Surgical Treatment of Lung Cancer Webcast May 11, 2010 Malcolm DeCamp, M.D. Nick Meck. Nick s Story

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1 Surgical Treatment of Lung Cancer Webcast May 11, 2010 Malcolm DeCamp, M.D. Nick Meck Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Nick s Story Lung cancer affects more than 200,000 Americas each year, and although the diagnosis can be terrifying, advances and treatment are making a difference to patients with lung cancer. Coming up, a leading expert will discuss minimally invasive surgery options and the importance of multidisciplinary care. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by Northwestern Memorial Hospital. I'm Andrew Schorr. Well, when you talk about cancer, lung cancer is right up there. It's the second most common cancer, more than 200,000 people diagnosed each year. Unfortunately, it is the most deadly. Now, we often think that someone who smokes a lot, or is exposed to smoke, is most likely to be diagnosed with lung cancer, and that's true, but there are other causes as well. There are people who have never smoked who develop lung cancer. We'd like to say there are always symptoms that are a tip off that lung cancer is there, it can be caught early, but sometimes there are no symptoms. So what do we do? Well, surgery remains really the mainstay of lung cancer treatment for many people diagnosed, and fortunately now there are much less invasive ways of doing it, that can in some cases even be curative, but certainly limit the effects of lung cancer. We're going to hear all about that with a leading thoracic surgeon from Northwestern Memorial Hospital, but first let's meet a patient. Nick Meck joins us from Cicero, Illinois, and he is 60 years old. Nick, you had surgery for lung cancer in February, just a few months ago. First of all, how are you doing? I'm doing fine. Doing fine. Now, I understand you're a golfer. Are you back to golfing? Yes, I am. And you have hope for the future.

2 Oh, yes. Okay. Well, let's back up, though, because if we go back to the summer of 2009 I understand you were at a wine festival in Naperville, Illinois, and there was an opportunity to sign up for one of those scans that you can get. You signed up. Correct. You had the scan. What did it show? It showed that there was a nodule in my right upper lobe. Now, did you understand just with this report that they sent you what a nodule was? Oh, not really. I knew there was something there that wasn't right but nothing that concerned me at the time. It concerned my sister more. Let's talk about that. You go back to your old home town of Girard, Kansas. I know your mother, Mildred, was very sick. And you re with your sisters. There's a sister who sees this report. She doesn't want to just forget about it. What does she do? She makes me an appointment with my mother's doctor. Good thing. So you go to the primary care doctor, I believe it was Dr. Liz Salvador in Girard. Correct. And what does she do? She starts running tests. 2

3 Now, did you have any symptoms at all? None. None whatsoever. So you were breathing okay. You were doing your normal activities? I wouldn't say I was breathing okay because I was such a heavy smoker, but I wasn't stopped from doing anything. And you were smoking. Yes. Now, let's talk about smoking. You started smoking as a teenager? Correct. And would you say over the years, how much did you smoke? Probably averaging it all out, two packs a day. Wow. Okay. So you were still smoking. Your breathing was limited some, but otherwise you felt okay. Correct. You had the test in Girard, Kansas. And was Dr. Salvador concerned? Yes. So you go home to Chicago, and Dr. Salvador said, knowing you were going home, what phone call did she make? 3

4 She called Northwestern to find me a doctor, and that's how she hooked me up with Dr. DeCamp. We're going to meet Dr. DeCamp in just a minute. She wanted you to see a specialist. Correct. So you go to Chicago. You meet Dr. DeCamp, who we'll be hearing from a lot in just a minute, and he says he thinks you need surgery. Now, how did you feel about that with the confirmation that you had lung cancer? Well, he does such a good job that I was very comfortable. He told me what they were going to do, said what we can do, and we'd have to go in and look and see what it called for. Now, you were told that you could benefit from what's called video-assisted thoracic surgery, where they can go through little spaces in the chest rather than opening the whole chest. Correct. That meant for a quicker recovery for you, I imagine. Oh, yeah. I probably got on the golf course three months early. Oh, wow. Okay. And feeling good. How is your breathing? It's a little bit better. I see my other doctor about that on Monday, so I'll find out if I've showed any improvement. Okay. All right. So you feel like you've come through this pretty well? Oh, yeah. 4

