Lung cancer is the leading cause of cancer deaths worldwide and in the United States. At Stony Brook Medicine’s comprehensive Lung Cancer and Chest Disease Center, our experts provide multidisciplinary care for lung cancer, suspected lung cancer and other lung conditions. The specialized team works together to create an optimal, personalized treatment plan, collaborating with patients and their families to address individual needs and quality-of-life goals.
The Experts
What You’ll Hear in This Episode
- 00:00 Opening and Introductions
- 1:10 Smoking cessation
- 1:55 Signs and symptoms of lung cancer
- 3:00 Lung cancer screening and diagnosis
- 7:00 Support and lung cancer treatment at Stony Brook
- 8:30 Dr. Mani joins the conversation
- 9:12 Early-stage versus late-stage lung cancer
- 10:58 Advanced-stage diseases
- 12:00 Treatment options for early-stage lung cancer
- 16:50 Treatment options for advanced-stage lung cancer
- 24:00 Clinical trials
- 26:30 Closing Remarks
Full Transcript
00:00 Opening and Introductions
Announcer
Welcome to HEALTH Yeah!, where experts from Stony Brook Medicine come together to discuss topics ranging from the complex inner workings of an infectious disease to tips and tricks for staying safe and healthy all year long.
Ankit Dhamija, MD
Hello and welcome to HEALTH Yeah! Today we’re going to be discussing lung cancer. My name is Ankit Dhamija. I am the director of Lung Cancer and Chest Disease Center and a cardiothoracic surgeon. Let’s take a moment to introduce our fellow panelists.
This is Dr. Denise Albano.
Denise Albano, DNP
Hi. I’m the Associate Director and I’m a nurse practitioner. Great to be here.
Amna Sher, MD
Hi, I’m Dr. Amna Sher. I’m not sure I’m a thoracic medical oncologist. Glad to be here with the wonderful team.
Ankit Dhamija, MD
Wonderful. Thank you both for being here. Stony Brook Cancer treats around 1,000 patients for lung cancer each year. We have a comprehensive multidisciplinary team that takes the patients through the entire continuum of care from prevention, screening, diagnostics, treatment and follow up care.
So let’s dive into today’s conversation with our first question, which is for Dr. Albano.
1:10 Smoking Cessation
How can we help people stop smoking? And which is the cause most attributed to the 80-90% of cases of lung cancer?
Denise Albano, DNP
So we here at Stony Brook have our own smoking clinic, smoking cessation clinic, and we do a personalized appointment for them. We talk about their triggers. We talk about nicotine replacement. We talk about medications like Wellbutrin and Chantix. We have support groups. We also utilize our social work team for, you know, additional support. And then we also can send them out to the community. And they have a six week program there that they can do weekly also. So we have a very comprehensive program here.
1:55 Signs and Symptoms of Lung Cancer
Ankit Dhamija, MD
Great. And Dr. Sher, what are the signs and symptoms that one may have if they had lung cancer?
Amna Sher, MD
Right. I think some of the most common symptoms of lung cancer, which patients, you know, complain of is often cough. Sometimes it’s a chronic cough of which has been going on for a few weeks or months despite adequate treatment.
People often start to have hemoptysis, which means they start coughing up blood. They can have some shortness of breath as well. And sometimes they just have general symptoms of feeling unwell, weight loss. And if the cancer has spread already, they would start to have symptoms related to areas which are affected. For example, people can present with back pain, headaches, neurological symptoms.
And unfortunately, they’re found to have either advanced disease with brain metastases or involvement of the bones.
3:00 Lung Cancer Screening and Diagnosis
Ankit Dhamija, MD
Yeah, it’s amazing to see that there is lung cancer in the early stages and they actually don’t have much symptoms at all. Which then brings us to our next topic of discussion.
Dr. Albano, how is it that we find lung cancer? We usually have screening and we also then subsequently have incidental findings generally nowadays.
