Smilow Shares Primary Care: Lung Cancer

November 02, 2022

Information

November 1, 2022

Presentations by: Steven Benaderet, Michael Cohenuram, MD, Sarah Goldberg, MD, MPH, Vincent Mase Jr, MD, BS, and Daniel Rudolph, MD

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00:00Let's get started because we
00:02have a lot to go through tonight.
00:05Welcome to smaller shares with
00:07primary care. Let's see, Renee,
00:10do we have the? Slides up.
00:17My name is, my name is Anne Chang.
00:19I'm a medical oncologist and chief
00:22integration Officer, Deputy CMO for SMILO,
00:24and this is a series that Karen Brown.
00:30And I put together a really focusing on
00:36primary care and relationship with smile.
00:39Can you advance to the next slide?
00:44Thanks. So it's a monthly lecture series
00:47that really focuses on primary care
00:49perspectives on cancer and hematology
00:52and this is really done with Karen
00:55together the faculty panel has primary
00:57care docs as well as smaller physicians
00:59and we we'd like to focus on a a
01:02particular region even though our our
01:05audiences from across the entire network.
01:07So today we're doing lung cancer
01:09for lung Cancer Awareness Week and
01:12really in Bridgeport and this is.
01:14Always the first Tuesday of the month
01:16from 5:00 to 6:00 PM and you know,
01:19this is really to there's so much going
01:22on in cancer and hematology right now.
01:25That that we felt that this is
01:27really important to share with,
01:28with primary care and specifically
01:31around questions that you have.
01:33Karen, do you want to add anything?
01:36Just echo, you're welcome.
01:37And we have an expression at NE
01:40Medical Group in primary care as we
01:43keep trying to work smarter not harder
01:46and and that's because we we have a
01:48lot to do in the primary Care World.
01:50And so sessions like this are
01:54invaluable to help kind of guide us
01:56in in the collaborative approach to
01:59new malignancy and making sure our
02:01patients get the care they need.
02:02So I'm, I'm thrilled that we're
02:04getting this off the ground.
02:07Fantastic. So it's very case based.
02:11We actually have three cases tonight.
02:13I'm going to talk through aspects
02:15of screening and locally advanced
02:17disease and metastatic disease.
02:19We do want to have some some
02:21time at the end for open Q&amp;A.
02:24So if you have and we encourage you
02:26to submit your questions either
02:28through the chat you can do that
02:31during the the presentation or you
02:33can wait till the end or or unmute
02:35and and well actually I think I
02:37guess it goes through the chat.
02:38So, so with the with no further ado,
02:43let's get going and introduce our panelists.
02:46Karen, do you want to start?
02:48Sure. So I'd like to introduce
02:51Doctor Steve Benaderet,
02:53a Michigan native family
02:56medicine specialist in Westport.
02:59Under his leadership,
03:00patient care and quality scores have
03:02been amongst the highest in any MG
03:05and he is now the anchor of a new
03:08and expanded primary care office.
03:09He graduated from New York Medical
03:11College and completed his family
03:13practice residency at Stanford Hospital,
03:15where he also served as chief resident.
03:17He has 12 years of EMG practice
03:20affiliation and is the Regional Medical
03:23director for the Fair Fairfield area.
03:25I'd also like to introduce
03:27Doctor Daniel Rudolph.
03:29Dan is a pulmonologist and Trumbull
03:31and Fairfield and has over 40 years
03:34of experience in the field and over
03:3635 years of affiliation with the
03:39Bridgeport Hospital pulmonary group.
03:41He has extensive experience in sleep apnea.
03:46Pulmonary vascular conditions and
03:47a very special interest in lung
03:50cancer and developed the bronchoscope
03:52program at Bridgeport Hospital to
03:54include endobronchial ultrasound
03:55for staging lung malignancy,
03:58and that's one of the reasons he's here.
04:00He graduated from New York
04:02University in 1982,
04:03attended medical school at NYU,
04:05and completed his pulmonary fellowship
04:07at Albert Einstein.
04:08He has offices in Fairfield and
04:10Trumbull and is accepting new patients
04:12highly regarded in the community.
04:17Fantastic. Thank you.
04:18I'll introduce Doctor Sarah Goldberg.
04:21She got her MD from Mount Sinai
04:23and trained in internal medicine
04:25at MGH in Boston and completed
04:28her fellowship at Dana Farber.
04:30She's an associate professor in medicine,
04:33the Division division chief
04:35for Thoracic Oncology,
04:36the research director for the Center of
04:39Thoracic Cancers and Associate director
04:41of our Hemlock Fellowship program.
04:43Her research interests include
04:45personalized medicine immunotherapy.
04:47A non small cell lung cancer
04:48and a focus on EGFR,
04:50mutant lung cancer and brain metastases.
04:53Doctor Mike Conundrum is a medical
04:56oncologist for Smilow Cancer hospital.
04:59His primary focus is lung cancer.
05:01He also sees breast cancer.
05:04He trained it.
05:05He went to Med school,
05:07also at Mount Sinai,
05:08and did his residency at Brown
05:10and his fellowship here at Yale.
05:13He participates in the disease
05:15affiliated research teams.
05:17And thoracic oncology and breast cancer.
05:20He has been included on Connecticut
05:22magazines Top Doc list for several
05:24years and his focus is patient centered,
05:27compassionate care and and then
05:30finally Doctor Mays Benny.
05:33Mays is did his thoracic fellowship
05:35at the Brigham and Women's Hospital
05:38completed his training as in 2016
05:41he's the site director for thoracic
05:43surgery at Bridgeport Hospital
05:45and Park Ave Medical Center.
05:47He has over 24 years of army experience,
05:50both active and reserve time,
05:52and he's been the leader for
05:55lung cancer screening.
05:57And and Smilo and Bridgeport in the
06:00Bridgeport area and promoting military
06:03civilian medical affiliations.
06:05Welcome to our very distinguished
06:08panel tonight. So fantastic.
06:10I'm going to turn it over now
06:14to Steve and and who's going to
06:17lead us off with case number one.
06:21Great. Thank you so much and thank
06:22you for the lovely introduction.
06:23It is overstated.
06:26So as a primary care doc like you all,
06:30we run into these things
06:32all the time that we.
06:35Do one test and find out something else.