5 All right. Well, we're going to be back to you in a little bit to hear what you'd say to other people. I know you probably have some thoughts about smoking and kids starting smoking and also about pursuing an unusual finding on a scan and getting the care you need, and you may have something to say about Northwestern as well. Let's meet your doctor. Your doctor is Dr. Malcolm DeCamp, and he is actually the chief of thoracic surgery at Northwestern Memorial Hospital. He is a surgeon who specializes in this, helps a lot of people who need surgery for lung cancer. First, just one bit about minimally invasive surgery, Dr. DeCamp. It used to be when somebody needed surgery you had to make a big incision in the chest and go in there that way. That meant a longer recovery, maybe a higher risk of infection. It was more difficult. How do you do it now? With several difference advances in imaging, bright lights, xenon light sources, and microchip cameras we can see very, very well within various body cavities. In the chest it's called thoracoscopy. We can make five- to ten-millimeter incisions and put one of these, essentially television cameras, in the chest that really gives us excellent exposure and even magnification, so that we see better than we used to through large open incisions. I think there's a tremendous advantage, and it allows us to do quite a few of the operations that we traditionally learned through large, open rib-spreading incisions using minimal access, with small, port incisions. That translates for the patient into a lot less discomfort, a much shorter stay in the hospital, a much shorter period of recovery, a lot less pain medicine usage, and back doing things they'd rather be doing earlier. And you do a high percentage of your lung cancer surgeries, when surgery is indicated, that way at Northwestern. That's correct. Probably 70 to 80 percent of the operations we do are by VATS, which is an acronym for video-assisted thoracic surgery. There's still probably 20 percent of operations that are not appropriate for that, based on the size of the tumor or its location, but the vast majority of tumors that we approach can be approached minimally invasively. Risk Factors Now, I mentioned about lung cancer being our biggest cancer killer, and I think if you rolled up the deaths from a number of other cancers it still wouldn't total the people we lose to lung cancer. I mentioned about smoking. So smoking is a big risk factor, right? 5

6 That's correct. It's clear that the majority of people that get lung cancer are or were smokers. There is probably five or eight percent of nonsmokers who get lung cancer. A number of those unfortunate patients have been around areas where there was a lot of tobacco smoke, and that's caused us to learn about some other associations, in terms of exposures that can contribute to lung cancer, but far and away tobacco use is the number one reason. Earlier in this last century, before there was mass production of cigarettes, lung cancer was a pretty uncommon disease, but in the last hundred years it's now killing more people than breast, colon and prostate cancer added together. Now, I mentioned that there can be other causes, as you said too, and we'll just put those on the list for people. Asbestos, for sure, can play a role, and I understand also even radon that might be coming up from the soil and be in someone's basement, that could be a factor. Now, we're talking about the minority of cases, but they're on the list as well. That's true. And asbestos is a little confusing because asbestos exposure alone without tobacco has not been shown to really contribute to lung cancer. It does contribute to a more unusual, but difficult to treat kind of cancer called mesothelioma. When you combine smoking and asbestos the risk of lung cancer goes up even higher than those that simply smoked. Radon is another associated risk factor. In areas of our country where there is radon exposure, it's been associated with lung cancer. It hasn't been proven as cause and effect. Same thing with uranium miners and a few other unusual occupations that that have been associated with a higher rate of lung cancer. But with cigarettes, it's one of the few absolute causes where we biochemically know and have proven that the carcinogens in tobacco smoke cause lung cancer. That's pretty unusual. There are a number of cancers where we don't know what causes them. This is one example where we do. One word about smoking because we're always telling people don't start, or quit. If somebody quits, they still are at risk years later, but does their risk go down over time? Absolutely. Absolutely. There's a whole lot of health benefit from quitting smoking, and, you're right, the primary prevention or never starting is the best solution, but in the absence of that it's clearly beneficial to quit. The various disease risks go down in different ways. Within five years of quitting smoking your heart disease and stroke risk relative to smoking approach that of a nonsmoker. Now, you may have other risk factors for those diseases, but at least that conferred by smoking goes back towards normal. If you don't have emphysema you're unlikely to develop it if you quit. 6