Denise Albano, DNP
Exactly. I always say we’re so fortunate to have lung cancer screening because prior to 2015, before the national lung cancer trial, we used to do chest X-rays. So we did chest X-rays and we thought that with the chest x-ray we would be able to find things.
But fortunately in 2015 they changed the criteria and we now do a CAT scan, a low dose CAT scan, minimal radiation for our patients. And these are patients between the ages of 50 and 80 that smoked for about 20 years and quit less than 15 years ago.
So if they meet this criteria and if you meet this criteria, make sure you get screened. But if they meet this criteria, then we should do a lung cancer screening. And the great thing about lung cancer screening, unlike Dr. Sher’s patients, whose she gets to see more advanced. I get to see the patients that usually are cured. So we find small little nodules, tiny little nodules that we can fix, cure, and they can go about their lives and they never have any symptoms.
Ankit Dhamija, MD
Which then Segways to the other modality in which we actually find lung cancer, as well as an incidental finding in patients that subsequently go to the emergency room and have CAT scans just because they were having chest pain, for example, and or, you know, urgent care centers where they may be able to find slightly larger imaging on X-rays and so forth.
Additionally, on CT scans that are done for coronaries, we can also find lung cancer nodules from there as well. And we find them, as you had mentioned, at different sizes and at different points.
Denise, what are the different kinds of modalities that we can use to diagnose lung cancer?
Denise Albano, DNP
Sure. I like to say that it’s not just smokers that get lung cancer – because our screening population is only going to get smokers. So these incidental lung nodules that we find are, you know, are so important because people that don’t smoke assume they’ll never get lung cancer. And unfortunately, as you guys know, we have lots of patients that have never smoked.
So we have a lung nodule clinic here at Stony Brook. So any nodule, even if it’s two millimeters in size, we’re going to see, we’re going to follow, we’re going to talk about risk factors. We’re going to talk about their family history. We’re going to talk about their exposures, what puts them at risk, asbestos and World Trade Center and radon and family history and all those things, and kind of add it all up and come up with, you know, when should we see you again?
I mean, we certainly go by national guidelines like physician of society guidelines, but then we also put our own kind of, you know, what we think is going to happen and follow them, you know, every three months, six months, a year.
If it grows above eight millimeters in size, we usually worry a little bit. We get a PET scan that we send to you guys at thoracic surgery. And we look at everything with our tumor board to see, with our multidisciplinary team, to see what we should do next. If they need a biopsy, if they need surgery, if they need radiation, if they need medical oncology, if they need us to check their lymph nodes and things like that.
Ankit Dhamija, MD
Yeah. Usually when Dr. Albano and her team ends up finding a nodule that then meets those criteria and becomes a little suspicious, we tend to follow them up from an interventional pulmonology standpoint or thoracic surgery and either diagnose the patient with a guided biopsy or a robotic bronchoscopy.
And if there’s an indication to then subsequently stage the patient, meaning figure out at what point of the lung cancer modality that there is, we sometimes consider doing certain procedures to sample lymph nodes.
When it comes down to treatment of these, then it comes down to a decision that happens at a multidisciplinary board, as you had mentioned.
7:00 Support and Lung Cancer Treatment at Stony Brook
What do we have here at Stony Brook in terms of a support group for patients that have lung cancer?
Denise Albano, DNP
So we have a support group that we run here, either myself or Dr. Plank, and we are here every third Wednesday of every month, over at the Cancer Center, we’re here from 6:00 to 7:00, everybody is welcome. It doesn’t matter the stage. Please come. We would love to have you.
Ankit Dhamija, MD
Dr. Sher, tell us about what happens to a patient once they have a suspicious nodule, for example.
Amna Sher, MD
So, as Denise mentioned, we have the guidelines we follow. But if it’s a complex patient, we have the multidisciplinary tumor board where we have all the specialties under one roof, we review that patient and then come up with a consensus decision. What would be the best next step in the management of that patient?
And I think that is the key because we all know that patients who are treated under a multi-disciplinary platform have better outcomes, and I think that’s the beauty of our team here, and the Lung Cancer Center here at Stony Brook.
