Smilow Shares Greenwich: Advances in Lung Cancer Screening and Treatment

November 18, 2020

Information

Roy S. Herbst, MD, PhD - Ensign Professor of Medicine (Medical Oncology) and Professor of Pharmacology; Chief of Medical Oncology, Yale Cancer Center and Smilow Cancer Hospital; Associate Cancer Center Director for Translational Research, Yale Cancer Center

Justin Blasberg, MD, MPH, FACS - Associate Professor of Surgery (Thoracic)

Anne Chiang, MD, PhD - Associate Professor of Medicine (Medical Oncology)

Vincent Mase, Jr., MD - Assistant Professor of Surgery (Thoracic)

Bruce McGibbon, MD - Assistant Professor of Clinical Therapeutic Radiology

ID5895

To CiteDCA Citation Guide

00:00Latest in screening and
00:03treatment for lung cancer.
00:06So I'm going to start with some
00:10introductory remarks and then I'll
00:14introduce the speakers in turn.
00:17Tonight we have Doctor Glassberg Chang.
00:21Mace and Mckeeman so Renee.
00:22If I may have the slides, please.
00:52So, so welcome, I'm glad to
00:54see so many people on tonight.
00:56I wish we could be in a lovely
00:58venue in Greenwich tonight.
01:00I think we all do,
01:02but that will happen again soon.
01:04From what I hear the from our
01:06experts at Yale Medicine.
01:07Just this morning,
01:08people are quite optimistic about the
01:10vaccines and hopefully we'll have plenty
01:12of them to Connecticut quite soon.
01:14In the meantime, of course,
01:16we have to be very careful,
01:18you know, over the next months.
01:21Well, I want to talk a little bit
01:22about lung Cancer Research at Yale.
01:23Just give a little introduction.
01:24So on the next slide.
01:35These are my disclosures. Next slide.
01:39When your lung cancer is A is a
01:41major disease worldwide and it's the
01:43reason we're here tonight to talk
01:45about some of the latest advances,
01:47is the leading cause of cancer
01:49death in most countries.
01:50With over 2 million new cases worldwide and
01:5518% of cancer deaths are from lung cancer.
02:01In the US for lung cancer we have
02:04about 228 thousand new cases a
02:06year with 100 and 35,000 deaths,
02:09most of lung cancer is non
02:11small cell lung cancer.
02:13About about 84% of it is
02:15the other 15% is small cell.
02:17If you look at the pie chart on the
02:20left you can see lung cancer is pretty
02:23much the biggest piece of the pie.
02:25This is new cases,
02:26now breast cancer.
02:27We screened for breast cancer.
02:29We screened for lung cancer too.
02:31As you learn tonight.
02:32But we screen more for breast cancer.
02:34Colorectal cancer.
02:34Of course we screen for as
02:36well and you can see those are
02:38big pieces of the pie as well.
02:40But lung cancer certainly is a
02:42major enemy and will talk tonight
02:44about some new treatments next 5.
02:48Well, the good news is we
02:50are making progress and I'm,
02:52uh, I'm old enough to tell
02:54you that we definitely are.
02:56'cause I've seen this over 25
02:58plus years working in the field.
03:00If you look back men on the
03:03top and women on the bottom,
03:05the red line is lung cancer and
03:07you can see the number of people
03:10who succumb to this disease.
03:12Look how it peaked around 1990 for men.
03:15Why? Because that's about
03:1720 years or 25 years after.
03:19All the ads and an efforts to
03:21get people to smoke and you know,
03:23that's probably why you know
03:24lung cancer really hit its peak,
03:26but it's coming down.
03:27And then if you look at women
03:29you see the peak for women occur
03:31in a little bit later.
03:33Why?
03:33Because women started to smoke after men.
03:36But still you can see that peaks coming
03:38down as well and the mortality rate
03:41has declined by 51% since 1990 for men.
03:4426% since 2002, in women,
03:45due to reductions in smoking,
03:47and we're continuing by
03:48the way to work on that.
03:50Certainly in the Connecticut area,
03:52especially in the New Haven area proper,
03:54many people 18% or so still smoke
03:56higher than the national average.
03:58But if you look at the chart on the right,
04:01the table on the right man,
04:02males and females,
04:04you can see the incidence is coming down.
04:07Minus 2.6,
04:07but the mortality is coming down even more,
04:10minus four point 3%.
04:11And then if you look at women,
04:13the incidence is coming down minus 1.2,
04:16but the mortality is coming down even more,
04:18minus 3.1. So what does this means?
04:21I think it means some of our
04:23treatments are having an effect.
04:24Our immuno therapies are targeted therapies.
04:26Let me show you some examples.
04:28Next slide.
04:32Now back. 20 years ago,
04:36maybe a little longer.
04:37This is what it looked like.
04:39If you had lung cancer,
04:40the median and this is for advanced disease.
04:43When your cancer had already
04:45spread from your lungs,
04:46you can see that you only survived.
04:48You know at one year only 1/3 of the
04:50people would survive this disease.
04:53It's much better now.
04:54The median was 7.9.
04:55It was clear if you click again
04:58Renee that something new was needed.
05:00So on the next slide.
05:04You can see that we developed new treatments
05:06and these are miracle treatments.
05:08This is Jeff it. If this is a drug
05:11that targets epidermal growth factor,
05:13which actually is a mutation that occurs
05:16in patients who have never smoked or
05:18smoked very little and you can see
05:20this is actually work that I did with
05:23Doctor Larusso who leads our Phase one
05:25group at Yale published this in 2002.