7 The cancer risk, though, takes a long time to go away. It probably doesn't really start going down for about four or five years, but when you get, say, 10 and 20 years out from quitting, your cancer risk is coming down much closer to that of a nonsmoker. So there's a lot of health benefit, but those who have smoked more than 15 or 20 years, or in a higher dose such as Nick, where he smoked two packs a day, when we get up though those levels that patient is always going to have a somewhat higher risk than a nonsmoker and would be an appropriate patient for us to be vigilant about doing surveillance. Symptoms & Detection Yeah, we're going to talk about that and what the thinking is. I just want to tell a brief story. I've been married almost 25 years now, happily. The wedding gift that my mother-in-law gave us was to quit smoking. So what you just said about that rate decreasing, the fact that she stopped 25 years ago and is healthy, I feel good about her risk being pretty low now. Let's talk about surveillance. So here Nick had no symptoms. His breathing was affected, which he felt as a smoker, but there wasn't any change that he noticed, and I understand sometimes there can be no symptoms. What are symptoms that might be seen, and how do we have proper surveillance no matter what? Sure. Great questions. Unfortunately, the symptoms related to lung cancer usually also go along with advanced disease. The symptoms of coughing up blood, recurrent pneumonias, hoarseness, and then some of the general symptoms of cancer, such as weight loss and chronic pain, are usually the type of symptoms that occur in patients with advanced disease, where our chance of fixing the problem is much less. So in fact the patients who benefit the most are the ones we find like Mr. Meck, who don't have any symptoms. That's more typically early-stage disease where our chance of cure is much higher. So that begins to beg the question of can we identify a group that's at risk, and look more aggressively, or even screen that population? And that becomes a bit of a controversial topic in medical investigation, but from my perspective and a common sense perspective, I think it makes great sense to look in that group. And Nick would be smack in the middle of that group, a gentleman with some obstructive lung disease, clearly the smoking risk factors, and that would be the ideal population to look more aggressively, to find them early like we found his. And when you can find it early, Stage I, what's the prognosis versus when it's so much more advanced? Stage I lung cancer is a tumor in the lung that hasn't spread to any lymph nodes, and it varies a little bit based on the size of the tumor, but the cure rate with just 7

8 surgical removal is between 65 and 80 percent, depending on the size of the tumor. So if it's a small tumor, under two centimeters, the cure rate approaches 80 percent without the need for any additional treatment. That's far, far better than the more advanced stage diseases, for example the patient that presents with hoarseness where the cure rate is probably only 20 or 25 percent. Oh, my. Now a little bit about surveillance, and then I want to talk about more surgical options and understanding that. There is this controversy, for instance there's research going on about what I think you call spiral CT? Should someone have a certain kind of CT exam regularly if let's say they've been a two pack a day smoker, or exposed to a lot of secondhand smoke risk factors? And would it be helpful or would it simply find things that really didn't need to be treated at all? Yeah, that's the controversy about CT screening for lung cancer. One is an economic argument that you will find other things that drive up the cost of healthcare that are unrelated to what you're looking for. And while I understand that, I'm more interested in taking care of my patients like Nick, where if we find lung nodules and we're thoughtful about how we approach them, and we find the majority of these are early stage, and we don't subject patients to unnecessary operations, that we're going to change the overall survival of lung cancer. As you know, there are a little over 200,000 people diagnosed every year, and unfortunately only 15 percent of that whole group survives. That means we're finding a lot of late cancers. If we could flip that over and find a lot of earlier cancers we'd see tremendous improvement. So it flies in the face of common sense to me not to pursue this. Hopefully later this year we're going to have some preliminary information from a large, more than 10,000 patient study, called the National Lung Screening Trial, that hopefully the early results will be released here in Chicago next November. Northwestern has been one of the leading institutions involved in this, and we may begin to develop some scientific evidence to support screening for lung cancer, just like we do for breast, colon or prostate. Nick, you were a lucky guy to have that screening, to be at a wine festival and be offered a free screening, get it and for it to show up and get the ball rolling on this, weren't you? Did you think it saved your life? Definitely. I think I have a lot of people to thank for that. Yeah, you wouldn't have been playing golf yesterday had this not been caught as early as it was. 8

9 We're going to take a quick break. When we come back, Dr. DeCamp, we want to talk more about the work-up, like there were various tests that Nick had or what typically would be done to see what are you dealing with, and then how you decide what approach can work, recognizing that surgery is the mainstay so often and, as you said, potentially curative. So we'll be back with more Patient Power and a discussion of surgical options for the treatment of lung cancer right after this. Treatment Welcome back to Patient Power, as we're visiting with Dr. Malcolm DeCamp who is chief of thoracic surgery at Northwestern Memorial Hospital. He helps people surgically with lung cancer, among other illnesses, and surgery really is a mainstay in many cases of people with lung cancer. Dr. DeCamp, help us understand that. So there are many other cancers that simply have drug therapies and things like that, and radiation can come into play, but surgery is often the foundation when it comes to treating lung cancer, isn't it? That's correct. The vast majority of patients that are cured of lung cancer have their cancer removed at some point in the course of their disease. The way we decide that is assessing the stage of the disease, whether other areas of the body are involved and then tailoring or customizing a treatment plan for every patient based on the biology of their tumor, the stage of it, how advanced it may be, and also the physiology of the patient, what other medical problems they bring to the table. We have to tailor treatments both to the tumor and to the patient. Now, that brings up this term "multidisciplinary team." So you meet with physicians with related specialties, I think, every week, and you discuss cases. Tell us about the team discussing and seeing what's best for Nick, or other people like him, so you make sort of a group recommendation to the patient. I think that's really the future of medicine. We're going to organize groups of specialists by disease state, instead of by what we do. The traditional medical centers have been silos of medicine, or surgery, or radiotherapy, but patients are interested in what's the best treatment for their disease. So we have a multidisciplinary team that gets together every Wednesday to discuss patients with lung cancer. We have a similar team that gets together on Tuesdays that talk about patients with gastrointestinal tumors, and it's made up of thoracic surgeons, medical oncologists, radiation oncologists, and pulmonologists, with participation by our diagnostic radiologist, as well as our pathologist, so that we try to look at all aspects of the patient's problem. And typically we talk about the x-ray data that we have about the tumor, the information we would get from fancier tests to assess where it may or may not have spread, and then we all agree on a particular treatment plan, which would be 9

