Guidelines take years of cigarette smoking into account

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Lung cancer remains the leading cause of cancer deaths in the United States, and screening people who are of high risk for the disease is improving lung cancer survival rates.

Recommendations for who should consider screening have recently been updated, so for help understanding whom this applies to, I'm talking with Dr. Michael Archer. Dr. Archer is an assistant professor of surgery at Upstate specializing in chest surgery.

Welcome to "The Informed Patient," Dr. Archer.

Michael Archer, DO: Thanks so much, Amber. I really appreciate you having me on.

Host Amber Smith: Now, the idea behind screening is that you can find and treat cancers early, is that right?

Michael Archer, DO: That's exactly right. We know, generally speaking, that cancers that are identified early have a much higher rate of cure. And so, as we've seen demonstrated for breast cancer and colon cancer, when we find those cancers early, we can do a much better job with providing folks a cure.

And, similarly, there's good research to show that when folks are screened for lung cancer, we identify tumors earlier, and we are able to get patients treated to cure more frequently.

Host Amber Smith: I'm curious about how fast lung cancers grow and at what point or what stage people might experience symptoms.

Michael Archer, DO: The short answer is they all grow at different rates, but, generally speaking, the doubling time for lung cancer is somewhere around 500 days, so it's over a year for it to double in size. But the reality is, is we want to find these things when they're a centimeter (less than half an inch), not when they're 5 centimeters or 7 centimeters.

And for those of you who don't deal with lung cancer all the time, those 5-centimeter, 7-centimeter tumors, those are big deals. And your question about symptoms: Again, the idea with screening is, we want to catch these things before they ever become symptomatic, because unfortunately, once somebody's having symptoms related to a lung cancer, that often means that the tumor's done something bad, right?

It's either grown into a chest wall, which can cause pain, or sometimes people end up coughing up blood, and that typically means the tumor's invaded some sort of structure that is going to make it more problematic to treat and very unlikely to be able to achieve a cure when we're getting into those much later stages of lung cancer diagnosis.

Host Amber Smith: OK, so who qualifies for lung cancer screening?

Michael Archer, DO: The U.S. Preventive Services Task Force has updated the recommendations for lung cancer screening. So it includes individuals who have smoked greater than 20 pack-years. And what a pack-year is, is we look at what you smoke per day. So somebody who smokes a pack per day, and has been doing it for 20 years, meets that criteria. They are considered a 20 pack-year smoker. And so, as you can imagine, not everybody smokes a pack a day. Some people smoke two packs, some people smoke a half a pack per day, and so we do that sort of calculation.

So it's a 20 pack-year history. Anyone who is between the ages of 50 and 80, and that recently dropped to include younger individuals, and then those who have quit within 15 years. So there is still some risk of lung cancer, even in those who have quit up to about the 15-year standpoint. And then once we get to 15 years, we think that we go back to our general risk of the general population.

So, 50 to 80 years old, 20 pack-years or greater and then, if you've quit smoking within 15 years.

Host Amber Smith: So among those people you described or the categories, who is it the highest risk? Is it the person who has smoked the longest and the most, necessarily, or not?

Michael Archer, DO: So pack-year history, you can be 50 years old and still have a 100 pack-year smoking history.

We know that the more that somebody smoked and over a longer period of time, that absolutely increases the risk of lung cancer. And so within that group of individuals, we might say that those are the folks that we're trying to get to. But the reality is that even if you've smoked 21 pack-years, and you're just 51 years old, you're still at risk, right?

That's what the trials have demonstrated, and really the idea is, we want to get people in to get them cured of their lung cancer and not be in a situation like you had mentioned, where you're coughing up blood, or you're having chest pain, or we find out, long after we had a chance to cure something, that we can't.

So get people in early and really getting the word out has been the biggest hurdle that we've had, is just making sure that people know that lung cancer screening exists. I mean, we all know that breast cancer screening is there. Everyone knows to get their mammogram and to get their colonoscopies for colon cancer screening, but not everybody knows about lung cancer screening.

And platforms like this are incredibly helpful to inform not only patients, but other health care providers, that this is something that there's very good data to support -- lung cancer screening -- and that we are capable of really reducing the risk of dying from lung cancer.

Host Amber Smith: Now for pack-years: When you talk about a pack-year, does it matter what type of tobacco was smoked?