05:28You can see the picture on the left.
05:31Did both the same patient within one
05:34week of taking this oral drug can fit in.
05:36You can see the amazing response.
05:38You can see the lung has cleared
05:41up on the next slide.
05:43That led to a whole new era
05:45of lung cancer therapy,
05:46but we call targeted therapy.
05:48The fact that we could target the
05:50epidermal growth factor receptor showed
05:52on the left with drugs in patients
05:54with lung cancer as shown on the right.
05:57Cecily the woman in that picture
05:59was spent nine years on June 15
06:01amp with metastatic disease.
06:02Remember the same disease I mentioned
06:04would only have about a 1/3 chance of even
06:07lasting one year with standard therapy.
06:09And this was written about in the Wall
06:12Street Journal by Tara Parker Pope.
06:14I think she now writes for the New
06:17York Times that you could live with
06:19lung cancer with these new drugs
06:22on the next slide.
06:24And then we developed our newer drugs.
06:26You know,
06:27'cause people become resistant
06:28to these drugs and this is just
06:30showing a drug called OS American.
06:32If the next generation oral agent
06:34for this type of lung cancer and
06:36what you see with those lines below
06:38the negative twenty negative 40,
06:40those are all patients whose tumors
06:43shrank when they took this new drug.
06:45So the next slide.
06:49Next slide and these are data just
06:51from the New England Journal of
06:53Medicine about three weeks ago.
06:55Let out of yell you can see these are
06:58patients who had lung cancer and had surgery,
07:00but they had this vacation in this in
07:03this epidermal growth factor receptor gene
07:05and on the left you can see two curves.
07:08The blue curve on the right are
07:10patients who got this drug after
07:12their surgery and the orange or yellow
07:14curve below are those who didn't,
07:16and you can see the big difference.
07:18Actually a 70.
07:202% actually excluding an 82% improvement.
07:25And then if you look at the right,
07:27you can see that in the brain the
07:30solid blueliner patients who got
07:31the Aston Martin in the new drug
07:34versus those in yellow who didn't.
07:36You can see again a big improvement
07:38in outcome,
07:39actually 82% so new therapies are coming.
07:41There's really a lot of hope in this disease,
07:44one or two more slides.
07:45Next slide, Renee.
07:47So we have it yell much research going
07:50on most if not all the investigators
07:53talking to that are involved in this.
07:55We work with our surgeons or pulmonologists,
07:58radiation oncologists,
07:59medical oncologists and we're trying
08:01to target lung cancer with a big grain
08:04from the National Cancer Institute
08:05called a specialized program of
08:07research excellence and you can see
08:09some of the ways we're targeting lung
08:11cancer by targeting immunotherapy on
08:13the left epidermal growth factor,
08:15resistance on the right.
08:17A smoking cessation on the very bottom.
08:20Next slide.
08:21We have a team.
08:23Here is the current team and some
08:25of our leaders.
08:26I won't go through this for the sake of time,
08:30but yell Cancer Center smile Cancer
08:32Hospital is committed and all of
08:34its sites to providing the most
08:36up-to-date treatments and these
08:37treatments are developed in the lab,
08:39bringing them close to the clinic.
08:41Targeting immunotherapy,
08:42targeting growth factor abnormalities
08:44like I just showed you and trying to
08:48treat cancer in the most updated way
08:50on the next slide. This is the team.
08:53This is the Phase one team.
08:55It's led by Pat Larusso.
08:57She's in the blue shirt.
08:58Tried the right of the picture
09:01about third from the from the
09:03from the right and these are some
09:05of our investigators and staff.
09:07It really takes us a team of
09:10investigators of conditions of nurse.
09:13Should workers of coordinators
09:14to make these trials happen and
09:16then on the next slide?
09:17I think this is about the end.
09:20Now I get to have the fun part of the
09:22evening and introduce the panel so
09:24there's so much progress in this disease.
09:27What we've tried to do is put
09:30together a group of.
09:32Physicians tonight,
09:32who will tell you about some
09:35of the latest advances,
09:36mostly dealing with early stage lung cancer,
09:39and we have four doctors tonight
09:41and the first is Justin Blasberg.
09:44Doctor Blasberg is the associate
09:46professor of surgery and director
09:48of robotic thoracic surgery at
09:50the Yale School of Medicine.
09:52Here in his medical degree from the
09:55Albert Einstein College of Medicine and
09:57completed his cardiothoracic training
09:58at the Massachusetts General Hospital.
10:01Doctor Blasberg's practice includes
10:02minimally invasive and open management
10:04for diseases of the esophagus,
10:06lung, mediastinal, chest wall,
10:08thoracic thoracic outlet and diaphragm
10:10is a particular interest in benign and
10:13malignant disease of the trachea and
10:15performs the majority of his surgeries,
10:18when possible,
10:18in a minimally invasive fashion.
10:21If we could put up Justin,
10:23Slide will see this head of
10:25his talk welcome Justin,
10:27Thank you. I
10:30wish my mom was listening now it's so nice.
10:33Yeah, you could say don't
10:35stop I'm gonna share my screen
10:37because my slides have videos OK?
10:41Just make sure this works.
10:45OK, after grant access.
10:53OK, I actually have to log right back on.
10:55I'm sorry I'll be right back one second.
11:04In the meantime, Anne,
11:05why don't you introduce yourself and
11:07tell us a little bit about the 15
11:10plus sites around Connecticut where
11:12we have smilow cancer care? Sure,
11:14my name is Ann Chang.