8:30 Dr. Mani Joins the Conversation
Ankit Dhamija, MD
Thank you for your time this morning. We are going to shift over to Dr. Mani, and thank you for our listeners and viewers, don’t go anywhere. We’re going to come back in a few moments with Dr. Mani.
Welcome back, everybody. Dr. Mani is now joining us. Dr. Mani, can you please introduce yourself?
Kartik Mani, MD, PhD
Absolutely. Very nice to be here. My name is Kartik Mani. I am the clinical director in the Department of Radiation Oncology. So I treat many forms of cancer with radiation. I’m very excited to be here today to talk about our options for lung cancer, and also to be in the same room with you guys because we have a lot of our meetings virtually, so this is a nice little treat that we have. So kudos for that. But I’m very excited to continue this conversation.
Ankit Dhamija, MD
Great. So just a Segway from earlier. You know, we diagnose and treat lung cancer and that’s what we’re focusing on. And so what is it that defines an early stage lung cancer versus a late stage lung cancer?
Dr. Mani, if you want to spend a few moments talking about early stage lung cancer.
9:12 Early-Stage Versus Late-Stage Lung Cancer
Kartik Mani, MD, PhD
Yeah, this is a great question because it really gets to the point that not all cancers are created equal. So when you have early stage disease, that means that you have disease that’s identified in the lungs itself, maybe in one spot. And that spot can be very small, like just a few millimeters to a few centimeters.
When we get into a sort of intermediate stage disease, which is more like stage two, that’s where the tumor is growing a little bigger or it’s involved some of the lymph nodes. And those are kind of drainage pathways in the chest. So we have the lungs and they kind of connect in to the chest. The first area is called the high limb and then the mediastinum. And that’s where the heart is and a lot of really essential organs.
So there are lymph nodes there that sort of the cancer can find ways to get in there. So when we talk about later stage disease, we think about diseases not only in the lungs, but now it’s gone into the mediastinum or even into the lower necks.
And then, of course, later stage disease. That means it’s gone outside the chest so it can go to the adrenal glands, liver, sometimes brain, sometimes bone. And so there’s this whole spectrum of disease. And each of these is kind of a unique problem. And it’s always kind of interesting to see each case as its own particular thing. So we have our own strategy for that particular segment, but the first step is really identifying the stage once we have a diagnosis.
10:58 Advanced-Stage Diseases
Ankit Dhamija, MD
Which then brings the importance of us talking in our tumor board about each of these patients. And as you mentioned, there is no patient that is exactly the same as the last patient.
So, Dr. Sher, tell me a little bit about advanced stage diseases. Where is it that lung cancer goes to if it was to go beyond the lymph nodes or so?
Amna Sher, MD
You know, we all know that some of the most common sites where lung cancer spreads is the liver, the adrenal glands, the bones and the brain. So at least 30 to 40 percent of the patients with lung cancer have brain metastases at diagnosis. And about 10 percent of those are asymptomatic, meaning they have no symptoms.
And same thing what we talked earlier, they come to the emergency room for some different complaint and they have a lung mass. As part of the staging workup, when we do the brain imaging, they’re found to have brain metastases. So those are the common sites. And people can then have symptoms related to that site involvement.
They could have bone pain, seizures, you know, headaches. Those are all some of the symptoms related to where the cancer may have spread.
12:00 Treatment Options for Early-Stage Lung Cancer
Ankit Dhamija, MD
Great. So when it comes down to then focusing on, you know, general categories so it’s easier to explain to our viewers today what it is and how we treat them. Let’s focus on perhaps the early stage lung cancers first.
Those are the lung cancers that have the best survival. And we try to spend a lot of time figuring out the best modality for each patient. And sometimes that involves radiation, which Dr. Mani will talk about. And sometimes that involves a surgical evaluation. With a surgical evaluation, what happens is if it’s an early stage, it is amenable to a robotic surgery.