06:37So the first case is sort
06:38of based off of that.
06:39You have your 63 year old male patient
06:42who's returning for his annual exam.
06:44He's been your patient for many years,
06:47struggles with weight BMI 32.3 has lacked
06:51the motivation to exercise over the years,
06:53but he's generally healthy and
06:55socially drinks, has never smoked,
06:57has no real significant past medical,
07:00surgical or family history.
07:02Currently is not taking any medicines,
07:04doesn't take any supplements
07:06during your exam.
07:07You know, no complaints.
07:09He states he's doing great.
07:10He's looking forward to his
07:13upcoming upcoming retirement.
07:14However,
07:14in the past few years has LDL
07:17has continued to change and he
07:19started off in the low 100 years
07:21ago and it's been creeping,
07:22creeping, creeping.
07:24Now his LDL 158.
07:26So you appropriately order
07:28a coronary calcium score,
07:30which the great news is you get
07:32a coronary calcium score of 0.
07:34However incidentally found is,
07:36and we're going to go over that
07:39case now with Doctor.
07:43Thank you, Steve.
07:48Thank you, Steve.
07:50This incidental pulmonary nodule
07:53problem is challenging for both
07:56primary care and for pulmonologists
07:59because they're so common.
08:01The FLEISCHNER criteria,
08:03which is what radiologists
08:04based some of their reading on,
08:06was developed to evaluate
08:08the risk of malignancy.
08:11So when we have cases like this,
08:13what the radiologists don't
08:15appreciate and what we have to
08:17appreciate as primary care providers
08:19and sub specialists who deal with
08:21this is the risk stratification
08:23for these pulmonary nodules.
08:25That's part of the FLEYSHER criteria,
08:28although the radiologist darn including it.
08:31But when you look at the fleischner
08:33criteria on the slide that I brought,
08:35you can see that it is complicated.
08:39Algorithms, but if you simplify it,
08:43there is a low risk and high risk category.
08:48Which all patients should be evaluated for.
08:52And as you probably know,
08:53risk includes smoking,
08:55chronic lung disease,
08:57occupational exposure to pulmonary
08:59toxins and family history of malignancy
09:02or history of other malignancy.
09:04So when we look at these incidental nodules,
09:07not only do we have to look at the size,
09:10the shape, the morphology, but also have to.
09:14Understand the risk profile of the
09:18patients that are being imaged.
09:21Now,
09:21one thing about coronary screening that
09:23you probably know is doesn't have a complete.
09:26Chest image.
09:27It includes only about 2/3 of the lung image,
09:30so it's an incomplete image,
09:33and it very commonly can have associated
09:38incidental nodules that have to be evaluated.
09:42So as a pulmonologist,
09:43when I deal with this,
09:44the first thing I do is,
09:46as I mentioned,
09:47risk stratify the patient and
09:50then look at the nodule size,
09:53because size greater than 6 millimeters,
09:56if we simplify the algorithm,
09:58is the most important distinguishing factor.
10:02Larger than 6 millimeter nodules.
10:04Need more immediate follow-up.
10:08Smaller nodules don't
10:10necessarily need follow-up,
10:12and unfortunately all the coronary
10:15screening of nodule cases very
10:17often need a complete CT image.
10:20So the question and the
10:21challenge is when do you do?
10:26Tools which are two,
10:27three or 4 millimeters are
10:30felt to be insignificant if
10:32the risk stratification is low.
10:35So unfortunately these are more
10:37complicated than a simple size and
10:41recommendation from a radiologist.
10:44They really have to be looked at
10:46carefully for risk size,
10:47shape, and sometimes require
10:51more immediate follow-up.
10:54Now classically the recommendations
10:56are six month follow-ups,
10:58but sometimes if the risk profile is
11:01is significant and the size of the
11:04nodule is greater than 6 millimeters.
11:06We actually look at a more
11:09immediate 3 month follow-up.
11:11But the biggest disadvantage is
11:12that we don't have a full CT image
11:15when we're doing these scans.
11:16If you look at the next slide,
11:18I try to simplify the FLEISCHNER
11:21criteria for primary care doctors.
11:25The size of 6 millimeters is
11:27a real important issue.
11:28Greater than 6 millimeters,
11:30the risk of malignancy is much greater.
11:32The type of nodule is important too.
11:34The ground glass nodules that
11:37are reported are less risk for
11:40malignant change than solid.
11:42Nodules and there's an assortment
11:43of other findings that sometimes are
11:46included in these reports including
11:48calcification would suggest it's a
11:50granuloma benign tree bud abnormalities
11:52would suggest chronic lung disease.
11:54So there's a lot of factors that
11:56could be taken into account when one
11:59makes a decision about follow up.
12:02The risk profile, if I can just emphasize,
12:05is really important and that's where
12:08the radiologists don't have information.
12:10You have to really look at
12:12each individual case.
12:13This is a patient with a
12:15coexisting malignancy,
12:16chronic lung disease,
12:19exposure to pulmonary toxins.
12:22That group has to have more immediate follow
12:25up and a full CT image within three months.
12:28Others very often that are low risk,
12:32less than 6 millimeters or
12:34scattered multiple nodules.
12:36We can do a longer interval follow-ups
12:40and each one of those has to be
12:44taken into account individually.
12:45Some, if they're very small,
12:47two or three millimeters do not need,
12:49if they're low risk, a full CT image.
12:54So those are the simple fleischner
12:57principles that I thought we should discuss.
13:02In this particular case,
13:03if the risk profile was low and the
13:07nodule was less than 6 millimeters,
13:10we might not have to consider
13:12a full CT image and follow up,
13:15particularly if the patient is a
13:17younger age group less than 50.
13:19If the patient's greater than
13:2050 and there was risk factors,
13:22then we'd have to do a full CT
13:24image within three to six months.
13:31We can move on to the next phase or?
13:35A discussion of screening CT imaging,
13:39Steve, if you want to go.
13:51Sorry about that. Stuck on mute.
13:54Um, so case number 2.
14:02So your 52 year old female patient
14:05returns for her annual exam.
14:07She's relatively new to your practice.
14:09She has a past medical history of
14:12controlled hypertension on an ARB pre
14:15diabetes that is currently diet controlled.
14:18Her family history includes
14:20a mother with breast cancer.