11:16I'm a medical oncologist treat lung cancer,
11:19and I also have an administrative
11:21role as Chief Network Officer,
11:23so we have Milo care centers
11:25throughout Connecticut.
11:2615 different centers smile.
11:27Greenwich is one of ours,
11:29and it's very exciting.
11:31I see on the panelists.
11:32Sorry in the attendees,
11:34I see several of my patience.
11:36So hello, but we have a great
11:39program for you tonight.
11:42So now we're going to hear from
11:45Justin about robotic surgery options
11:47for lung cancer. Can you guys
11:49see my slides?
11:52You can see my slides yes very well great.
11:54I feel a little bit like Frank right now.
11:57Sorry, trying to trying to make this
11:59work and I'll get a chuckle out of any.
12:01So tonight I wanted to talk
12:02about robotic surgery,
12:03which has become a big part of my
12:05clinical practice and I think it
12:07represents a huge step forward
12:08in terms of how we manage lung
12:10cancer in terms of disclosures.
12:11I am a Proctor for Intuitive Surgical,
12:13which is the company that makes the
12:15robots that we use in the operating room.
12:19We're talking a lot about
12:21lung cancer tonight.
12:22When we think about the optimal
12:24management of early stage lung cancer,
12:26which includes smaller
12:27tumors and localized disease.
12:28We know from outcomes data that
12:30surgery is associated with the best
12:32chance of five year survival and the
12:34lowest risk of disease coming back
12:35over the five years following surgery.
12:37We also have other tools in our
12:39toolbox for these early stage
12:41patients that cannot tolerate surgery,
12:43like radiation therapy or ablation.
12:44And we'll hear a little bit more
12:46about that later,
12:47and these are really great
12:49treatment options for patients.
12:50That we use all the time and
12:53are associated with success.
12:54I'm going to talk a little bit about
12:56the evolution of our surgical field
12:58because I think it's interesting
13:00for people to know how we do these
13:02procedures safely and effectively for
13:04early stage lung cancer resection.
13:05Our traditional approach back in the
13:07day was to make a fairly sizable
13:09incision to divide some muscles in
13:11the chest wall to spread the ribs
13:13with retractors so that we could
13:15access the lungs with our hands and
13:17actually perform these receptions
13:18under direct vision to the right on
13:20my screen is a scene for one of my
13:23favorite shows on Netflix, the Crown.
13:25And were King George the six
13:27actually underwent this kind of
13:29surgery and pneumonectomy inside
13:31of Buckingham Palace in 1951.
13:33So these incisions can be uncomfortable,
13:35but that discomfort can be managed
13:37pretty well with pain medications.
13:38Patients need to stay in the
13:40hospital for some period of time,
13:42usually a few days,
13:44sometimes upwards of a week.
13:45And it does take time for patients
13:47to return to their normal activities
13:49of daily living,
13:50some sometimes around four to six weeks.
13:53Starting around 25 years or so ago,
13:56we took a big step forward in a
13:58minimally invasive lung surgery
13:59with the development of miniaturized
14:02cameras and instruments that work
14:04through keyhole incisions which led
14:05to the adoption of video assisted
14:07thoracic Copic surgery,
14:09or that surgery as it is known,
14:11has magnified optics. The vision is 2D.
14:13The surgical instruments can perform
14:15some complex functions and lung resection.
14:17Surgery can be performed through
14:19these small incisions to remove
14:21and add an abnormality of interest.
14:23A year we have expert that surgeons
14:25who perform these procedures almost
14:27every single day of the week across
14:29our network.
14:30This operation is safe,
14:31it's reliable and we train our
14:33residents how to do these cases
14:35with proficiency.
14:36We've also been very successful with
14:37our bats lung and Asafa Geo programs,
14:40and this has been our standard
14:41approach for many years now,
14:43allowing US patients together,
14:44allowing us to get patients out
14:46of the hospital faster,
14:47usually around three to four days.
14:49These patients require less pain
14:51medication then open incisions and
14:53their return to their baseline is much, much.
14:55Shorter compared to open surgery.
14:58So that brings us to robotic surgery,
15:00which is one of the things
15:02I'm most interested in,
15:03and at least in lung cancer,
15:05it represents an opportunity to
15:06bridge the gap between open and video
15:09assisted surgery by combining the
15:10technical advantages of open surgery,
15:12but with the patient specific benefits of
15:14minimally invasive video assisted surgery.
15:16So in this type of technique,
15:19a surgeon sits at the console.
15:21They control robotic instruments inserted
15:23through similar keyhole incisions or ports
15:25that we use in video assisted surgery.
15:27But these instruments actually
15:29attached to robotic controller arms.
15:30The instrument tips can move with
15:32multiple degrees of freedom.
15:34They can perform complex functions,
15:36and essentially they perform the
15:37same technical functions as if my
15:40own hands were doing the operation.
15:42I move these instruments around
15:43using hand controls.
15:45As you can see here that allow.
15:47Motion the exact that allow for the
15:49exact motion of my hand and they let
15:52us do things like dissect important
15:54structures in and around the lung.
15:57These motions are basically the
15:58same as if I were performing this
16:00procedure at the bedside open,
16:03except that I'm viewing structures at 10
16:06times magnification in three dimensional.
16:083 dimensional camera and this allows
16:10me to divide blood vessels the airway
16:13or remove the lymph nodes using robotic
16:16energy devices with increased precision.
16:18The value of robotics is that it
16:21simulates open surgery but with
16:23a huge technical advantage,
16:24not just the 3D visualization or
16:27those articulating instruments,
16:28but the size of the incisions
16:30in the incision.