And what it is is basically a few small incisions in which we actually dock a robot in which I or one of my partners ends up controlling and utilizing the robot with ten times magnification and the wrist articulation that exists with that, we’re able to identify, remove the lymph nodes as well as the lung cancer in and of itself.
The official pathology often doesn’t come back for a few weeks, but when it does come back, we can have a sit down conversation with the family and the patient and discuss what their treatment algorithms are based upon the pathologic results. So that’s one of the things that we can offer from a stage one or early stage two of lung cancer.
But Dr. Mani, do you want to talk about another alternative option for patients with that disease process?
Kartik Mani, MD, PhD
Would love to. So glad you asked that question, but it’s always fantastic to hear about your end of the world and all the innovations you guys have made taking surgery from a very kind of morbid process to these minimally invasive techniques with the robot and these small incisions and the quick recovery time.
So again, kudos to you and your team for all of those marvelous options.
So in a parallel world, I imagine my scalpel as being x-rays. So I can use radiation with x-rays just like you get with a CAT scan or a chest x-ray. And if we just turn up the energy and we kind of point them precisely where we want, you can actually treat cancer very effectively.
So it’s a little bit of a paradox. You know, we think of radiation as causing cancer, but it’s actually a really useful tool for treating cancer. So there’s been a lot of innovations in this field, like radiation started for the lung 50 years ago, 60 years ago. We didn’t have a very good idea of where the radiation was going or even where the cancer was. We sort of had an X-ray and we could draw a box and we could point radiation at that box. But you can imagine there’s a lot of normal tissue that gets treatment during that process.
So where we evolved in two ways was our machines got better. So we could kind of shape the radiation to a certain way, but also the software that supports the machines got better and the understanding of how radiation is deposited.
So now we have techniques called intensity modulated radiation therapy. And kind of the best example of that going even further is called stereotactic body radiation therapy. Some of our viewers may have heard ads on the radio for CyberKnife. These are all versions of this technology. And what that is, is if we can really amp up the precision of the radiation, then we can deliver these huge doses in just a week of treatment.
So that’s 3 to 5 sessions, outpatient, no anesthesia, no cutting. And the patient comes in, they often walk out feeling exactly like they did when they walked in. And it’s because of these precise ways we can image the patients and know where the cancer is. So SBRT has really kind of found a home in treating early stage lung cancer.
Originally we started out with the patients that you couldn’t take to the operating room. You know, they were the patients that were very sick, poor lungs, poor hearts. You know, you wouldn’t touch them with a ten foot pole, but we could get them in and they actually did surprisingly well. You know, we weren’t expecting long survival from these patients. But, you know, lo and behold, they did very well.
And so we moved it into now testing SBRT with patients that could go to the operating room and have found very good results there. So now our early stage patients have two good options that they can discuss. And, you know, for our viewers out there, I just want to say that, you know, this is one of the magic points of Stonybrook, is that when you come to see us, you don’t get one opinion.
You know, you don’t go to the surgeon and they say how great surgery is and you don’t go to the radiation oncologists and they say how great radiation is and okay, you make a decision now. So we actually try to talk amongst ourselves and come up with a consensus. I think that’s sort of the finest point of what we do is really that it’s a team process.
So very happy to share those details of radiation. And again, very happy to collaborate with you guys on these patients.
16:50 Treatment Options for Advanced-Stage Lung Cancer
Ankit Dhamija, MD
Completely agree. I love having those conversations with you in regards to what the best modality is for a patient when they come to see us. So let’s switch gears maybe to advanced stage lung disease. I’m Dr. Sher, can you talk to me a little bit about what a patient’s options are based upon perhaps the general category of the staging that they have?
Amna Sher, MD
Sure. So, what Dr. Mani explained earlier, I mean, I think in simple terms, we can kind of say stage one tumor is small, there’s no lymph node involvement. Stage two is when the tumor starts to get bigger, generally more than four centimeters.
And then there is high level lymph node involvement, meaning the lymph nodes, which are, you know, the first to drain the tumor. And stage three is when we have a larger tumor, more than five centimeters. It starts to invade other major vessels. And then there are lymph nodes which are farther away in the mediastinum.