Michael Archer, DO: That's an interesting question. I think, generally speaking, the pack-year came from the fact that cigarettes are packaged in packs, and we all generally know how many cigarettes are in a pack.

Whether or not a cigar smoker or somebody who uses marijuana regularly, whether those folks are, in fact, at the same risk as somebody who smokes cigarettes, I don't know that we exactly know that. We know that smoking anything really can have some effect on the lungs.

And we know that the things that are packaged within commercially available cigarettes are carcinogenic, and we have very good data over a very long period of time to demonstrate that, whereas for things like marijuana and cigars, we probably don't have as strong a data.

So, as it pertains to the screening, it really does primarily select out cigarette smokers.

Host Amber Smith: The guidelines don't really talk about vaping because vaping's new, but for future 50-year-olds, is vaping as much of a risk factor as cigarettes?

Michael Archer, DO: That's a very interesting question as well.

I mean, things are so new about vaping, I don't think we know. Anecdotally, we've seen a lot of young individuals who have vaped, who've had lung injury that is not completely unrelated to lung cancer, but patients that have developed lung injuries to the point where they need oxygen, or they're in the ICU (intensive care unit) on the ventilator, and we think that this is a vaping-related phenomenon. And so clearly, inhaling anything other than ambient air is likely not good for your lungs. And I do worry about folks that are vaping in 2023 and what that might look like in 2073, right? I just hope that it's not as much of a risk maybe as cigarette smoking.

Because I think, initially, some lung cancer providers thought that it was a good way to get people not to smoke cigarettes anymore, so, "OK, you want to vape? Go for it." I know for my patients, I don't suggest that that's a good alternative, only because I've seen how vaping can kind of go sideways.

And so, I guess time will tell with that.

Host Amber Smith: What about the person who years ago, in college, say, smoked briefly? They didn't do 20 pack-years, they just smoked socially, maybe during college. They don't really qualify for the screening, it doesn't sound like, but is their risk still higher?

Michael Archer, DO: No. That's why we selected this group out, is because we know that there is certainly increased risk, and the highest-risk group of individuals for lung cancer are smokers, right?

But there are about 10% to 20% of lung cancers that are diagnosed will occur in never-smokers or nonsmokers, so that can be confusing to some people. And it actually leads to stigma amongst patients that develop lung cancer because everybody has this idea, "Well, I smoked for so many years, I did this to myself."

The reality is, is just like any other cancer, there are some cancers that are sporadic, and they'll come up just by chance. And as we age, you may develop those. And so you smoke briefly in college, that person doesn't need to be screened for lung cancer. Really, we talk about anyone who smoked less than 100 cigarettes in their lifetime is really considered a never-smoker, right? That they're basically equivalent. And as it pertains to lung cancer risk, that 20 pack-year threshold is there for a reason, because we know that that's the inflection point where we really do need to be more concerned about the development of lung cancer.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with chest surgeon Michael Archer, an assistant professor of surgery at Upstate.

Well, you brought up nonsmokers. What about the nonsmoker who lived for many years with a heavy smoker?

Michael Archer, DO: Gosh, a great question. Again, the reason we were able to develop guidelines, from an institutional level and from a national guideline perspective, is that we had to create studies that were going to answer questions.

So the, biggest question that was posed to all of us was, we know that smoking is a risk factor for lung cancer. How can we identify these things earlier? So we had to kind of select out those folks that we thought were at the absolute highest risk.

So if you lived with a smoker -- you know, I grew up around a smoker, right? I don't sit around worrying about my risk, even though I know that I am probably, compared to the population that was never exposed to secondhand smoke, I'm at slightly increased risk of developing a lung cancer.

But as it stands right now, we don't have any data to suggest that we should be screening individuals who have a secondhand smoke exposure. Similarly, we have things that we know are carcinogenic for developing lung cancer. Things like radon and asbestos exposure. They're not included in the guidelines. And so, even though we know that that is a risk factor for developing lung cancer, it's not something that we can offer screening for right now.

Host Amber Smith: Well, I'd like to have you explain what's involved in the screening. First, it's paid for by health insurance, right? It's covered?

Michael Archer, DO: Exactly right. Both Medicare and Medicaid in the state of New York will cover lung cancer screening. Most private insurers will also cover it.

The screening process itself is really straightforward. There has to be a conversation about the risks and benefits of doing lung cancer screening, right? There's always a risk that we might identify other things or maybe a nodule that's not cancerous that might lead to a procedure, but that risk is pretty low.