14:22Fortunately, your patient is up to date
14:23with her mammograms, which are normal.
14:25She rarely drinks and seems
14:27told to watch her sugar.
14:29She exercises regularly,
14:30but notes occasional mild dyspnea that
14:33she believes is from deconditioning.
14:36She has a history of smoking at least a pack,
14:38or maybe more a day through her
14:41college years and into her late 20s.
14:44She quit briefly when she decided to have.
14:50In the past 10 to 50 years.
14:52Uh, you do the math. She's a smoker.
14:55She's got a 20 pack year history
14:58and she is between the ages of say,
15:0150 and 80. So you order an initial
15:04lung cancer screening test.
15:06And the results come back as follows.
15:18So let me just jump in
15:21about lung cancer screening.
15:23There's a another radiologic classification
15:25we use called lung rats for evaluating.
15:30Pulmonary nodules in this high risk group,
15:34it's categorized from one to five.
15:37This group includes 20 pack year
15:40smokers who are over the age of 50.
15:44Of that group, again,
15:45I'm going to simplify this.
15:47If the nodule is greater than 6 millimeters,
15:50we have a much higher concern about
15:54malignant potential and three months
15:57to six month follow-up is recommended.
16:00Above 8 millimeters there is a great
16:03concern about malignancy and then
16:05further work up with pet imaging
16:08and possible biopsy is recommended.
16:10Greater than 15 millimeters,
16:12which is the highest classification
16:14usually is malignant and
16:16requires immediate attention.
16:17So the screening process a lot similar
16:21to incidentals is based on size, shape.
16:24However, this group of patients
16:26have high risk categories,
16:28so they have more immediate.
16:30Need for a follow up and all of
16:32them need yearly screening scans,
16:35low dose screening scans.
16:38If I might make a pitch for
16:40our pulmonary nodule clinic,
16:41because after reviewing all
16:43this literature and seeing the
16:45challenges of primary care doctors
16:47face in dealing with these things,
16:49we developed a pulmonary nodule clinic
16:52at Smilow and Trumbull to try to deal
16:56with the follow up communication
16:59and evaluation of these nodules.
17:02We have a multidisciplinary clinic.
17:06Megan and I karini is the APR.
17:09And who's developed it?
17:11Who's leading some of the development
17:15of this community development?
17:18And many Mays,
17:20myself and a radiologist at Yale
17:22named Doctor Gange is involved in
17:25reading all of the scans for us.
17:28She's a chest radiologist who's
17:31assisted us and allowed us to.
17:35Improve the excellence of this
17:37clinic so we can give the best care.
17:40If you feel that you need help,
17:44we have epic link that you can link
17:47into at the Montgomery nodule clinic
17:49and we will immediately contact the
17:52patient and evaluate the patient.
17:54Communicate back to the primary
17:57care providers and offer excellent
18:00care evaluation.
18:01If need further staging,
18:03we refer directly into.
18:06Doctor Macey's office Doctor Mike
18:08Cohen Durham also is involved
18:11if we have any problems.
18:12So this is a great opportunity
18:15for those who want to access some
18:18specialty help in this expanding
18:20group of patients that have incidental
18:23nodules or abnormalities on screening.
18:35I think we can move on to the third case
18:37actually. So Vinny,
18:39do you want to Doctor Mays,
18:42do you want to talk a little bit
18:44about that because you were trying
18:45to put some things in the chat,
18:46but that doesn't go to
18:47all the people who are
18:48attending. Can you
18:49go, can you go to the next slide, please?
18:53But these are the names of the folks that,
18:54Umm, you know, in the Bridgeport and
18:56Park Ave area that are part of the
18:59multidisciplinary team for whether it's
19:01lung cancer screening or pulmonary nodules.
19:03You know, there's a,
19:05there's an effort across Milo,
19:07you know, at Greenwich, at L&amp;M,
19:10at York Street, you know,
19:12to basically these, these.
19:15Capabilities, whether it's lung cancer
19:17screening or the nodule clinic or or
19:20throughout the Smilo Cares network.
19:21And there's currently, you know,
19:23an effort over the past about
19:2518 months to you know,
19:26standardize the processes at
19:29each at each campus.
19:31What I put in the chat was just for
19:34folks that do get lung cancer screening
19:37or have images on the third Friday
19:40of each month from 12:30 to 1:00,
19:44all of these folks here we review.
19:46All of the CAT scans over the past 30
19:48days for a quality control perspective
19:50and also any that you might want
19:52to be reviewed to look at whether
19:54it's your patients or a patient.
19:56You ordered a scan on their images to,
20:00you know,
20:00kind of review and see if all the
20:02management's been appropriate.
20:03It's also CME event and opportunity
20:05over lunch if you're interested.
20:07Again, it's the third.
20:09Friday of each month from 12:30
20:11to 1 via Zoom.
20:12Like we review images and kind
20:15of talk about them.
20:17Thank you.
20:24And now we're going to transition.
20:26You know we talked about mostly
20:28the first two cases where
20:30patients with without symptoms,
20:31you know it was an incidental
20:34finding or lung cancer screening.
20:36Historically as patients
20:37that don't have symptoms,
20:39doctor Conarium is going to
20:41talk about this pet scan in
20:43particular was a patient that
20:45presented with a with a cough and.
20:48Gotta work up.
20:49That wound up leading to the
20:51PET scan that you see here.
20:54Hi, everybody. This is Michael.
20:56When you're ramp,
20:57as I'm sure you've all seen in this
21:00probably occurs as frequently as with
21:03the cardiac scans and screening scans.
21:06Oftentimes you'll have a patient who
21:08presents with a persistent cough that
21:10are empirically treated for bronchitis
21:12or pneumonia that doesn't resolve at
21:13which point the next step is to go
21:16on to a CAT scan and that's exactly
21:18what happened with this patient and
21:20this led to a biopsy to the PET scan.
21:24I mean obviously you can see a very large
21:27left sided mediastinal mass with the
21:29tumor very close to the cardiac border
21:32and that was really the challenge here.
21:35So then I don't know if you want to
21:37talk a little bit about how you would
21:39view this from the standpoint of a
21:41thoracic surgeon and what your thoughts
21:43would be about up front surgery?