10 in some patients a sequence that would involve surgery first, and then consideration of other treatments based on the pathology report. And sometimes we have preliminary information that already suggests that the tumor may be more advanced, and we may start out with chemotherapy and/or radiation first, and then talk about surgery later based on how the patient responds to the initial treatment. So that's the art of what we're doing, trying to tailor, or individualize, or personalize medicine to fit every patient's problem. Let's talk about that where sometimes it would be flipped. Surgery might not come first. Is the goal there to use radiation or drug therapy to shrink the tumor so that it's more defined for you to remove surgically? Well, the goal is to do the right thing for the patient, and we think of surgery and radiation as local treatments, local modalities. They fix what you aim them at, whether it's my hands or the radiation beam, and the role of medical oncology and chemotherapy is to control the disease distantly or remotely or even the microscopic disease that we can't detect but we know statistically is there. So we talk about that when we talk about staging of in this case lung cancer. So if we find disease has already spread to lymph nodes in the middle part of the chest we know that that's stage III disease, and that's a marker that there's very likely microscopic disease elsewhere in the body, and the way patients fail treatment is not usually in the chest but somewhere distantly. So the most important part of their treatment is to get started on treatment that's going to attack the microscopic disease elsewhere. We would start with chemotherapy. We often add radiation initially so that we're addressing not only the disease distantly, but also the disease in the chest, and then if we see that there's good evidence that the patient is responding, that reassures me that we have an effective systemic arm of treatment to stand on in the long-term and that it justifies the risk to the patient to undergo a sizable operation to clear the tumor out of their chest. That's the thought process that goes into it for a locally advanced tumor. Fortunately, in Nick's case there was no evidence by the PET scan that things had spread anywhere. We went one extra step at the time of surgery and using a different minimally invasive technique looked at the lymph nodes in the middle part of his chest at the time of surgery, had our pathologist examine those while he was asleep, and reassure myself, and in that sense Nick, that there was no microscopic disease in those lymph nodes. That tells me in real time that he indeed does have earlier stage disease, where an aggressive surgical approach is likely to be curative. Now, we talked about this multidisciplinary approach. That involves, once there's a recommendation on a plan, and someone like Nick says, yes, let's go ahead, so 10

11 there's coordination too. So there may be coordination between radiation oncology, medical oncology, surgical oncology, everybody working together most efficiently for that patient. That's exactly right. So we talk about these patients like Nick, almost, I won't say weekly, but on a regular basis, as he progresses through the treatment. So when we spoke about him early on, after I first met him in January, and in that situation it looked like he had earlier stage disease, but he had some breathing problems, and so I needed to get our pulmonologist involved to get him in shape to have surgery. So Dr. Kalhan, in our pulmonary group, became captain of the ship, got him buffed up, and then he came back to me, and we went on and looked at the actual tissue after I did his surgery. Fortunately, all those nodes were negative and benign, and so he had early stage disease. So when we talked about him the next time in our multidisciplinary group we knew he had Stage I disease, and our medical oncologist agreed that there's no role for chemotherapy at that stage, that he's in good shape, and that he had a complete resection and no margins were involved, so that the radiation therapist didn't need to get involved in this particular case. That's one end of the spectrum. The other end of the spectrum is situations where there may be nodes involved, or margins involved, and you end up with all three oncology disciplines involved in caring for the patient, surgery, radiation and chemo. Dr. DeCamp, I want to talk about statistics for just a minute. The statistics are tough in lung cancer when somebody themselves or a loved one is diagnosed with it, but I'm sure in your career you've seen statistics defied, if you will, in individual cases. And also, the statistics are based on the last few years and hopefully we've been trying to make some progress. But when you have someone sitting across from you and they've been diagnosed, you give them the lay of the land, but their situation could be better or worse. I mean, it could vary, right? Absolutely. You're exactly right. Statistics are groups of patients and usually in large numbers, and then my job is to try to translate that for the patient into individual information that's useful. So that when you look at overall statistics it can be really depressing. 200,000 people diagnosed and 180,000 people dying, people get pretty depressed about that. But that glosses over the details of what's specific about this patient. What exact stage do they have, and even within that stage is it bulky disease, is it microscopic, so that I can take the staging information and try to individualize the information for the patient. There's a tremendous amount of nihilism about lung cancer in the lay world, and even in the medical world, yet we have effective treatments for almost every stage of the disease now. Some of those treatments help people live longer with their 11