The test itself, you show up to get a CT scan, the whole visit should take about 15 minutes, and the scan itself takes about two minutes, maybe even less to go through the CT scanner. You lay down on a bed, it slides you through a big doughnut, and you're out within a couple minutes.

Host Amber Smith: Are there concerns about radiation exposure from the CTs?

Michael Archer, DO: Not really. We've augmented the type of radiation and the type of scan that we do, so it's a lower-dose CT scan. There are other CT scans that are done for other medical problems that do provide a higher dose of radiation.

But for lung cancer screening, it's a reduced dose, and it's just slightly more than you would be exposed to for, say, a mammogram. So when we think about how ubiquitous mammography is in helping individuals identify early-stage breast cancers, similarly, there's not much additional radiation to doing a CT scan, a low-dose CT scan, for lung cancer.

Host Amber Smith: What happens if a suspicious spot is found?

Michael Archer, DO: So a number of things can be done and, typically, when we look at CT scans all the time for folks that have been screened for lung cancer, there are certain nodules that may be identified, which we know straight out of the gate: This looks like a lung cancer. It was identified in screening, so by definition we know we're dealing with somebody who is at high risk.

And there are certain instances where we might just want to get a couple of additional tests, and we might think about just going in to remove that spot for diagnosis and potentially as a therapeutic maneuver, so, to treat the lung cancer,

There are other instances where it might prompt a biopsy, which would be done under CT scan guidance. So a little needle would go in between the ribs and biopsy that nodule. There are other times where we look at the nodule, and it might not look like a lung cancer, it might look like an old infection or something that looks very benign appearing.

And in those situations, we would likely just recommend another CT scan at some sort of interval, whether that's three months, six months, or maybe even a year, depending on how suspicious or not that nodule looks.

Host Amber Smith: But that doesn't happen at the same visit when you come for the screening. That would be scheduled for later?

Michael Archer, DO: Exactly right. So typically, what happens is you have your scan, it does take a few days to get that scan interpreted and for those results to either get back to you or back to the ordering provider, whether that's your primary care doctor or your lung doctor. And then it does take some interpretation, and then we would inform you on what we think the most appropriate next step is, whether it's biopsy or maybe even a referral to someone like myself, who's a lung cancer surgeon, where we see folks, and we see these nodules all the time, and we understand the nuances between what these nodules look like and whether or not we need to do more invasive testing or maybe just get another CT scan.

Host Amber Smith: So, let's say that you do discover an early lung cancer. How might that be treated?

Michael Archer, DO: Early-stage lung cancers, there's really two modes of treatment to achieve a cure. And so if somebody has good lung function and good heart function, we typically think about doing an operation.

I won't get too much into the details of that, but typically these days we do that minimally invasively, with the robot, so several small incisions, and we remove the spot. Sometimes it's just with a small piece of lung, sometimes it requires a little bit more of the lung substance, but that can only be offered to somebody who has good lung function to begin with.

And as you can imagine, there's the association with smoking and lung disease, so COPD (chronic obstructive pulmonary disease) and emphysema. And so if somebody's showing up already on oxygen, or they're already having trouble breathing, putting them through an operation usually does more harm than good. Fortunately for those individuals, we can offer radiation at abbreviated doses over a shorter term, called stereotactic beam radiotherapy. And that treatment can provide a cure that in some individuals will be comparable to what they would achieve with a lung cancer surgery.

And so, even if your lungs aren't in the greatest of shape, and you're already having trouble breathing, there are still ways that we can provide a cure for early-stage lung cancers in those individuals as well.

Host Amber Smith: If someone has one lung cancer that's discovered, are they at greater risk for another? I'm getting at whether they need to continue the screening after.

Michael Archer, DO: So we know they certainly are. And that risk is about 1% to 2% per year to develop what we call a second primary lung cancer. And so, as part of any lung cancer treatment for early-stage cancer, it typically involves getting CT scans on a regular basis.

So, after a lung cancer surgery for an early-stage lung cancer, we do a CT scan every six months for the first two years, then every year thereafter up to five years. Unfortunately, some people don't quit smoking even after they've had a lung cancer, and so those individuals get re-enrolled in screening at that five-year mark, and if we get to the five-year mark, and we don't identify another lung cancer, typically at that point, we think as long as somebody's quit smoking, we typically don't have to continue to follow them after that five-year mark, although some people would choose to do that. It's partially based on patient preference, and sometimes, just the type of lung cancer it was might drive us to maybe follow somebody along a little bit longer.