21:46Yeah, thanks. We can go to the next
21:48slide and just please I'm I I'm a
21:50little chat deficient here and zoom,
21:52but if you have any questions just throw them
21:55in the chat and see if we can answer them.
21:57And you know for the most part when we
22:00think about any of these patients it's
22:03really a multidisciplinary approach.
22:05You know of those patients that are operable,
22:07it's a multi disciplinary
22:09multi targeted approach.
22:10It's it's really each patient
22:12gets tailor made treatment whether
22:14they get neoadjuvant treatment.
22:16Before an operation or whether they
22:19get surgical treatment, you know,
22:21after they get chemotherapy,
22:23the multidisciplinary setting happens.
22:27Across multiple domains,
22:28there's a tumor board that meets Umm
22:31at Bridgeport Hospital the 2nd and 4th
22:33Wednesday where it's a group of the,
22:35the thoracic surgeons,
22:36the the Radio Board certified
22:38radiologist and Thoracic surgery,
22:40Umm, the medical oncologist,
22:42radiation oncologist, pulmonologist.
22:43We review pretty much all the,
22:46you know,
22:47new cases and complex cases to kind of,
22:50you know,
22:50come up with a treatment paradigm
22:52that's tailored to the patient
22:53that typically for these patients
22:55like the one that Mike presented.
22:58Um, you know,
22:59that consists at least of some sort of media,
23:02media style staging,
23:03whether it's via endobronchial ultrasound,
23:05which happens at Bridgeport,
23:08or, you know,
23:09I have a patient that recently got.
23:12Sent to me that has a PET scan similar
23:15to that who's going to be getting a
23:18mediastinoscopy just for some staging
23:19as well as a brain MRI and really about.
23:24I would say,
23:25you know,
23:25probably up front about a third
23:27or 2/3 we can wind up doing some
23:29sort of surgical management and you
23:31know it happens in that manner.
23:34And then I think Mike,
23:35you're going to talk about the folks
23:37that either aren't operable or the
23:38neoadjuvant or adjuvant treatment.
23:42Clear enough? We have the next slide.
23:46Um, I apologize but if to pull this up really
23:49close because I have this on my phone.
23:52But you know as Vinnie said,
23:55there's really not a one-size-fits-all
23:58for these patients and it really truly
24:02requires multidisciplinary evaluation.
24:04I think with the input both of
24:06the thoracic surgeon that we have,
24:08doctor Mason, Dr Dettelbach, Dan here,
24:10we will also very frequently work with
24:13some of the thoracic surgeons up on
24:16who primarily operate at a New Haven,
24:18but really primarily this is through
24:20Doctor Mace with the main issue.
24:23Being if this is locally advanced,
24:26be it stage two or stage three,
24:28and that is primarily dictated by
24:32the extent of lymph node involvement.
24:34Can they be offered surgery?
24:37Would they be better off with
24:39radiation based treatment?
24:41Are they physically able even if
24:43the surgery is an easy surgery?
24:45And also sometimes it's patient
24:47preference alone,
24:47sometimes patients have their own
24:50inherent biases about radiation
24:52versus surgery and that drives us
24:54and fortunately we have a lot of
24:56options and really the most important
24:59thing is you know the vast majority
25:02of cases of new lung cancer.
25:04Are not chipshot surgeries and with
25:07surgery alone still run a very
25:10high risk of recurrent disease?
25:15One of the options and what we
25:17offered the woman whose pet scan we
25:19just looked at was to give her up
25:22front chemoimmunotherapy in hopes
25:24that we could shrink the cancer and
25:26then allow her to go on to surgery.
25:30And actually I just went back and
25:32looked at the time of her surgery.
25:34She went from almost a 7 centimeter
25:37tumor to out of the 8 centimeter
25:39tumor bed that was removed,
25:41there was only 0.3 centimeters of.
25:44Viable tumor,
25:45so 92% of it was all dead necrotic tissue.
25:50So pretty close to a pathologic
25:53complete response which was seen
25:55in almost 1/4 of the patients
25:57treated on the Checkmate 816 trial.
26:00We don't quite yet know whether this is
26:03leading to increased long-term survival,
26:06although we have a pretty strong
26:08suspicion that it will be.
26:10Umm.
26:10However,
26:10if the patient is better off going
26:13to upfront surgery and there is
26:15always the concern that if we delay
26:18things with systemic therapy or the
26:20patient is the unfortunate patient
26:23who doesn't respond that we really
26:26want to get them to surgery quickly,
26:29we can simply offer a similar
26:32treatment backbone following surgery.
26:33And this is based on the empowered
26:3610 study which used a slightly
26:38different immunotherapy.
26:39It didn't use nivolumab, it used to.
26:41Azelis map,
26:42but really the hazard ratio in terms
26:45of disease free survival was about the
26:48same with well over a 30% improvement.
26:53Sort of been there.
26:53Anything else you want to say?
26:56You know, I think you know,
26:58clearly there's a lot of detail
26:59here and there's some nuances
27:01with regards to your patients.
27:02You know, one of the things I certainly want
27:04to talk about are are things that you know,
27:06you may think about hopefully they'll
27:07come up in the Q&amp;A section is you know,
27:10access to care. You know,
27:11at least for you know when we look across,
27:14you know, Park Ave and General
27:16Access to care is is very good,
27:19at least for thoracic surgery.
27:20The access to care averages about
27:2310.7 days and for the most part it's,
27:26it's a lot better.
27:27And that there's there's a patient or
27:29two that occasionally just stops to you
27:31know not come within that week period.
27:33So our goal is really you know
27:35one was to give you you know some
27:37information but also you know learn
27:39from you with how we can serve you
27:42better and you know any issues that
27:45that we can either talk about or
27:47learn about from you to help make
27:49the patient experience better.
27:51You know when they learn that
27:52they have a lung nodule that needs
27:54to be evaluated which for many.
27:56Is unsettling or two for patients
27:58that have a recent biopsy where they,
28:01you know,
28:01they saw in my chart before anyone could
28:03reach them that they have lung cancer.
28:20So it looks like Doctor Chang just told me.
28:22So she put a slide in about next day access,
28:24which really I think dovetails nicely
28:27with what Danny just brought up.
28:30Can't see the actual data.