12 disease, or improve their quality of life, and others of them lead to cure. And if we don't have a more proactive approach to this then we're not going to make great progress. So I think the future is improving. If you look over the past 30+ years, in the 70s when the Surgeon General's report came out, where we started to label cigarettes and things like that, 60 to 70 percent of adult Americans were smokers. Now that number is down around 30 percent. So from a public health standpoint a lot of good things have happened. You're just seeing it takes a long time to start affecting the actual number of folks dying. We've got to get our president to quit smoking. I'm not sure whether he has. Maybe he's trying. Oh, I hope so. I don't care how many times people have tried, I encourage them to try again. There are a lot of good tools to help people. It's a tough addiction. It's more addicting than heroin or cocaine, so nicotine is a real problem. But there are a lot of aids. None of them will do it for the patient. They all require the patient to be motivated, but I think just because you've failed in the past doesn't mean you shouldn't try again. Amen. And I know Northwestern has some really good programs to support people. Let's talk more about surgery. So, first of all, the goal of surgery is to cure someone if you can, but you also mentioned about quality of life. So you take out, let's say, Stage I with Nick, you take out the nodule. In some cases you have to take out part of the lung, or I imagine there are even cases where maybe you even remove one of the two lungs? How does somebody go on from there? Can you live okay? And I know it varies, but describe the sort of recovery and life after surgery. Sure. A lot has to do with what type of operation we do, and I think minimally invasive surgery has helped a lot with the general recovery. It's less painful. There's less need for pain medication. There's less chronic pain, but a lot also depends on how much lung we need to remove. And that's a combination of what's the right operation for the tumor and what's the right operation for the patient. So Nick has some fair amount of obstructive lung disease, called COPD, and if we had tried to take out too much lung then we'd trade curing lung cancer for making his emphysema worse. For a lot of patients, their quality of life is as important, if not more important, than their quantity, so we have to make those kind of judgments ahead of time and talk about innovative compromises. So we can take out a lobe of the lung. Sometimes we take out a segment of the lung. Lobes are made up of segments. It's still a good cancer operation because 12

13 you remove the tumor and the draining lymph nodes (that's the operation we did for Nick) but it preserves a little more lung function. And I think it's appropriate especially when we find small nodules. So his nodule was under two centimeters in size, and there's some emerging data that a smaller operation may be just as good as a bigger operation in that case, and it helps preserve quality of life. I also expect his lung function will improve now that he's continuing to quit smoking, though those improvements take more like months to see them. So I hope when he has his follow-up with his pulmonologist this week, we will see that the numbers have gotten better. I'm really more interested in how he's feeling, so I'm kind of happy to hear that he's back on the golf course. Nick, how is your golf, by the way? How are you scores? Too high. It's costing me money. Okay. But the point is it's got to be a blessing that you can get out there and do it at all. Oh, my friends and I, we thank God every day. Well, they're very thankful if you're losing money to them. Oh, yeah, they're happy for that. Dr. DeCamp, now, we mentioned in passing the biology of someone's lung cancer. I know the majority of times it's something called non-small cell lung cancer, but there's also small-cell lung cancer. So is it part of that multidisciplinary meeting you have, part of it is discussing not just how big the tumor is or where is the cancer but what's its biology? And I understand the approach can vary. Do you want to comment on that for a second? Sure. About 85 percent of lung cancers are non-small cell, so that makes up the majority of tumors. And that's almost always the kind of tumor in someone who has quit smoking. Small cell is a minority of cancers. It's almost always in someone who is actively smoking. It's a more aggressive tumor and there's much less role of surgery and a bigger role for chemotherapy and radiotherapy for small cell. But even within non-small cell, which is that big majority number, there's a lot of subtypes within that. That's where there's a lot of excitement in the field because we're now approaching for example adenocarcinoma, which is a subtype of 13

