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Dr. Mike Smith (Host): A diagnosis of lung cancer can obviously be quite a scary thing to go through, but research is producing better treatments. Welcome to The GW Hospital HealthCast. I'm Dr. Mike Smith, and today's topic; lunch cancer risks, treatments, and research. My guest is Dr. Keith Mortman. Dr. Mortman is Director of the Division of Thoracic Surgery and an Associate Professor with the George Washington University School of Medicine and Health Sciences. Dr. Mortman, welcome to the show.

Dr. Keith Mortman, MD, FACS, FCCP (Guest): Thank you for having me.

Host: So lung cancer. Obviously this is- it is as I said at the beginning I think can be a very scary diagnosis for everybody. How about if we just start with giving us a nice overview about lung cancer and maybe some of the different types.

Dr. Mortman: Sure. So there are two main types of lung cancer. It typically gets divided at least initially into- we'll just call it non-small cell, which is by far the more common variety, accounting for approximately 90% of cases. And then there's a small cell carcinoma accounting for another 5% to 8% of cases. That's usually how it gets divided initially.

Host: Yeah, and so when you say non-small cell versus small cell, what does that actually mean? Does that mean the cancer cells are small? Maybe can you enlighten us a little bit on that?

Dr. Mortman: Sure. In a sense that's really referring to what we call the histologic description or how it appears to the pathologist under the microscope. So the patient isn't necessarily going to sense any difference in terms of how they present. They can present with very similar symptoms, they can have very similar radiographic or x-ray findings. So that's more of how the cells appear under the microscope. Either way regardless, lung cancer still remains a very significant problem, particularly in the United States. As it has been for several years now, unfortunately it remains the number one cancer killer in both men and women in the U.S. So unfortunately, more people succumb to lung cancer than the next three leading causes of cancer combined, which is breast cancer, colorectal cancer, and prostate cancer.

Host: So when we look at how initially you can divide the type of lung cancer, let's talk about the one you said is the most common. That's the non-small cell cancer. Tell us about who's at risk for developing that one.

Dr. Mortman: Certainly we know the number one risk factor is smoking, is tobacco exposure. That's been extensively studied, but we know it's not the only risk factor. We know radiation is a risk factor, exposure to asbestos can predispose patients to cancer, secondhand exposure as well. So approximately 15% of the lung cancer patients that we now see have actually never smoked.

Host: Wow, and they are developing the non-small cell type of cancer here? 15%.

Dr. Mortman: By and large, exactly. More commonly that is what we're seeing.

Host: Let me ask you about secondhand smoke. How important is it for the listeners to really understand that that is a risk factor?

Dr. Mortman: It's certainly a risk factor. Even though these days it's less common to be exposed to that in the workplace or when you're out dining, certainly that exposure has been there for years or decades, prior to more recent regulations. Or if you live with a family member or loved one at home who's a smoker. So that's accumulative risk over time.

Host: I remember, Dr. Mortman, when I was a kid flying on airplanes, and do you remember that you used to be able to smoke on airplanes?

Dr. Mortman: Sure, sure, sure.


Host: And I can remember, so I think you're correct to say that maybe the secondhand smoke exposure got a little bit better based on new regulations. But for my generation, I'm assuming you and I are probably pretty close in age, we definitely I think were exposed to a lot more- to the secondhand smoke. What about other chemicals, toxins in the environment? Is anything else that we're often exposed to today been linked to the non-small cell lung cancer?

Dr. Mortman: Sure, I mean there are a number of known cancer causing chemicals that are called carcinogens, whether benzene and others. So if somebody does work in a particular field and they are exposed to a lot of chemicals or solvents, that could be a predisposing factor for those patients.

Host: Yeah. So that's the non-small cell type. Let's talk a little bit just about the less common type, which is the small cell lung cancer. Tell us who's at risk for that type.

Dr. Mortman: Well, it's almost similar risk factors in a sense, in terms we see that many of these patients who present with small cell lung cancer are also smokers, so that tends to hold true for both varieties.

Host: Yeah. So if somebody is listening and maybe is a smoker, obviously we're going to encourage them, Dr. Mortman, to stop smoking. It's like the best thing anybody could do. What are some of the symptoms they might want to watch out for that might indicate there's something going on?

Dr. Mortman: So some of the symptoms that patients with a cancer can present with can be varied, whether it's either a new cough, or a change in a chronic cough, whether it's coughing up blood, new shortness of breath, new discomfort or pain in the chest. Even non-specific symptoms such as fatigue or weight loss can be some of the common symptoms that we see in patients who actually have symptoms. The other thing to keep in mind is that a very early stage cancer, no matter the cell type, are cancers that tend to be smaller and actually do not have symptoms associated with them.