16:31Placement can be performed in areas where
16:34there's less discomfort for patient.
16:36For patients that is a simulating.
16:39Open surgery,
16:40these instruments allow us to
16:42be extremely thorough with our
16:44dissection and to keep patients safe,
16:46especially during the most
16:48complex components of the case.
16:50There are other patient specific benefits
16:52like reduced incisional discomfort,
16:54shorter length of stay,
16:56reduced blood loss,
16:57and with a significant amount of
16:59experience we've been able to
17:02successfully integrate this out
17:03this platform into our system level
17:06to reduce our length of stay to
17:09improve our short-term outcomes.
17:10Most importantly to get patients back
17:13to their standard quality of life
17:15and their activities of daily living.
17:18As this technology improves,
17:19actually these the platform
17:20is getting smaller.
17:21This is a video of a single port robot
17:24that we now use it Yale and were one
17:27of the first sites in the country
17:29to have access to this technology.
17:31Instead of four separate keyhole
17:33incisions for four instruments,
17:34the platform allows for one port
17:36that contains all instruments.
17:38So for abdominal surgeons they can
17:39hide this portal at your in your belly
17:42button and remove your Gallbladder
17:43without compromising on safety or quality.
17:46And we're really excited about.
17:48These kinds of opportunities,
17:49mostly because we think it'll help
17:51patients recover faster and clearly.
17:53This is the direction where
17:54small incision is going.
17:56Small incision surgeries going
17:57especially for our lung patients.
17:59We're also excited about some of the
18:02about the opportunity to use robotics
18:04to help biopsy or mark tumors that we
18:06can easily remove in the operating room.
18:08Here's an example of a robotic system
18:10that uses a flexible catheter to
18:11navigate through a patients airway.
18:13We now have the ability to perform these
18:15kinds of procedures or computer software,
18:17identifies a nodule within the long as
18:20an the pathway to access that nodule,
18:22and then using a control unit,
18:23an operator can drive out of
18:25robotic catheter into the lung,
18:27allowing us to biopsy a nodule or even
18:30inject it with a specific kind of dye
18:33that we can see in the operating room.
18:36As a result, we're really proud
18:38of our surgical results,
18:39were able to perform minimally invasive
18:41lung resection in 90 to 95% of our
18:44early stage lung cancer patients.
18:46That's both bats and robotic surgery
18:48are average or average length of
18:50stay is well ahead of our national
18:52of the national averages and our
18:54academic peers are complication.
18:56Risk after surgery is very low in our
18:58surgical mortality is also very, very low.
19:01As important in the lion share,
19:03where patients are discharged home
19:04rather than needing a transitionary
19:06period and either rehab center.
19:08Center or sub acute nursing facility.
19:10Now that we're bringing all of these
19:12minimally invasive technologies to
19:14the hospitals across our system,
19:16including Greenwich and Bridgeport,
19:17there's a great opportunity to
19:19offer more patients.
19:20These options for early stage lung
19:23cancer and other thoracic cancers.
19:26And with that,
19:26I'd be happy to take any questions.
19:30Thank you Justin, that's phenomenal.
19:35Are we going to get some questions 1?
19:38One person on the line has asked can you
19:41do a paradisus using the robotic rats
19:44procedure so upper decices a sticky
19:47procedure where we usually either scratch
19:49up the surface of the chest wall or
19:52put in medications like a baby powder,
19:55chalk powder or an antibiotic.
19:57Doxie cycling to cause the lungs to stick.
20:00The chest wall to prevent it from collapsing.
20:04Procedure that similar to that is actually
20:06referred to as a horror ectomy where
20:08we strip the lining of the chest wall
20:11and that allows for the same effect.
20:13Actually and even better if it and so
20:15a robotic pleurectomy is a commonly
20:17performed procedure by our group,
20:19is very effective and it's great
20:21with the robot because there's a
20:23little bit less bleeding and I think
20:25it's a little bit more thorough.
20:29Great thanks so please put
20:31your questions in the chat.
20:32I have a few others here.
20:34Someone's asking just if
20:35and when you go to video
20:36games when you were a child.
20:39So I did play a lot of video games as
20:41a child and I think that does help with
20:43hand eye coordination, but my parents
20:45also forced me to play the cello,
20:46so I think that was probably that
20:48probably helped so we can have our kids
20:49both through the music lessons.
20:51Then they can play a little bit.
20:52You know, at the arcade.
20:55No, but seriously, when you went,
20:57have you always trained in robotic
20:59surgery or did you have to make a
21:01transition at some point in your career?
21:03And what about surgeons more
21:05advanced in their career? Was
21:06it hard for them to learn these techniques?
21:09So this is the interesting
21:10part about robotics.
21:11I actually trained at MGS where
21:13there was no robotic surgery and
21:15no back surgery is essentially all
21:17open surgery even in 2011 to 13
21:19when I was there not too long ago.
21:23I learned that surgery in my at my
21:26first job and I learned robotic surgery.
21:29Actually here at Yale.
21:30When I started with Tony Kemp,
21:32the value of robotics is that
21:35because it simulates open surgery,
21:36it's actually much easier for a
21:39traditional open surgeon to learn
21:41rather than bats the learning curve.
21:43That's as much higher, much deeper.
21:45So it is an interesting phenomenon
21:48that minimally invasive surgery
21:50is better for patients and.
21:52Add more open surgeons to transition
21:54to minimally invasive surgery,
21:56increasing the overall performance
21:57of minimally invasive surgery.