28:32But I do know that relatively
28:35recently we built into our schedules
28:37save times for urgent cases just
28:40like this where they really need to
28:43be seen very quickly and we could
28:46oftentimes see the patient either that.
28:51And many of us are seeing about
28:532 cases a week on that basis.
28:56And I think that really offers
28:58very timely expeditious therapy.
29:00It's a relief to the referring
29:02physician and most importantly,
29:04a real relief to the patient that they
29:06not only have this terrifying diagnosis,
29:09but at least now they are under
29:10the watchful eye of someone
29:12and they have a game plan.
29:25And Steve, I guess you're
29:26talking about Case 3?
29:28Yep. I think it's that we're
29:30going to the next one.
29:32This is the one that we we primary care.
29:35People dread is when people are
29:36symptomatic and not feeling well.
29:38You're 74 year old male patient returns
29:40to your office for a sick visit.
29:43He's been your patient for many years.
29:44He's very compliant with any
29:47recommendations and medication.
29:49This past medical history includes
29:52controlled hypertension on an ace.
29:55Hydrochlorothiazide and routine.
29:56He has controlled high cholesterol
29:59with statins and he successfully
30:01takes allopurinol for chronic gout,
30:03which is rarely an issue.
30:05His family history includes a maternal
30:07grandfather dying of lung cancer.
30:09However, he worked in the coal
30:11industry and it was blamed on that.
30:13His father passed in his 90s of old age and
30:16his mother died of a stroke in her age.
30:19He is the oldest of four siblings,
30:21all of which have high blood
30:22pressure and high cholesterol.
30:24One brother has survived in MI.
30:26He rarely drinks no more than a
30:28glass of wine and a family party.
30:30He has a very,
30:32very remote history of smoking
30:33for years in the military,
30:35but never that much.
30:36He's been in the office in
30:38the past for bronchitis,
30:40and he even had an ammonia many years ago.
30:43He presents today with complaints
30:45of some upper back pain and a
30:47persistent dry nagging cough that's
30:49been around for as he closed a while,
30:51which when he questioned him,
30:53it's been present off and on
30:55for six plus months.
30:56You decide to order a CAT scan
30:58of his chest and this is where
31:00Doctor Sarah gets him down South.
31:06So hi everyone. I'm Sarah Goldberg,
31:09a medical oncologist and at Yale.
31:12And it's really a pleasure to be
31:14here and to talk about lung cancer.
31:17So this is has Steve
31:18said this is a case that.
31:21You know as a medical oncologist
31:22I I feel like occurs all the time,
31:24but I think in in reality it maybe
31:26it's not quite as common but it
31:28does happen where a patient comes
31:29in who's extremely symptomatic,
31:31so a cough, severe pain,
31:33a lot of times more systemic
31:35symptoms like fatigue,
31:36weight loss,
31:37anorexia and so in this case this is
31:40a not exactly the same patient but
31:42it's a good example of something that.
31:45You know, the,
31:46the patient that was presented might
31:47might actually have on imaging a lot
31:49of times there's much more disease than
31:51we even would realize based on symptoms.
31:53And so this cat scan here
31:55shows multiple lung nodules,
31:57really innumerable nodules as well
31:59as adenopathy in the hilum and in the
32:02mediastinum and bone metastases or
32:04bone lesions throughout the spine.
32:06After we see this on a chest CT,
32:08we often will then get a pet CT
32:10that's that's typically the next
32:11step in in a work up for this.
32:13And you can see here on this pet
32:15scan that you see multiple FDG
32:17avid lung nodules as well as lymph
32:19nodes that are avid and also liver
32:21lesions and bone lesions all of
32:23which have FDG avidity.
32:24So really widespread metastatic
32:27disease that we can see on imaging.
32:32So I'm going to talk about about how we
32:36think about work up and treatment for
32:39advanced lung cancer and then we'll go
32:41back to the case and I'll follow up on,
32:43on what happened with this
32:45patient who's imaging we see.
32:47So it's actually I think pretty amazing
32:50how much we've learned in the last.
32:5315 to 20 years about the molecular
32:55characteristics of lung cancer and in
32:57this in this slide here I'm showing you
32:59specifically of non small cell lung cancer.
33:02Back in 2004 we were first starting
33:04to learn about the the molecular
33:06underpinnings of non small cell lung
33:08cancer specifically adenocarcinoma.
33:11I'm showing you there that that back
33:12in in that time we knew about EGFR
33:14mutations and care as mutations in
33:16lung cancer although we didn't really
33:18know much of what to do with it.
33:21Over the years and I have another
33:23time point of 2009,
33:24we started learning about more alterations
33:26in non small cell lung cancer.
33:28We learned about ALK fusions and
33:30B RAF mutations.
33:32We were starting to get more
33:33familiar with targeted therapies
33:35for these mutations which I'll
33:36show you more about in a minute.
33:38By 2014 we again learned a lot
33:39more we should found out about an
33:42alteration called Ross One and Red
33:43and met and we're really starting
33:46to become more advanced with
33:47our molecular profiling and DNA.
33:50Sequencing so that we can we can
33:52find more and more alterations
33:54in non small cell lung cancer.
33:55If you click again we'll show
33:57you where we are today.
33:58So this is today I I find it really
34:00amazing how many alterations you can
34:02find when you look for them in in
34:05specifically in lung adenocarcinoma
34:07as opposed to almost 20 years
34:09ago now where most patients had
34:11no known alteration because our
34:13sequencing wasn't wasn't so good.
34:15We now can find a molecular alteration
34:18in almost all patients with lung cancer.
34:21And so in the next slide,
34:21we'll show you why this is relevant.
34:23So it's relevant because now we have
34:26some really outstanding targeted
34:27therapies that we use for lung cancer.
34:30And so this is that same high chart
34:31that I just saw on the last slide,
34:33but attached to it are all the
34:35different targeted therapies that
34:37we have to treat lung cancer in
34:38this case specifically advanced
34:40or metastatic lung cancer.
34:42There's different types of drugs
34:43that we use for each of these
34:45different alterations in the kind
34:47of that brownish color.
34:48These are small molecule
34:49tyrosine kinase inhibitors,
34:50they're oral drugs.
34:51We have monoclonal antibodies.