14 non-small cell, with a regimen that might be a little different than if it's a squamous cell tumor. So we're being able to dissect through the biology and come up with much more tumor-specific treatment. I think what we'll see in the next 10 or 20 years is that we'll come up with very tailored treatment plans based on the better understanding of the biology of the tumor. I think you've spoken with some of my colleagues in the past in medical oncology about how we're trying to come up with personalized treatments based on more than just the size, as you said, of the tumor. Right. Traditionally someone would say, well, tell me, how big is the tumor and has it spread, and those were the key questions. And now we're talking about the actual biological makeup. And just so people understand, cancer didn't come from somebody else. It's not an infection you receive, but it's your own cells growing inappropriately, kind of bad copies, if you will, and they just keep growing and in some people more aggressively. I always think of it like a copy machine that's making bad copies, and sometimes that copy machine can just go crazy or it just makes bad copies at a lower rate, and that varies. So that discussion of what's right for an individual patient then is really key. It's not at all a one-size-fits-all, is it? Not at all. Not at all. It needs to be tailored, as I said, to the biology of the tumor and the physiology of the patient. And even following that there's a large number of those patients. Even if surgery is the right procedure, the majority of those can be approached less invasively. It's unusual in this day and age for us to take out a whole lung. If you have normal lung function you would do fine with only one lung. God blessed us with a lot more breathing capacity than we need as long as it's still normal. So we have to base those decisions not on how much we should take out, but how the patient is breathing, where the tumor is located, what's right for the cancer, and what's right for the patient. Now, let me ask you about basing decisions on different criteria. What about age? So Nick is 60. What about if somebody is younger? What about if somebody is a good bit older? Where does that come into play? Again, age by itself is somewhat of a risk factor for complications of surgery. It seems less so when you are able to do things minimally invasively, meaning that if you used these minimally invasive techniques that seems to mitigate some of the risk related to age. But my experience with patients is the older they get the less worried about how long they live enters their thinking and they're much more concerned with their quality of life, so that smaller operations, more focused operations on the tumor, or less radical operations are appealing. They're willing to trade something that might give them a lower risk of recurrence for something that is a lot less invasive or a lot less likely to reduce their breathing capacity. 14

15 So there's some data out there that if you do a resection smaller than a lobectomy that the risk of recurrence is a little higher. Instead of two percent per year it might be up to four or five percent per year, but if you're in your 80s five years later that means your risk is still only 25 or 30 percent that it might come back and you'll be 85. We make that kind of trade-off all the time. But I have that discussion with the patient ahead of time, and it really is based on what they're most concerned about. One question about recurrence. Nick is going to be followed, and you said he has his meeting with his pulmonologist. So there's going to be surveillance with Nick. What if something shows up again? Could he have minimally invasive surgery again? Sure. We haven't burnt any bridges, and that's one of the nice things about the minimally invasive approach. Re-operations are probably a little bit easier, actually. Surveillance is very important. We know the population with the highest risk to develop lung cancer is the patient who has already previously had one. So if there's an argument to be made about who should be followed the closest it should be our patients that have already had lung cancer operations. So we're going to see Nick on an every six-month schedule for at least the first two years, and maybe a little longer, and then probably at least once a year until we're out five years. Those will be with CAT scans to follow him very carefully. When we get out beyond five years we're still going to see him on a regular basis. We may alternate the kind of imaging we do just to minimize the radiation exposure. You may have a whole new technology by then. Yeah. We're going to take another break. When we come back we're going to talk more with Dr. DeCamp. We're going to hear more from Nick Meck. It's all part of our discussion on surgical options for the treatment of lung cancer and also our overriding message of prevention. We'll be back with more Patient Power right after this. Welcome back and thank you for joining us for our Patient Power discussion about lung cancer and surgical treatments. We're visiting of course with Nick Meck from Cicero, who had surgery a few months ago. Fortunately, his lung cancer was detected through a scan he had that he sort of won, if you will, at a wine festival, and he followed up with the urging of his sister, and it was a nodule that could be removed and it was caught early. Now, he's a man who smoked his whole life so 15

16 he's going to be followed carefully because, as we just heard from Dr. Malcolm DeCamp, the thoracic surgeon, that he's a higher risk for it coming back, but he could have surgery again. We want to catch it early. So, Dr. DeCamp, let's talk a little bit about recovery. So Nick goes in or someone else goes in and they're having this minimally invasive approach. Do they have to be at the hospital days before, and how long do they stay? Just tell us about that experience. Well, almost all of our patients are admitted the day of surgery, so the era where you come into the hospital days in advance is behind us. We have people up and in a chair often on the day of surgery and walking the next day. A typical stay for a resection smaller than a lobectomy like Nick's is only one, two, three nights in the hospital. The lobectomy is more like three days in the hospital, and that's half of what we used to see for traditional surgery where we made larger incisions and had to spread the ribs. The practical issue is there's just a lot less pain. But I think it might be better to get that from the patient's perspective. From Nick. Right. Nick, tell us about it. So you go in the day of the surgery. Yeah. And then how long were you there for and how were you feeling in the days afterwards? I think I was there three nights. Friday night, Saturday night, and Sunday night. The first two days I didn't feel real, real good. I didn't want to dance or anything, but by Monday I felt pretty good. A little bit of soreness, a little bit stronger than I'd say soreness, and I was ready to go home. So then you went home, and as far as your activities, now we're a few months out and you're playing golf. And were you working on it? Was there some therapy or something to help you keep your lungs getting healthier? Well, just some breathing exercises, and I had some inhalers, and that's about all I did. I wasn't supposed to lift anything more than a gallon of milk, so I didn't have to take out garbage for a month or two. 16