Host Amber Smith: For the more advanced lung cancers. in terms of treatment, do you ever remove the lung? Would that remove the cancer?

Michael Archer, DO: There are still rare instances where we will find cancers that are either large or in a particularly precarious position within the lung, that it might require removal of an entire lung. That's called a pneumonectomy.

A pneumonectomy by itself is, kind of a big operation to go through and can really only be offered to really fit individuals. So again, the idea behind screening is that we're hoping to catch these things beforehand.

What we know now is that we have some more tools in the toolbox for lung cancer. So, whether it's chemotherapy or immunotherapy, there are certain strategies that can be used to maybe make a tumor that's big maybe a little bit smaller, to be able to get that out, but without having to remove the entire lung. But a few times a year, we'll still remove someone's entire lung, and as long as you choose the right person, living with one lung is certainly doable.

Host Amber Smith: Are you surprised, as a physician and a lung surgeon, or a chest surgeon, are you surprised that lung cancer kills more people than breast, colorectal and prostate cancers combined?

Michael Archer, DO: Unfortunately, I'm not. I'm not surprised by that. And I think if you just drive downtown, or you're out on a weekend, you see the number of people that, despite years of hearing about the ill effects of smoking, I mean, people still do. And I totally get it. I mentioned earlier, I came from a family that had smokers in it, and I know how difficult it can be to quit. But it doesn't surprise me because we've had such incredible uptick in colon cancer screening, prostate cancer screening, breast cancer screening.

It's become something that you go to your family doctor, and you're, "Oh, have you gotten your colonoscopy yet?" It's on the forefront of everyone's mind. But when it comes to lung cancer screening, it hasn't had the same uptake. I mean, the screening rates are abysmally low, not only nationally, but even in the state of New York, somewhere in the 5% to 6% range for patients that are actually at risk.

And, some of that revolves around this nihilistic approach that says, "I've smoked for so many years, I'm bound to get lung cancer. Why should I look for it? I've done this to myself, right?"

And the reality is, we know that smoking's a risk, but you haven't done this to yourself, right? And it doesn't mean that it has to be a death sentence just because you've partaken in cigarette smoking, right? And so trying to break that stigma down, that it's OK to get screened for lung cancer, it's OK to have been a smoker and have a lung cancer, that we're here to hopefully find these things early and get folks treated, so they can live long and healthy lives after their diagnosis.

We want to avoid people getting into the situations that we mentioned earlier, where they're sitting at home, and next thing you know, they're coughing up a bit of blood or something like that, that even smokers will tell you it's a scary thing to happen. And if we can avoid doing that, it's probably better for folks, not only from a psychosocial standpoint, but certainly from a medical standpoint and an ability to achieve a cure.

It's certainly better to find these things smaller.

Host Amber Smith: You mentioned the low rate of people actually getting the screening. Do you think if half or two-thirds of the people who are eligible for screening actually got screened, do you think that could have an impact on survival rates so that lung cancer wouldn't be the biggest cancer killer?

Michael Archer, DO: No doubt. Over time we've seen anti-smoking campaigns and restrictions placed on cigarette smoking that have helped curb that overall trend of lung cancer-related deaths. But it's still, as you mentioned, it's still the cancer that tends to get folks.

I think if we were able to increase screening, that those numbers would drop fairly quickly. It's just we are way behind, and we need to do better from an institutional standpoint. And I work with New York state and the American Lung Association and the American Cancer Society. We're all very motivated to get the word out about lung cancer screening because that's our overall goal. If I could get rid of lung cancer tomorrow and not have to do another lung surgery related to lung cancer, I'd actually be pretty happy about that.

I think that'd be great.

Host Amber Smith: Well, Dr. Archer, I appreciate you making time to explain these new screening guidelines. Thank you.

Michael Archer, DO: No problem. Thanks for having me.

Host Amber Smith: My guest has been Dr. Michael Archer, an assistant professor of surgery at Upstate, specializing in chest surgery.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at glenviewelectric.com/informed.

If you enjoyed this episode, please tell a friend to listen, too, and you can rate and review "The Informed Patient" podcast on Spotify, Apple, YouTube or wherever you tune in.

This is your host, Amber Smith, thanking you for listening.