And stage four is unfortunately, when the cancer has spread outside of the lung, either to the bones, liver, adrenal glands or the brain. So that is the advanced stage of lung cancer.
Ankit Dhamija, MD
And what are the treatment options for those patients?
Amna Sher, MD
So, you know, when we talk about lung cancer, there are two main types of lung cancer, non-small cell lung cancer, which is 85 percent of all the cases of lung cancer, and about 15 percent is small cell lung cancer.
So I would focus more on the non-small cell because, you know, it’s the most common type we see. So generally, decades ago everyone would get chemotherapy. I think that has changed. You know, one size fits all is not the solution anymore for patients with stage four lung cancer.
Treatment is based on the patient’s histological tumor subtype. The mutational analysis is what we do once we have the biopsy specimen based on the PD-L1. So, you know, technology has evolved so much over the last few decades that we are able to give treatment towards an individual patient. So one patient with stage four non-small cell lung cancer is not going to be the same as, you know, a second one with exactly the same stage and involvement.
So it’s going to be very different. So in general, you know, there is going to be a combination of either chemotherapy or immunotherapy. And nowadays we know that targeted therapy has evolved rapidly. When we see a patient with stage four lung cancer, we generally recommend doing a full genomic analysis of the tumor, which includes multiple mutation analysis of PD-L1, and then the treatment is based on that.
So in general, I mean, if I see a patient, you know, I give them a little brief overview when we don’t have any of those results, that once we get those results, our options could be either a targeted pill if the patient has any of those mutations and if the mutations are negative, we may be able to treat them either with immunotherapy alone or a combination of chemotherapy and immunotherapy.
So I think the treatment has evolved over the last few decades. And, you know, we now have chemotherapy-free options for patients where there are some patients who are hesitant to get chemotherapy or they may not be strong enough to get chemo. And, you know, we are able to give treatment towards their wishes. And also, we know that immunotherapy works well for certain subtypes of lung cancer.
Ankit Dhamija, MD
Great. And, you know, Dr. Mani’s here as well and you can use certain modalities for advanced stage lung cancer as well to help with pain and perhaps even local regional control. Is that correct?
Kartik Mani, MD, PhD
Absolutely. So I talked first about the early stage options and we can use surgery or SBRT for those. But for our late stage patients and generally those who are considered unresectable – so if the cancer is in the nodes and it’s just involving too many structures that you might have trouble with, then they come to us and with Dr. Sher’s team and collaborating with them, we can give radiation to all the disease that we can see and usually that’s on PET scan or by bronchoscopy to sample the areas that are involved. And that’s concurrent with chemotherapy.
And then we follow that with a year of immunotherapy. And these medications are just marvelous innovations. I just have to say. So before I gave you kudos but now I’m going to give her kudos because it’s really kind of changed the paradigm in terms of survival outcomes in lung cancer, the immunotherapy in both stage three and in later stage disease is just remarkable.
So we have that kind of paradigm. So if they can’t ultimately get surgery for later stage disease, they can come to us and get chemotherapy and radiation together. That’s a six week course. So that’s not the fancy one week you’re in or out. So the longer a little more conventional.
And then we have our metastatic patients. So I’m going to dork out here a little bit. Metastatic actually means a slightly different thing. So a patient can be oligo metastatic or poly metastatic. So oligo means that they have spots that are involved outside the lung, but it’s only a few of them. So in some definitions three, in some definitions five. So in those kinds of patients, we actually have found out that we can be more aggressive with them.
So they get the great medications that Dr. Sher’s team can offer, but then we can come in and offer what’s called consolidated radiation. So there’s five spots initially, three of them respond and there’s two left. Now, initially they would say, okay, those two are responding, so we have to switch drugs to something else. Usually that would be drugs that the patients couldn’t tolerate very well.