So it's often asked, "Well, how do we know about those tumors? How do we find those if there are no symptoms?" And usually we find those when we're not looking for them. So in somebody who has certain risk factors for cancers, but doesn't have any signs or symptoms, they might have their yearly check-up with their primary care doctor, some of those patients might be sent for an x-ray or a newer type of CT scan called a low-dose CT scan. So we're finding that we're actually picking up more of these smaller earlier stage tumors by this mechanism, by just scanning certain patients who meet certain criteria and who are at risk. Of course the other way that we find some of these smaller tumors before symptoms present, is for instance, if somebody is coming into the hospital let's say for a hip operation or a knee operation, and they just happened to get a pre-operative chest x-ray. So sometimes we can find some of these small nodules and work the patients up from there.

Host: Right, and it brings up I think a point, and I want to ask you this. On this show we've had other cancer specialists and we've talked about different types of cancers, and the consensus usually is if there are symptoms, if that cough is changing, get checked quickly because the earlier the diagnosis is made, the outcome is better. Is that true for lung cancer?

Dr. Mortman: That's certainly true for lung cancer. We know so much more about the diagnosis and the risk factors today than we did years ago. The treatment options have been better refined over the years, whether these are surgical treatments, whether they're medical treatments such as chemotherapy. Some of those agents are more targeted, our surgical options are more minimally invasive, more precise, shorter hospital stays. So I think all of the treatments across the board are so much better today than they were decades ago.

I think many patients have sort of this preconceived notion that a diagnosis of lung cancer today can be a death sentence, for instance, and I think one of the messages I'd like to get across is that's not necessarily the case. I certainly want to stress the importance of not ignoring a patient's symptoms should they have those, and to get, as you said, checked earlier so that if someone does have a tumor, we can catch it early when it's confined to the lung and hasn't traveled to other parts of the body. And we do have the potential to cure these patients of earlier stage disease.

Host: Well let's talk a little bit about that then. Where were we with the treatment of lung cancer? Where are we today? And where do you think we're going when it comes to treatment of lung cancer?

Dr. Mortman: Well I think as a thoracic or chest surgeon, where we've come, the scales have certainly shifted in the past I would say fifteen years for sure, in terms of the common treatments that we offer. I would say twenty years ago, the so-called standard of care would have been a larger incision for patients who were offered surgery, what we called an open thoracotomy, which required- it was certainly more invasive, there was more discomfort from that approach, required a longer hospital stay, and longer recovery afterwards.

These days, the scale is tilted the other way so that the majority of patients are now offered minimally invasive surgery. I'm happy to say that more than 90% of the patients I operate on, I can offer a minimally invasive approach to. Some of these patients can be treated with using the surgical robot. That's just one way to do a minimally invasive operation. And the benefits of a minimally invasive approach are not just merely the cosmetic- the cosmesis of it and having smaller incisions, but we know that there's less pain afterwards, which leads to faster recovery, shorter hospital stays, getting patients back to their families, back to their job sooner, overall faster recovery, and we know in patients who might need additional treatment after surgery, such as chemotherapy, that now they're better able to tolerate those treatments. And there's actually even more data coming out now, more research that shows that people who have a minimally invasive operation may actually have better survival afterwards as well.

Host: That's fantastic to hear. You know, we've talked about a lot in this interview, Dr. Mortman. How about we end this way; what would you like the listeners to know about lung cancer?

Dr. Mortman: To know that obviously it's an extremely serious disease, that it is even more common than I think most patients realize, that if anybody has any new symptoms such as the ones that we discussed such as a new cough, or coughing up blood, shortness of breath, to please consult with their primary care physician so that they can be worked up a little bit more. For patients who are at risk for lung cancer, meaning they're in the 55 to 77-year-old age range, if they have a prior smoking history where they've smoked more than one pack a day for thirty years or the equivalent, or even if they've stopped smoking, and they've stopped smoking within the past fifteen years, we know that that is the highest risk group, and that's a group that can be offered a screening exam such as a low dose CT scan, where we can find these tumors when they're smaller and curable.

Host: Very good. Very nice summary, and Dr. Mortman, I want to thank you for the work that you're doing, and also thank you for coming on the show today. You're listening to The GW Hospital HealthCast. For more information, go to www.GWDocs.com. That's www.GWDocs.com. I'm Dr. Mike Smith, thanks for listening.