17 Good for you. There are benefits to this, I guess. So now you're working on your golf game. What's your hope for the future? You're going for regular checkups. What's your hope? I hope that I never see that again, my golf game gets better and I retire before long. Right. Now, you've got a little grandson. What's his name? Logan. Quitting Smoking So you want to be able to visit Logan and just look for a bright future, but you look back on your years of smoking, and this is no judgment because I know you're in the printing business, and I bet a lot of the workers in the printing plants smoke, right? At one time there was a 70, 80 percent of all of them smoked. Right. So you were smoking, you were around it. But if there's, let's say, someone listening who has the opportunity to smoke or maybe they have a teenager in their family who is thinking about smoking, what would you say to them? Oh, try everything you can, just keep trying to quit. It's a smelly, dirty habit. I enjoyed it for 40 years, but it's the smelliest, dirtiest habit I've probably ever had. And you were aware that you were at a risk for lung cancer, right? Everybody knows that. Oh, yeah. I enjoyed it too much. It's so addictive. It's so addictive. Any word about that, Dr. DeCamp? People, should they enroll in a program? My mother-in-law just chewed that nicotine gum like her jaw was going to fall off, but you don't have to do it alone these days. There are a lot of programs, aren't there? 17

18 There are a number of programs. We have a great outpatient program. Sometimes these sort of things are easier to do in a group setting where there's some shared experiences with peers and a little peer pressure to keep going. Whatever tools appeal to the patient. There are quit lines in almost every state in the country QUITNOW, usually will get you access to some resources that can be helpful. Every state is a little different about what services are free and what costs a little bit, but there's so many different tools they're often complementary. There is nicotine replacement, like the patch or the gum or those little nicotine inhalers. One of the misconceptions is that it's the nicotine that's bad. The nicotine keeps you addicted, but it's not what causes the cancer. My own mother was, as I used to call them, a dedicated smoker for 30 or 40 years and she tried 10, 20, 30 different times to quit, and has finally been successful, and she still chews nicotine gum when she feels a little stressed. So I think that's a fair trade off. I've encouraged Nick to stick with it. It's hard. A lot of folks gain weight when they quit. That's okay. I think the health benefits of quitting smoking are still better than worrying about a little bit of weight gain. And then you get over the psychological hump and you can work on the weight a couple of months down the road. Whatever works. Now, of course for your mother it might have been thinking her pride in my son, the doctor. I've been doing this for about 20 years so it's taken me a lot of my adult life and practice to help her be successful. But as I said earlier, nothing is going to do it for you. The patient has to be motivated, and they have to decide themselves that they want to do this. I appreciate Nick's continued efforts and I hope people will not wait until they get a lung cancer to do this. Now, I should mention that in our library on the Northwestern Memorial web site in the ihealth section there is a program we did with Carol Southard, who is a nurse who has the tobacco treatment program. She's involved in that at Northwestern. Right. So that's support right at Northwestern, but there are programs, and as Dr. DeCamp said there is a phone number you can call. There was that lawsuit against the tobacco companies years ago, and all the states set up quit lines and have programs for you. So you don't have to do it alone, but it is important to do it. And whenever you start or try again, that's all to the good. 18