21:59Combining Vatsan robotics and so it is a
22:01more natural platform for open surgeons,
22:04and that's that was the case for me as well.
22:08Right, we have another question.
22:10You know there are
22:11disparities in health care.
22:12A lot of places don't have
22:14surgeons like you inviting others.
22:15Can this be done remotely?
22:17So could could you control an
22:19operation from Cedar St someone
22:20someplace else in the country where
22:22there might be fewer physicians
22:23that have that expertise?
22:26So the answer is technically yes,
22:28although I don't believe
22:30anyone actually does that,
22:31I think there was a landmark
22:33case years ago where they they
22:36remotely operated on a patient,
22:38a cross in the ocean between countries,
22:41but I don't believe that there is
22:43any site that's actually physically
22:45doing surgery remotely.
22:47Maybe in the military,
22:48and Vinny could speak to that,
22:51but I don't believe in any other capacity.
22:54It's not what we typically do,
22:56but there are so many.
22:58Robotic surgeons across the country
23:00now that it doesn't take much to find
23:03somebody within your region who can
23:04who can provide something like this.
23:08Well that was fantastic.
23:09You know? Maybe not.
23:10Now with the Covid virus racing,
23:11but someday I'd like to join you in the
23:14operating room and see how that that works.
23:16And I'm not sure I could even tie in that.
23:18But maybe the robot could
23:20help me do it for you.
23:21Yeah, OK, well thank you Justin.
23:23That was fantastic.
23:24OK moving on and I see some
23:26questions in the chat,
23:27but I'm going to wait till they are
23:29relevant to the topic of the talk and
23:31some of them will be relevant now for
23:33an Chang Doctor Chang is associate
23:35professor of medicine in medical
23:36Oncology and Chief Network Officer
23:38and Deputy Chief Medical Officer.
23:39For the Smile Cancer Network,
23:41she specializes in thoracic oncology
23:43with the background and translational
23:45research in metastases as well as
23:48extensive experience in clinical practice,
23:50both academic and community settings.
23:53Text Chang's research interests focus
23:55on development of clinical trials and
23:57translational studies to test novel
23:59agents and combinations with immune
24:01checkpoint inhibitors for both small
24:02cell and non small cell lung cancers
24:05to received medical degree from
24:06Cornell University Medical College.
24:08My alma matter actually and her PhD
24:10from Harvard and it's wonderful
24:12having here talking about some of
24:14the new medical oncology treatments
24:16for for lung cancer Ann.
24:20Q. My pleasure and I'm gonna share my slides.
24:25I wanted to talk about the advances in
24:27treatment of lung cancer from targeted
24:29therapy to immunotherapy and and Roy.
24:31You did mention a little bit of this,
24:33so thank you very much. I'm let's see.
24:40These are my disclosures.
24:42I'm going to talk about non small
24:44cell targeted targetable mutations.
24:46I'm going to talk about non small
24:48cell patients that incorporate
24:50advances that incorporate combination
24:52immunotherapy and chemotherapy.
24:54I'm going to talk a little bit
24:56about side effects associated with
24:58immunotherapy and then end with
25:00treatment of patients with small cell.
25:03So there's a lot to cover an I will do my
25:07best to go through this relatively quickly.
25:11We'll see how we do at time.
25:14I'm I'm supposed to finish in 15
25:16minutes so as Doctor Herb said,
25:18lung cancer comes primarily in two forms,
25:21non small cell and then small cell which
25:24is around 15% and of the non small cell.
25:27Most of it is adenocarcinoma 35 to 40%
25:31squamous cell carcinoma and then large
25:33cell and those are histologies and
25:35that's actually shown in this slide.
25:37So underneath the microscope
25:39small cell looks like.
25:40Little blue small cells as named add no
25:44carcinoma adeno means Greek gland in Greek,
25:47and so it describes the formation
25:49of these little glands.
25:51Squamous cell often has what's called keratin
25:54pearls hoops and then that's large cell,
25:57which is sort of the the other category.
26:02Doctor Hoopes mentioned the mortality
26:04and incidence of lung cancer is coming
26:07down and this is a paper from the New
26:09England Journal of Medicine that came out
26:12this year that shows this very exciting.
26:14For on the on the left men and on the
26:17right women both in blue the incidents.
26:20So how often it occurs and
26:22then the mortality in red.
26:23So that's both going down for men
26:26and women for small for non small
26:29cell and for small cell and in
26:31part due to many of the advances.
26:33That I'm going to talk about tonight.
26:36So let's first talk about this concept of
26:40personalized medicine in lung adenocarcinoma.
26:42So back in 2004,
26:44we really talked about that.
26:46We would we would do profiling or look
26:50for mutations in the tumor tissue and we
26:53were really looking for only two things.
26:56EGFR in K rests that were described at the
27:00time and now in 2014 and and even more so.
27:05Now we're looking for a dozen
27:08targets that actually have.
27:09Drugs that that can be used against them.
27:13So I'm going to start with,
27:16specifically EGFR therapy.
27:17That's epidermal growth factor
27:19receptor and there are mutations in
27:22this particular gene that basically
27:24are most common in never smokers,
27:26females, Asians, and adenocarcinomas,
27:28and if you have these mutations then
27:32you can take an oral EGFR inhibitor
27:35medication or a pill and you can
27:37have very good response rates.
27:39And here's an example of a patient who had.
27:43A long lesion in that's here in
27:472016 and you can see some shrinkage
27:51in in the next panel over there.
27:54And this is another example of a patient.
27:57This is a CAT scan and at day zero before
28:00they started taking that medication,
28:02they had a lot of cancer.
