independent risk factor for lung cancer. Within the first six months of a diagnosis, you're at your highest risk for lung cancer. With the COPD onset, if you have an exacerbation of symptoms that's outside the normal, that is also a signal that you may have a lesion. It actually is for increase of risk for lung cancer. Again, well-controlled COPD helps to decrease your risk. The most severe cases of COPD, where you have repeated exacerbations - and I may defer this to Dr. Dhillon - that chronic inflammation, those episodes of severe inflammation and infection change your risk, and we do know that. But, again, within six months of the diagnosis of COPD, that's when your risk of lung cancer is the highest.

Tim: Dr. Dhillon, anything you wanted to chime in on that as she offered that?

Dr. Dhillon: Smoking is a risk factor both for COPD and lung cancer. And studies have shown that even if you control for the effect of smoking on lung cancer, COPD itself is an independent risk factor for lung cancer. It increases the risk of having a lung cancer in somebody who has smoked. And I agree with Dr. Reid that we consider it as a risk factor, and we evaluate our patients for COPD. Sometimes we offer them a breathing test and we kind of weigh it closely when we are working up our patients and managing their nodules.

Tim: Another question that came in prior to the webcast tonight: "If you're diagnosed with lung cancer and there is metastasis, how can you tell if the lung cancer is the primary or the secondary source?" An opportunity right now to discuss who reads this type of a screen and why that's so important.

Dr. Dhillon: It can be a very complicated question. We face this question a lot of times. I think it's important for us to look at the overall clinical picture, do an appropriate scan - for example, in this center, you can order a PET scan to see what areas light up and what could be the possible source of cancer. And then, it also depends on what you see on the biopsy. You need an expert team of pathologists who can take a look at the tissue. Sometimes by looking at the biopsy, they can tell what's the origin of the tissue. And sometimes they run a lot of complicated immune markers to see what's the origin. So if you have a nodule or mass in the lung that you biopsy and they see all the markers of colon on it, they're able to determine that this is from the colon.

So, a lot of times we are successful. There are a few times when the tumor does not fit into any pattern, and it's known as a "tumor of unknown primary." And in that case, you need a team of expert oncologists to decide what's the best treatment for that. So, I think a multidisciplinary team, which consists of physicians, pathologists, radiologists, oncologists, is the key in such complicated scenarios.

Tim: All right, Dr. Dhillon, thank you. Another question coming in: "I'm 54. Smoked since I was 14 and still smoke one to one and a half packs a day. Do I qualify?"

Dr. Dhillon: Almost. I think the current insurance sets the limit at 55, so I think within a few months you'll be able to qualify, because you'll be age 55 and you have almost more than a 30-pack-year history, and you're a current smoker.

Tim: Dr. Reid, anything to add there?

Dr. Reid: This is the paradox. If you wait six months and you become 55, did this really change? There has to be a cutoff. This cutoff optimizes our chance of finding a lung cancer and being able to do something about it. We know age is a risk factor. Does it seem trivial, given that you have a substantial smoking history, that we have to wait six months? We do have to follow the national guidelines. We also don't want you to be screened unless you're willing to pay out of pocket, because I think the insurance companies are, especially during this time when we're learning about what happens in this high-risk group who are screened, are going to be fairly rigid about the 55-year cutoff. So, again, try and quit smoking. When you're 55, you should be eligible for lung cancer screening, and you should call Roswell.

Tim: We've talked a lot about all the different risk factors. And certainly and foremost this evening we've talked about smoking. Our next question, though, talks about industry. "I worked in the automotive industry for 20 years, and I'm concerned about all the chemicals and fumes I encountered. Prior to that, I grew up and worked on a farm where chemicals and dust were prevalent." The question goes on into some greater detail, but really is asking the question about environmental exposures. How concerned do we need to be about environmental exposures with regard to lung cancer?

Dr. Reid: Well, we do know that there are some really important environmental and occupational exposures that contribute to the risk of lung cancer. Certainly asbestos is one. There are several other metals and exposures in many of the industries that surround the Buffalo area. We know that arsenical pesticides contribute to lung cancer. When you are evaluated by a clinician prior to having a CT, you'll be asked about occupational exposures. The auto industry and the farm industry are two hot spots, as well as chemical companies and steel mills. Those were all occupations that contribute to the risk of lung cancer.

Those alone will not get you into a screening program. However, when we evaluate a nodule for more aggressive follow-up, those factors do come into play. Because we know that people who have these other additional exposures, have asbestos-related lung disease, radon exposure, that changes the likelihood that we're going to find cancer when we biopsy a suspicious nodule. But these definitely contribute. And again, as we learn more about the genesis of lung cancer through this screening, as a country and throughout the world, we're going to be able to fine-tune the impact of these additional exposures on lung cancer risk.