34:53In some cases you can see that it
34:55listed in blue for each year some
34:57EGFR mutations and then kind of
34:59the the newest class of drugs that
35:01we use to target alterations in
35:03cancer or antibody drug conjugates.
35:05These are antibodies that go after
35:06a specific alteration in cancer
35:08linked to a chemotherapy is kind of
35:09like a smart chemo that finds the
35:12cancer and direct directly delivers
35:13the chemotherapy drug and we have
35:15that now for her two mutations.
35:17You could see many of these are
35:18small pieces of the pie but when you
35:20add them up almost 50% of patients.
35:22Um with lung adenocarcinoma,
35:24we'll have a targeted therapy that
35:26we could consider for use either in
35:29standard practice or on a clinical trial.
35:31And next slide,
35:32actually next part of this slide.
35:34So why is this important?
35:35Well, it's because it's been shown
35:37over the years that targeted therapy
35:39can improve survival sometimes
35:40quite significantly in patients with
35:42advanced non small cell lung cancer.
35:44So on the top right,
35:45I'm showing you a Kaplan Meier
35:47curve for this is really looking
35:48at multiple mutations across the
35:50board and patients who have a driver
35:52mutation are basically those that I
35:54listed in the pie chart there and
35:56they receive a targeted therapy.
35:57That's what TTX is.
35:59They have a significant improvement
36:00in their survival.
36:01Compared to patients who either don't
36:03have a driver alteration or even
36:05those who have a driver alteration
36:07but don't get a targeted therapy.
36:08And then on the bottom,
36:09I'm showing you one specific
36:11example pulling out the patients
36:13with EGFR mutant lung cancer.
36:14There have been many studies over the
36:16last several years looking at targeted
36:18therapy in this patient population.
36:19This is one of those trials.
36:21This is a trial that was published
36:23in New England Journal of Medicine
36:24a few years ago showing that our
36:26third generation drug OSIMERTINIB
36:27has a significant improvement in
36:29survival over or even our prior
36:30generation of drugs or Latin adventure.
36:32But I think maybe the most important
36:34take away here is that figure on the
36:36bottom right which is showing the
36:37overall survival for these patients.
36:39And you can see this this the
36:40follow up in this study at this
36:43point ends around 24 months.
36:44But you can see well more than half of the
36:47patients who received osimertinib were
36:49still alive 24 months and and beyond.
36:51And so the the prognosis for patients
36:54with advanced non small cell lung
36:56cancer has significantly improved
36:58because of alterations like this and
37:01targeted therapies like those summer.
37:03Next slide.
37:05We've also seen,
37:06really sorry about the formatting here.
37:08We've also seen significant advances
37:10in immune therapy for patients with
37:13advanced non small cell lung cancer.
37:14I'm just showing you a few examples here.
37:16There's many other ones.
37:17Basically every trial gets published
37:19in New England Journal of Medicine
37:21because they're all a significant
37:23smashing success when you compare
37:24immune therapy with chemotherapy.
37:26Overall patients do much better
37:28with advanced lung cancer.
37:29This is showing you that on the left
37:31with that study with pembrolizumab,
37:33one of our PD1 inhibitors.
37:34On the right, a study with atezolizumab.
37:36PDL one inhibitor patients do much
37:38better when they receive immune
37:39therapy compared to chemotherapy
37:41when they have the biomarker which
37:43in this case is called PDL one.
37:45And so with high PDL one expression,
37:47these patients are doing really
37:48well with a chemo free regimen.
37:50And again you can look at for
37:51survival several years out more than
37:53half of these patients are still
37:55alive and that is a significant
37:56difference than just a few years ago.
38:00Next slide.
38:01So you can kind of click through,
38:02there's a couple of animations here.
38:04So this is just really showing
38:05you an overview of all the,
38:07I think there's one more of all the
38:09advances that well maybe not all of them,
38:10but many of the advances we've
38:12seen from non small cell lung
38:14cancer in the last 20 plus years.
38:15First we got some better chemotherapies
38:17but those were never good enough.
38:19We then have targeted therapies
38:20and you can see multiple of them
38:22listed there and now immune therapy.
38:23And so we've really seen significant
38:25advances and so that that has has
38:27changed the way that we think about
38:29treating patients with advanced disease.
38:31Next slide.
38:33I think this is my last slide.
38:35So what has this done?
38:36Well you know the the we always
38:38are every year they come out with
38:40overall data for how we're doing and
38:43in mortality and other statistics
38:45in cancer this is looking at on
38:47the top left is looking at men and
38:50on the bottom left is is women.
38:52Overall in terms of mortality
38:54for different cancers,
38:55lung cancer continues to be the
38:57number one cause of cancer mortality
38:58in the US that's that red line.
39:00So still the the highest cause of
39:02cancer deaths in this country.
39:04And worldwide,
39:04but you can see and highlighted in blue,
39:07there's been a significant decline
39:08over the last several decades.
39:10And you can see in that table
39:12on the right that incidence has
39:14declined but mortality has declined
39:16even faster than incidence.
39:17And so why is that?
39:18Well, there's probably a couple of reasons.
39:20Reduction in smoking has
39:22probably improved the,
39:23the incidence has reduced the incidence.
39:25I think that's pretty clear cut,
39:26but I think also the improvement
39:28in screening has helped.
39:29But I guess maybe I'm partial,
39:30but I think in in large part it's because
39:32of our improvements in therapy and.
39:34In,
39:34in,
39:35out,
39:35because metastatic disease is so common in
39:37lung cancer, the improvements in
39:39immune therapy and targeted therapies
39:41have really changed the outlook
39:43for patients with advanced disease.
39:45Next slide. Oh, I have one more slide
39:47which is going back to this case.
39:48So this is really an amazing case because
39:50this patient was very symptomatic,
39:52had a biopsy of a liver lesion that
39:55showed adenocarcinoma from lung primary,
39:56had molecular testing that showed
39:58an EGFR mutation.
39:59That was one of those pieces of the
40:00pie I showed you found in about 20%
40:02of patients with lung adenocarcinoma
40:04was started on osimertinib.
40:06That was at a study I showed you where
40:08there was a benefit of osimertinib versus
40:11other targeted therapies and he had
40:13a significant improvement in in symptoms.
40:15Pain and cough even in just a few
40:17weeks and we see that quite commonly
40:19where even just a couple of weeks
40:20people start to feel better when
40:22they get a successful therapy.