But now I can come in, target those two spots using a very quick course of radiation. Now they can continue on immunotherapy or their regimen as before, and everything’s better. Their survival is better, their quality of life is better. So that’s in the oligo metastatic spectrum. So that’s a very special case for us.
And I do want to kind of highlight patients with, you know, disease that looks well-controlled in the chest but may have disease in the brain.
We can also use a form of SBRT. It’s called stereotactic radiosurgery, SRS, in the brain. It’s literally as it sounds like, it’s like having surgery without the surgery. So we can treat many spots in the brain and spare the patients a lot of the older side effects that came with brain radiation. So kind of a shameless plug for that kind of option there.
Last thing I want to mention is palliation, which is super important. So our patients who are just, you know, they’ve crossed the line and now they’re poly metastatic, I’m sorry, using the big words, but they’re poly metastatic. They have too many spots that we can’t, you know, just go after one by one. So they may have, you know, a bone mat that’s really painful or causing back pain or something that’s really debilitating.
We can go in and offer just one or two weeks of radiation with very, very significant pain relief. So now we’ve you know, we haven’t cured their disease, but we’ve really improved their quality of life. So the thing I love about my job here, aside from working with you guys and I’m going to keep plugging that, I’m sorry, but, you know, it’s just that from early stage, we talked about curative options all the way to late stage, and we’re talking about comfort care and things like that.
You know, my modalities of treatment have a place in all of that entire spectrum. So, you know, I couldn’t be happier working with this team. But that’s kind of an overview of our late stage options.
24:00 Clinical Trials
Amna Sher, MD
I was going to add one thing. I think immunotherapy really has revolutionized how we treat lung cancer. And matter of fact, any cancer these days, I mean, it’s really been ten years since the first immunotherapy was approved for lung cancer.
But I would also like to add that I think clinical trials are a key component of how we treat patients here. And I think I’m really excited to say that we have clinical trials for almost every stage of lung cancer patients.
We have trials for early stage lung cancer patients who are amenable to surgery, but as we discuss in our multidisciplinary platform, you know, they may benefit from your adjuvant. So we have trials involving new adjuvant settings with immunotherapy or some other novel agents.
We have studies for patients who have undergone surgery but still have a residual disease and there is a vaccine trial actually opened here, which we can offer to those patients.
And then we have a trial for locally advanced or unresectable and similarly for advanced stage lung cancer. And I think participating in clinical trials is a key component and thank you to all our patients who have participated and we are here because of their efforts.
Ankit Dhamija, MD
Agreed. And surgery as well has provided a role. I’m excited about the immunotherapy agents because it has offered an opportunity to consolidate perhaps a mid to early stage lung cancer where the lymph nodes may have been involved or the mass itself was so large that the patient may have not been amenable to a surgical resection, to now having the opportunity to have a complete excision with negative margins and no lymph node activity after a course of chemotherapy and immunotherapy.
So from a surgical standpoint, this offers a whole opportunity of treatment algorithms that we can offer our patient as well.
We also offer an excellent service within the Lung and Chest Disease Center where we follow all these patients from a survivorship standpoint. Once a patient has been treated, we follow them routinely as per NCI guidelines to look to see if there’s any recurrence. And that extends, again, as Dr. Albano had mentioned, to our support group.
Another point of mention is not only do we have a great cancer center here at Stony Brook, but we also have the Phillips Family Cancer Center, in which we are now also doing robotic surgery as well as have been doing radiation treatment and have excellent oncologists out there as well in that location out by Southampton Hospital.
26:30 Closing Remarks
Thank you both for your time today, and thank you to our listeners and viewers for tuning into this very important conversation today. The most important takeaway is that we can be a one stop shop for lung cancer management, inclusive of screening, diagnosis, treatment, including clinical trials, survivorship and support. We are here for you, our community.
Announcer
Stony Brook Medicine is Long Island’s premier academic medical center. We transform lives through scientific discovery, education and care, and we bring together innovative research, advanced education and extraordinary health care expertise to set the standard for how healthy communities thrive. For more information, visit Stony Brook Medicine or follow us on social media.