19 And then secondhand smoke is an issue too. I was thinking about it. Went by the supermarket yesterday, and I saw unfortunately two of the people I know who work at the supermarket outside kind of huddled in the rain and they were smoking. And while it was a social thing for them, they were kind of out in a corner, which in many states is where you're required to go now, but yet people continue. But at least we're trying to get smoke out of the public environment, and that's got to be to the good. Absolutely. I think that the most famous group for that were the Canadian flight attendants. A number of years ago they used to have smoking on airplanes and as soon as you took off, a passenger could light up, and the farce that there was a no smoking section, within ten minutes that tobacco smoke was everywhere. So the Canadian flight attendants participated in a study that showed that on transcontinental flights they had the same amount of tobacco metabolites in their system at the end of a long flight as the active smokers did, so that's been very helpful to help us get tobacco smoke out of the work environment and now out of the public environment. So you do see people huddled around outside all sorts of places, hospitals, bars, restaurants, workplaces. Shows you how powerful the addiction is, though, that they're out there in the rain. Progress and Hope for the Future Right. Or the snow. Right, absolutely. So looking forward related to surgery, you've made this really tremendous progress as far as the tools for the minimally invasive approach, and that makes a big difference for people as far as the recovery and all the other benefits you talked about. Is there any innovation you're working on that could be next to improve that still further? Well, I think we're hoping to demonstrate not only that the minimally invasive surgery is equivalent, but there is some hope that we'll be able to demonstrate scientifically that it's less suppressive to the body's immune system and perhaps the cancer outcomes are going to be even better with minimally invasive surgery compared to conventional operations. We're constantly trying to improve technique and remove less functional lung. There are some exciting new ways to ablate lung tumors with different kinds of energy sources, whether it's with radiation or radiofrequency ablation or cryo. It remains to be seen whether those are going to be as good as taking things out, but those are all under investigation. So I think the era where everybody has to have a big rib spreading incision is behind us. What I'm going to look for in the future, I think, is more collaborative and complementary treatments between myself and our medical and radiation oncology colleagues to really focus on the biology of the tumor and get away from the size issue and down to more of the cell types and the proteins and the molecules expressed by these tumors and really try to come up with individualized treatments. That's, I think, the most exciting development in lung cancer beyond 19

20 resolving the whole dilemma of early detection we talked about earlier, and the conversation about agreeing to look at the population at risk, coming up with some screening recommendation because it's the only cancer for which we know who is at risk. We know exactly who is at risk, we have a test that can detect it, and we just need to use it and have it adopted as part of standard medical care just like mammography and PSA and colorectal screening is. Right. Dr. DeCamp, at Northwestern the vast majority of the procedures you're doing are these minimally invasive procedures, but that's not done everywhere. So someone who s listening, they could be anywhere in the world really, or certainly anywhere in the country, or down the block, or across the state, or across the country. Do you welcome second opinions? Are you open to that so that if somebody says, well, gee, Northwestern takes this minimally invasive approach most of the time. Can I consult with them, because maybe that's not what they were hearing somewhere else? Absolutely. Absolutely. It's estimated in North America, or the US, only about 10 percent of the lobectomies for lung cancer are done using VATS or minimally invasive surgery, yet in our practice that's going to be greater than 50 percent and probably closer to 70 percent. So we're very happy to render an opinion, meet folks, not that we're disagreeing with whoever else they've chatted with, but we can explain the risks and the benefits and how we are making these decisions and help patients by providing them with the information they need to make an informed decision. I think that's all you can ever ask of a patient, is that they make informed choices. And in the end, it's their choice. Absolutely. Well, we call our program Patient Power, so I want to underscore just a couple of things we talked about. Well, a few things. One is prevention and surveillance if you're in that high-risk group. Nick was really fortunate that it was caught early, but also about how can you get informed so that you can understand what your options are and also maybe seek information from more than one source. Like we were just talking about second opinions where you can hear that at Northwestern they do this more often than a lot of other places, a minimally invasive approach, and that can have advantages for you. And then personalized care and this multidisciplinary team, I can't tell you how important that is when we discuss cancer because you want all those smart people talking about you and then making a recommendation coming from their different perspectives. And when we talk about biology of the tumor, and not just size and 20

21 where it is, and also your specific type and your own situation, all that comes into play. It sounds like you're doing a great job there with your team, Dr. DeCamp. I know you're on call today so we're going to let you go, but hopefully we can look for a brighter time in lung cancer, preventing it, and if you need treatment that it's caught early when you can do more, and people like Nick can go on and play golf, right? Absolutely. I appreciate the opportunity to help get the word out. Thank you. Thank you. And, Nick Meck, so I bet if you keep at it you're going to start seeing the money that you're losing to your friends come back your way. I sure hope so, and that you can enjoy every golf game. You can enjoy it no matter what, right? You better believe it. It's a lot nicer walking on top of the ground. Yeah, right. Well said. Anything you want to say to Dr. DeCamp because after all he's really helped you. Just to thank him. He's just a great doctor. Well, thank you, Mr. Meck, I appreciate it. Alright, gentlemen, thank you so much for being with us. This is what we do on Patient Power, and certainly when it comes to lung cancer, it's a serious diagnosis. You owe it to yourself to connect with the best care, get information, make sure it's well explained to you and that you feel confident, and then hopefully you can go ahead with a procedure, a treatment plan, maybe involving multidisciplinary providers, but whatever it is to cure the cancer if you can, certainly give you back the highest quality of life. Thanks for listening. Tell your friends about this program. It's an important one. They're all in the ihealth section of nmh.org and also many other places helping people on the internet. Thanks to Northwestern Memorial for being our long-time sponsor. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all. For more information or to schedule an appointment with a Northwestern Memorial physician, please contact our Physician Referral Service at or visit us online at Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 21