Tim: All right. Dr. Dhillon, I think you had some comments on that, as well.

Dr. Dhillon: I want to say that this is the beginning, but I'm glad that this has begun, because at least now we have something to screen and find lung cancer early. We still have a lot of unanswered questions and a lot of people who have increased risk where they do not meet the screening guidelines. But we are hoping that as we start screening and learn more and more about it, we'll be able to refine the process. We'll be able to develop more markers. I think we still need to understand the question of how to screen patients with asbestosis and exposure to various industrial toxins, but hopefully within the next several years, we'll study this closely and come up with guidelines for screening even those patients and quantifying the exposure.

Tim: Dr. Dhillon, you get the quote of the webcast award for "This is the beginning, but I'm glad it's begun."

Dr. Dhillon: Oh, thank you.

Tim: All right. I think that works. Dr. Reid, this is your cue to get ready with some information for everybody, because I know they can go to the website to find out more about how they can get screened, but we'll get to you in just a moment. Phone number, website, and all the information anybody might need to find out what they need to know if they're interested in finding out more about this lung cancer screening that we've been talking about on our live webcast here over the course of the past hour. Pam Germain, some parting thoughts, if you will, on how we shouldn't be afraid of asking the questions, finding out if this is something for us, and if it's something we can move forward with?

Ms. Germain: Yes, absolutely. I would encourage people to think about their risk. And certainly the guidelines are important, but you can always call ASK Roswell Park and go through the eligibility requirements and see. And there may be extenuating circumstances that may raise a few questions that would then go to the clinicians to make a determination whether in fact you should be recommended for screening. Then we would go to the insurance company and seek their authorization for care at Roswell Park if you don't necessarily meet the guidelines as presented.

So, be proactive. We're here to help. And again, as a multidisciplinary team, we're really looking to provide the right level of care when it's needed to our community of citizens. And we are all hoping to keep us all as healthy as possible as long as possible. And I do believe early screening for lung cancer is a wonderful start.

Tim: All right, Pam Germain. Thank you so much for being here. Pam Germain, Vice President of Strategic Initiatives here at Roswell Park Comprehensive Cancer Center. Dr. Reid, a lot of the information, if not all of it, is available online at www.RoswellPark.org. We've piqued some interest I'm sure out there tonight. What do people need to know? What can they do if they want to partake in the screening?

Dr. Reid: If you want to find out if you're eligible for lung cancer screening, you can call the ASK Roswell Park number, 1-800-ROSWELL. You can go on to the website and you can calculate your pack-year exposure. You can review some of the risk factors that will link you to ASK Roswell Park - which again, they will ask you some questions. If you're eligible, they'll be able to tell you at that point whether you're eligible. They will automatically refer you on if you are eligible to get a call for an appointment. Again, the website is very informative. It allows you in a sort of relaxed way to review the risk factors, to look at the team, to look at what CT is about. There is a lot of information there.

And we just really strongly encourage you, even if you think you're on the border, to call in and increase your awareness about lung cancer screening, if you have family members, to get them to call in, because lung cancer is a devastating disease. We don't want anyone to be diagnosed with late-stage lung cancer. And we're really hoping that now that we've started this that we can really change the face of this disease and achieve much more positive outcomes when people are diagnosed.

Tim: All of that hard work and you playing a leadership role in lung cancer screening here at Roswell Park had paid off, and I thank you for your time tonight.

Dr. Reid: Thank you very much, Tim.

Ms. Germain: Thank you.

Tim: That's Dr. Mary Reid, Professor of Oncology and Director of Collaborative Research here at Roswell Park. And Dr. Dhillon, really I think there's just a call to action you want to leave everybody with tonight.

Dr. Dhillon: I think for those who are at high risk of lung cancer and those who meet the criteria, I think we are very lucky to have this screening program, which is one of the most mature and most experienced screening programs here in the nation, because we have been doing lung cancer screening here since 1998. And we have a multidisciplinary team with all the expert technology that is needed to take care of any abnormal findings. Since this provides an opportunity to detect lung cancer early and to save lives and the test involved is painless and is actually noninvasive, I encourage all those who meet the criteria to contact us and please get screened, because lung cancer screening saves lives.

Tim: Dr. Samjot Dhillon, thank you so much for your time as well.

Dr. Dhillon: Thank you.

Tim: Dr. Samjot Dhillon is Chief of Pulmonary Medicine. And thanks to all three of you for taking time out of what I know are very busy schedules to join us on Cancer Talk Live. I'm Tim Wenger, and I'm happy to be here. And I hope we'll be doing this again soon. Thanks for joining us. And, of course, all of this information is always available at www.RoswellPark.org. You can follow us on Twitter too @RoswellPark, and we'll look forward to seeing you again soon.

Dr. Dhillon: Thank you.