40:23And then you can see on the right,
40:25the post treatment scans look amazing.
40:27So all those lung nodules are
40:29either gone or decreased.
40:30The bone lesions are better,
40:31the liver lesions are better.
40:33And this patient had an ongoing
40:34response still going on after two years.
40:37And again this is something we often
40:38will see in clinic where people have
40:40significant reductions in disease
40:42that can last for many years.
40:43It's not a curative therapy our targeted.
40:46Therapies and immune therapies when
40:47we treat advanced disease don't
40:49cure the disease like like binny's
40:50able to do when he does surgery or
40:52we're able to do with radiation.
40:53But we really can see amazing benefit
40:56with some of our newer treatments.
40:58Next slide.
40:59So sorry this is this went a little
41:01bit of out of order here but I wanted
41:03to just briefly mention some of the
41:05side effects because this is something
41:06I think in primary care you you'll
41:08you'll you either already have seen or
41:10you're going to start to see more often.
41:12Because as we see the benefit of
41:13so many of our treatments we're
41:15using them more and more.
41:16We use them in metastatic disease
41:17to start and now you heard from from
41:19the others about how we're using
41:21them in early stage disease as well.
41:22And so when we use immune therapies
41:24we're activating the immune system
41:26to fight the cancer but we're it's
41:28not specific specific.
41:30And so you can see immune related
41:32adverse events fairly commonly
41:33from our treatments and here's just
41:35a summary of all the different.
41:38Inflammatory conditions that we
41:39cause with these treatments,
41:40really any organ system can be involved.
41:43It's important to know that the
41:44onset can be variable.
41:45It could be immediate or a few
41:47weeks or months later,
41:48but it also could be months or
41:50years after therapy is completed.
41:51So absolutely something that you
41:53should know about when you're
41:54seeing patients who were treated
41:56with these these drugs.
41:57Most of the adverse events
41:59are treatable with steroids,
42:00but you know sometimes they
42:02require a long course.
42:03So something to be aware of and to to
42:06consider when someone presents with.
42:08A new symptom who's been
42:09treated with these drugs?
42:10So that's all that I had
42:11and happy to take questions.
42:23So now we are are to the question
42:27and answer part of our program and
42:31I'm glad to see that we have about.
42:3310 or 15 minutes left.
42:36Before we do that,
42:37I would like to ask those attending
42:39to make sure and complete that
42:41survey to receive the CME credit.
42:43And and we'd love to have you
42:46come back again in December on
42:48anemia and the first Tuesday in
42:51February on gynecologic oncology.
42:53So I'm going to turn it over
42:57to Karen to to for the Q&amp;A.
43:01And so far, I'm seeing only one
43:04question and I know people have more.
43:07So please type it in.
43:08And while you do, I'm going to ask
43:12Dan actually a question to tee off.
43:15So we use many different radiology
43:18services for lung cancer screening
43:20and many different radiology
43:22services for any imaging where
43:25incidental nodules are found.
43:29And it is possible that some of
43:32the radiologists may give slightly
43:35different advice on whether it exactly
43:38follows Fleshner criteria or not.
43:40Or have you seen that?
43:42And how quick are you to kind
43:46of overrule a bottom line on a
43:50radiologist suggestion for the
43:52interval of follow-up imaging if
43:54it doesn't match your understanding
43:55based on the criteria you outlined?
43:59That's the great question.
44:02I'll first say for medical legal
44:04reasons it's very difficult to
44:07overrule a radiology recommendation,
44:09particularly if you decide the
44:12intervals should be longer.
44:14Most important issue is risk profiles,
44:17and the radiologists don't really
44:19have a sense of what type of
44:22patients they're dealing with.
44:23And I know that there are different
44:27opinions and different radiologists will
44:29view different imaging differently.
44:32So we're kind of in a situation where
44:36you have to seek other opinions unless
44:40you feel confident as a primary care
44:42provider that you can make that decision.
44:45There is a problem in our community
44:48with two different radiology groups.
44:50Sometimes the imaging from one
44:53service is not available to the other,
44:56so very often I'm digging through
44:58old imaging to see if there's any
45:01previous imaging that wasn't compared.
45:03Comparison to prodder.
45:05Imaging is also an issue if you're using
45:08different groups for primary care doctors,
45:10so my recommendation to you
45:12is to stick with the same.
45:15Radiology group as the original scan
45:19and I would follow the radiology
45:23recommendation unless you have
45:25a another subspecialty opinion
45:28that supports your decision.
45:31Particularly if it's to ignore
45:34the frequency or the immediacy
45:36of the follow-up imaging,
45:38because the last thing you want is to find
45:42out that there is a significant change.
45:46In a nodule that you have decided
45:49was benign at a later date.
45:51So I don't overrule radiologists.
45:53I do bring patients in to to make
45:56certain of the risk profile and then I.
46:00Very often take command of of what
46:03I do in terms of follow-up imaging.
46:08If that helps.
46:10Well, I think end of life and you know,
46:12life expectancy and informed decision
46:14making around that is probably something
46:17we could also justify you know,
46:20with or without specialty consultation
46:22with very explicit discussion that I,
46:24I, I do see your point.
46:27I think they're older folks.
46:28I mean I have you know 90 year old
46:31patients that have incidental nodules
46:32and at that age the real question
46:34they have other medical issues.
46:36Do you really need to go through
46:38the process of follow up and that's
46:41that's where the primary care doctor
46:43can be instrumental in dictating what
46:45the patients wishes are and needs.
46:47But when you're dealing with a younger
46:49age group it's a different challenge.
46:56And then Steve, you've unmuted.
46:58I thought maybe you had a question.
47:02I do have a question and I
47:04would say I put this up to.
47:06Any of the other panelists.
47:08So as primary care one of our
47:11concerns is is sometimes we just
47:14want to know how to get the
47:17attention of of the of you guys.
47:20So we know we can sort of
47:23arbitrarily enter or referral into
47:24epic and we click a send button.
47:27But sometimes you don't,
47:29you don't know everything and
47:30and sometimes we want to just
47:32type in the in the box that
47:34says help because we want to.
47:36Thank you.