28:04These are these.
28:05These lesions here and you can see
28:07that really cleared up four months later,
28:10but then overtime you had some regrowth.
28:12And this is this concept of,
28:14you know, the medication works,
28:16but it doesn't work forever and there are
28:18some cells that can develop resistance
28:20and one of the ways that we've been able
28:24to characterize this many researchers.
28:26To then look at these cells that develop
28:29and look for mutations there and and
28:32so through that kind of analysis,
28:35folks were that researchers were able to
28:38find that sometimes it was a a secondary
28:42mutation that then caused difficulty
28:45for the drug to bind to its target.
28:47Or sometimes it was another path.
28:50Another pathway that was activated,
28:52or rarely maybe 5% of the time that.
28:56The cancer had actually changed
28:59and transformed into small cell.
29:02So this idea of you know precision
29:05or personalized medicine is
29:06shown in this graph here.
29:08And basically,
29:09you know before we used to think that
29:11lung cancer was one diagnosis and
29:14everybody got the same prescription
29:16with two as chemotherapy.
29:18And so with the advent of looking
29:20at particular mutations,
29:22then we could say OK if you were these
29:25folks in Green who had an EGFR mutation,
29:28you can be treated with in EGFR drug.
29:32If you have the reputation,
29:34you can be treated with a targeted drug,
29:37and if you had a different mutation
29:40you could be treated with Sameet
29:43inhibitor and everybody else would
29:45would get a different treatment.
29:48The treatment being that in that category,
29:51so this slide actually is that.
29:56Summary of all of these agents
29:58that really have been approved.
30:00Developed and approved and available
30:03for patients in the past decade and
30:07this is really tremendous work by many
30:10people and represents really the.
30:13The realization of that that
30:15idea of personalized medicine.
30:16So depending on the mutation that you have,
30:19there are multiple drugs available.
30:21The ones in bold are the ones that are
30:25recommended, but all of them are are
30:28developed even for the wrasse. Mutation,
30:30which has been one that has been very,
30:33very difficult to target and very often
30:36characterized characterized smokers
30:37folks who have extensive smoking history.
30:40Their mutation.
30:40We do have clinical trials now.
30:43That are very, very promising.
30:45Being able to target those rasme tations.
30:48So in conclusion, for the targeted therapy,
30:51you need to know the target,
30:53the mutation status in order to
30:55use the therapy.
30:56If you have disease, that and I saw,
30:58there was a question on this.
31:00If it's late stage or meta static.
31:03In other words, spread to different organs.
31:05You can use these agents,
31:07but it's not cure it if it can
31:09prevent the disease from growing
31:11and shrink it for a long time,
31:13but you have to be able to target,
31:16use biopsies and figure out what.
31:19Mechanisms of required resistance are
31:21occurring in order to continue to treat that,
31:23and certainly standard chemo alone
31:25and in combination with immunotherapy,
31:27is still an effective tool for
31:30these patients as well.
31:32So now I'm going to shift.
31:34Well,
31:35actually here you can see the advances
31:38that have a curd poops in the past decades.
31:41An all of these yellow and
31:44orange and light purple or what?
31:46I just highlighted those changes
31:48that those discoveries in the
31:50area of mutations and drugs that
31:53target those mutations.
31:54The light blue over here and this is Doctor
31:58Herbs paper in nature you could see that.
32:02Point to advances in immunotherapy.
32:04And that's what I'm going to talk about now.
32:08So just to go back to how immunotherapy
32:11works, think of cancer cells.
32:13They develop many mutations that make
32:16them appear foreign to the immune system.
32:19The T cells that's part of your immune
32:21system can actually recognize, attack,
32:24and kill these foreign cancer cells.
32:28However,
32:28cancer cells are really tricky
32:30and they express PDL one,
32:32which is a protein and that helps them
32:35become evade the immune attack and so
32:38that the immune system can't see them,
32:41and So what happens is that PDL 1.
32:45Basically,
32:45dampens or decreases that the
32:48anti tumor response.
32:50So that's why these therapies
32:52immunotherapy's that target PD one
32:55which is on the T cell and PDL one which
32:59is on the tumor cell are effective.
33:01So basically these.
33:04The drugs or antibodies.
33:06Here anti PD one anti PDL one will
33:09prevent the interactions between
33:10the T cell and the tumor cell to
33:14basically allow the immune system
33:16immune system to wake up and recognize
33:18those cancer cells is being formed
33:21and trying to get rid of them.
33:23And the advantage of immunotherapy over
33:26chemo is that it's very specific for
33:29that cancer cell as opposed to chemo.
33:31That sort of attacks all cells
33:34that are dividing quickly.
33:35There is a memory component,
33:37so a durable response.
33:41Because the immune system can remember,
33:43and then there's adaptability,
33:44so I'm going to just talk about
33:47a patient of mine just to sort of
33:50illustrate some of these points.
33:51So this is a patient that I saw
33:54for the first time in 2014 and
33:56had lots of pain and shortness
33:58of breath and had neck masses as
34:01well as a PET scan that showed.
34:05Disease in the left,
34:08lower lung and lymph nodes.
34:11I suggest the left lower lung and that's
34:14lymph nodes on the PET scan and the brain.
34:17MRI had three tiny lesions and
34:18so the biopsy of the cervical
34:21lymph node showed lung cancer.
34:23No mutations detected,
34:24so we couldn't use that targeted therapy.
34:26And that patient went on a clinical trial for
34:29drug called Pember Lizum app or KEYTRUDA.
34:32You might have seen that the
34:34commercials for that and.