47:37So how would you recommend with these,
47:39you know people on the on the
47:41line here who are primary care
47:43physicians that that we sort
47:44of say well is this the urgent,
47:46urgent case is this is there,
47:48is there certain things that
47:50you might want us to look at
47:51differently so that we can raise
47:53that red flag a little differently.
47:54You know,
47:55I was fortunate when he came into
47:56my office and literally sadly
47:58a week later I had somebody he
47:59did you know lung cancer surgery
48:01and I happened to seen him and
48:03I got his phone number and so I
48:04called him and he got someone in
48:06the next day for me and that was.
48:07Catholic but but not everyone on
48:09this has each others phone numbers.
48:11We don't all see each other and
48:13we also primary care.
48:14We don't want to raise the red flag
48:16for someone who's not a red flag,
48:18but we also don't want to to be
48:20the 10.4 days when it should
48:21have been the next day visit.
48:23Any advice you could give us on
48:25how to sort of let you guys know
48:27whether that's a a my chart message
48:29is that how do we let you guys
48:32know that we might be worried?
48:40Steve.
48:44I'll, I'll comment that you know I think.
48:47Any one of us I will maybe speak
48:50through would be happy to help
48:51guide you if you reach out.
48:53You don't need a phone number to e-mail
48:56us or to you know, epic message us.
48:58I and I often get calls or texts
49:01or emails from people saying,
49:04well this is what's going on,
49:05what are you suggested?
49:06I actually think it's helpful
49:08for a few reasons.
49:09First of all we can help get the
49:10person in if it really is urgent or
49:12even if it's not urgent but the person
49:13just really wants to be seen right.
49:15Sometimes even if it's not medically urgent,
49:16it's like emotionally urgent
49:17that the patient is seen and
49:19that's really important too.
49:20But we could also suggest some
49:22maybe some work up it you know to
49:24get things going while the while
49:26the appointment details are are
49:27processing you know we I might say
49:29oh you have a CAT scan that's great.
49:31We would also probably want a PET
49:32scan and a brain MRI you know
49:33like let's get that started. So.
49:35So I I think it's actually great
49:37to reach out to us and.
49:39Um, I think,
49:39I think any of us would be happy
49:41to help with initial guidance
49:43and and expediting appointments.
49:46Yeah, and I think, Umm, I asked Renee
49:48to put my cell phone in the chat too.
49:50You can call, you know, call me anytime.
49:54Just what Sarah said is sometimes
49:56that quick phone call we can say,
49:59well, I'll see them and if you're
50:01OK ordering a pet, we're getting
50:03enough a different kind of a CT.
50:04It helps when we see them.
50:06What I try and do is typically
50:09what happens is when you call us,
50:11you know, it's likely that you know,
50:13you're in the room with the patient and.
50:16Should I try and do is Umm,
50:18you know touch base with them
50:20hopefully either that night or
50:21the next day myself just so that
50:23they know that we've talked and at
50:25least for me you can always give
50:27my cell phone to the patients.
50:28I'm happy to have them text
50:29or call me directly as well.
50:34Great. And I am seeing right here
50:408 O 27344231 especially for those
50:43of you in the Bridgeport region.
50:45I think the the other thing that
50:48probably bears repeating again is
50:51access to you know the pulmonary
50:54nodule programs and how that
50:55looks in the various regions.
50:57It looks like Bridgeport has
50:59a great one built out.
51:00What what's the status of that
51:02in other regions?
51:03Where we have any MG and and
51:05other primary care clinicians.
51:10And do you want to take that?
51:13Yeah, I was trying to get the the
51:16so Renee actually put into the the
51:19question and answer and I'm not
51:21sure that everybody can see that.
51:24But that's the link to the lung
51:26screening that's across the network
51:28and it actually shows you who the
51:31contact person is in New Haven,
51:33Lynn, Tenui, Polly, Sather,
51:35who the contact person is in Bridgeport
51:39and then in Greenwich, etcetera.
51:41And so that's probably the best way.
51:44And somebody also asked for the epic link.
51:46And I guess, Renee,
51:48there's also if we go back to,
51:50for example, I think the the slide deck.
51:54Dan had provided the.
51:56The epic referral to pulmonary nodule clinic.
52:00So that
52:02actually bears putting up again because
52:04it's not intuitive when you search for it.
52:07You have to kind of know the name.
52:11So I don't know, Renee,
52:12you can share that again.
52:16Megan, I think if you
52:19search pulmonary nodule.
52:20On the Epic order platform, it'll come up.
52:24It says Jan was in my office with
52:26Megan and he actually just tried it.
52:28I just opened up a patient's chart and I
52:31typed in the word poll nodule and the that.
52:34It came up quite easily actually.
52:36So it was it was pretty similar.
52:39And if you keep on going, oops, go back.
52:45There's ambulatory.
52:47Referral to pulmonary nodule clinic,
52:49you know I think we've done a really
52:51great job of of creating a whole
52:54network for lung screening that's
52:55actually work that's done that's
52:57been headed by shavir Laurent and in
53:00genetics prevention and screening.
53:02And we have regular meetings of all
53:05the medical physician leaders but
53:08also of all the the the coordinators
53:10just to make sure that we're learning
53:12from each other and and doing things
53:15in a standard way across the network.
53:21Hopefully that answers the question.
53:24Yeah. No, I think we've actually
53:26addressed all the questions.
53:28Are there on Steve or anybody else?
53:30Do do we have any questions
53:32for each other or should we?
53:34Call it a successful program. Give everybody
53:39back 4 minutes.
53:43Yeah. So, so thanks everyone for coming.
53:46Again we we have anemia
53:48that's teed up for December.
53:51Please send us every send us some
53:53some feedback about this program.
53:55Again, we're really trying
53:58to to dial into questions and
54:01perspectives from primary care.
54:03I think the the overall
54:05picture for lung cancer.
54:07I'm also a thoracic medical
54:09oncologist as Sarah said and
54:11Mike said folks on the screen.
54:13Is that there really has been an
54:15amazing amount of research and people
54:17are living longer and longer for
54:20something that previously was really a
54:22terminal sentence of a year or less.
54:25People, not everybody,
54:26but there are many people who are doing
54:29much better and living longer life.
54:32So we're really excited about that.
54:33So thank you very much everybody
54:35and have a good, have a great night.
54:37Thank you.