34:36And started.
34:392014 and in February had scans
34:41that showed a really terrific
34:44response in the brain and body.
34:47And this is just to show that in 2016.
34:50So this is the advantage of a clinical trial,
34:53as you can really have some of
34:55those cutting edge therapies before
34:57they get approved by the FDA.
34:59And in this case it was really two
35:02years later after patients started
35:04that the FDA was able to approve
35:07the this drug KEYTRUDA for four.
35:09Short non small cell.
35:11So he did actually quite well
35:14until March of 2015,
35:15then had very bad diarrhea,
35:17was treated for steroids and this
35:19was a toxicity,
35:20so this was a side effect.
35:22He was on steroids for awhile and
35:25tapered off and then had symptoms
35:27and then was finally treated
35:29with a different drug.
35:30That really resolved the
35:32diarrhea and most exciting.
35:33I just saw him last month,
35:36six years after his original diagnosis
35:38and he has no evidence of active
35:40disease in his brain or his body.
35:43So this is really.
35:44I think a happy ending that highlights
35:47the importance of clinical trials and
35:51the excitement around immunotherapy.
35:53This is an article that that
35:56Doctor Herbst and I wrote.
35:59To basically show the different
36:01options now available for
36:03patients with squamous cell and
36:05non squamous cell lung cancer.
36:07And in addition to those this we
36:10wrote in about a year ago in the
36:12past year we've had an additional 3
36:15approvals for combination immunotherapy
36:17immunotherapy with two cycles of chemo.
36:21And then.
36:23Another age Amy no therapy for for
36:26high PDL one expressing tumors.
36:29So really a rapidly and very exciting field.
36:35This slide is just to show some
36:37of those trials which were phase
36:40three trials and what I highlighted
36:43is the impact on survival.
36:45So not that you have to know these numbers,
36:49but this for example this trial which
36:51shows the the the results of combination,
36:55chemo and immunotherapy,
36:56which has become our standard of care
36:59shows a 50% reduction in the risk of death.
37:03So really significant.
37:04Advances for lung cancer.
37:07One of the questions we have is is
37:10chemotherapy even necessary anymore?
37:12And I think that this is important
37:14question that a big trial.
37:16This is a national trial that I chair
37:19with has poor guy in and we have this.
37:23This trial will have 880 patients
37:25and we have about we're a little
37:28over 1/4 of the way through crew
37:30patients to this trial and what we're
37:33testing is whether or not you could
37:36start with immunotherapy alone.
37:38And then go to chemo if you happen
37:41to progress or if you can add
37:43chemo if you happen to progress
37:45and then this is our control.
37:47So very exciting clinical trial
37:49and this is open in Greenwich.
37:51Doctor Lee is.
37:52Other medical oncologist there can can
37:55can put patients on this trial as well
37:58can participate you can participate.
38:02This is just to show that the spectrum
38:05of toxicities is that you can,
38:07when you're ramping up the immune
38:10system to recognize the cancer,
38:11you can sometimes recognize.
38:14Your normal tissue as well,
38:16and the way that this is treated
38:19is usually with steroids,
38:21and I'm not going to go through this
38:23fly but but you can be quite effective
38:26in that way so that the conclusions
38:29here for immunotherapy is that we
38:32have these new PD one and PDL one
38:35inhibitors that that are active,
38:37very excited about the durability of
38:39response and the toxicity is manageable.
38:41It happens, but it is manageable.
38:43Requires very early intervention.
38:45And we're trying to study this
38:48area biomarkers to understand who
38:49can respond and that there are
38:52lots of drugs that are approved
38:54for non small cell lung cancer.
38:57And finally,
38:58I just a few slides on small cell,
39:01which is also a passion of mine.
39:03This is a.
39:05This is a little bit different
39:07than non small cell.
39:08These cancers unfortunately grow very
39:10quickly and they can metastasize and spread,
39:13but they're also exquisitely sensitive
39:15to both chemotherapy and radiation.
39:19This is the past decade decade of advances,
39:22and it's been pretty sparse
39:25over the past 30 years.
39:27However, again, that landscape is
39:29really changing now and there have
39:32been some very recent advances,
39:34both in immunotherapy and understanding.
39:36Small cell biology.
39:38This is just to show that again, small cell.
39:41We're starting to tease out what are
39:44the molecular drivers and understanding
39:47that it's not just one flavor.
39:50That there are different types that
39:52we can perhaps approach differently,
39:55and the key points here.
39:57The key updates 2 new FDA approvals for.
40:00Immunotherapy plus chemo in the frontline.
40:03That means when you're just diagnosed,
40:05one knew second line FDA approval for
40:08a drug called Bourbon Ected and which
40:10is a chemo and then just highlighting
40:13the need for understanding biomarkers
40:15and another other options for patients
40:18who might progress and immunotherapy.
40:20And I think my last slide is again one
40:23of these is a clinical trial that fellow
40:27had helped me to write and rear have.
40:30Open now,
40:31this is a clinical trial open.
40:33Also available in Greenwich where
40:35we're doing a biopsy pretreatment
40:37and then at week four for patients
40:39treated with combination immunotherapy.
40:41And we're really trying to
40:43understand with these biopsies,
40:45how can we see what changes in the tumor
40:48micro environment are going to tell us?
40:51Who's going to respond or not,
40:53and that way we can really understand?
40:57How did disease works and how to attack it?
41:00And this is just a moment of peace
41:03in this time of kovid and again
41:06hoping that all of you were are
41:08safe and wishing you the best.
41:11So that's it right?
41:12Thanks
41:13and that was wonderful.
41:15We have a lot of questions here.
41:18So someone's asking about EGFR,
41:20and I mean, in therapy.
41:21Why not use them both together?
41:24The EGFR drugs in the immunotherapy drugs?
41:26Wow, that's a great
41:28question, and there are clinical trials
41:30that are looking at both of them.
41:32You have to be tricky,
41:34though, because again,
41:35when you're combining two drugs,
41:37you have to be careful that
41:40there aren't specific toxicities
41:41that go hand in hand together.
41:43So that is a that is right now.
41:46It's not our standard therapy because
41:49those trials haven't resulted out yet.
41:51But we're learning more and more right now.
41:54We are using them as.
41:58It's working there for the marathon,
42:00so we're trying to develop as many tools
42:02in our kits to use and so we use the target
42:06therapy separate from the immunotherapy.
42:09But we're testing them together to see if
42:11we can get better and more effective tools.
42:15Great thanks and so was asking about
42:17whether you use liquid biopsy AKA blood
42:20in your practice for molecular testing.
42:23Absolutely, I think that's one
42:25of the most exciting things.
42:26And Roy there is a New York
42:29lung cancer conference reset.
42:30Recently, when several cases were
42:32shown an basically now you can.
42:34You can use the liquid biopsy of front
42:36and then you can use it along the line
42:39when you're developping resistance,
42:41and I think this is a really great tool
42:44that we're going to see more and more of.
42:48OK, uh, specific question.
42:50Someone says that the quality
42:52of drugs is improved.
42:54I was on Afatinib for four years
42:57and documented 14 different side
42:59effects with its use and knowledge
43:02are aggressive and have one mild
43:04side effect, so an thought.
43:07You know Afatinib is a really hard drug
43:10to take, so you know kudos to you.
43:14Oh, Summerton app,
43:15which is a third generation drug.
43:17Much, much, much more effective in the brain.
43:20It has really good CNS penetration
43:22and it's much easier to tolerate.
43:24So good for you,
43:26that's wonderful news either
43:27some specific situations where
43:28we still might use afatinib.
43:31There are and, so this is what,
43:33how again, we can use the idea of tools.
43:36We can sometimes recycle these tools,
43:38and if you think about.
43:42If you that idea of acquiring resistance,
43:44you may develop and you by
43:46acted different point in time,
43:48you might have been really effective
43:50in controlling one particular
43:52form of or clone of the disease,
43:54but it may have changed.
43:56And actually you might be able
43:58to go back to a fat in it,
44:01which is what I did with one of
44:03my patients relatively recently.
44:07Great and the last question I have
44:09here is about anti angiogenesis.
44:11The importance of those drugs.
44:13Then they still used a great deal. Anti
44:16angiogenesis is our that whole class
44:19of drugs is really important and I
44:22describe it usually to my patient.
44:25A tumor, or initially grows.
44:26It uses the blood vessels that are there,
44:29but as it really is, you know,
44:32developing it builds its own blood vessels,
44:34and so these drugs help to choke
44:37off the growth of knew tumor,
44:39associated blood vessels,
44:40and we're finding that you can combine
44:42those with chemo and with immunotherapy.
44:45Together in one case.
44:46And then there are also some
44:48clinical trials testing those drugs
44:50with the targeted drugs as well.
44:53Excellent, any more questions.
44:56I don't see any. Thanks Ann,
45:00really appreciate that talk and
45:02all you do for the clinical
45:04trials and for our network.
45:08So now I'm really excited also about the
45:10next talk because screening for lung
45:12cancer is so important and I'll tell you,
45:15I think it's underutilized.
45:16So we have to figure out how to get
45:19more people screen because finding these
45:21cats as early as you're about to see
45:23can make a big difference. So for that,
45:26we're very fortunate to have mini maze.
45:28He's amazing assistant professor of surgery,
45:30thoracic and he cares for patient
45:32and smiles main campus and at the
45:34Smile Cancer Hospital Care Center in
45:36Trumbull received his medical degree
45:38from the University of Vermont.
45:40And completed his fellowship and thoracic
45:42surgery at Brigham and Women's Hospital.
45:44Another one of my alma mater's doctor.
45:47Mays used the latest technologies for
45:49the surgical treatment of lung cancer,
45:51chest wall deformities,
45:53and other problems that affect the chest,
45:55including the diaphragm and esophagus.
45:58He is skilled in performing minimally
46:00invasive thoracic surgery and as an
46:01interest in quality outcomes research.
46:03So this is like I love to see tons
46:05of questions from this.
46:07'cause who do we screen?
46:08When do we screen?
46:10Why do we screen?
46:11So if any of the
46:12floor is yours, great
46:14thank you. Can everyone see my slides?
46:17Yes. Great, I think I just for
46:20the the people that are on.
46:22We started with about 55 and now we have 57.
46:25So for those of you that have
46:27are here tonight with the Smilow
46:28family I just want to thank you
46:31for you know sticking with us.
46:32It's a great crowd.
46:33I actually see some of my patients
46:36and actually some of the family
46:38members of some of my patients in
46:40the in the in the in the room there.
46:42So thank you very much for joining us
46:45tonight and I just want to let you know.
46:47I mean after this you know.
46:49After this session, you're all in a way,
46:51a subject matter expert when it
46:53comes to the advances in lung
46:55cancer and lung cancer screening,
46:57so you know,
46:58go out and educate your family and
47:00friends about what you learn today.
47:02Certainly encourage you to do that.
47:04Basically,
47:04what we're going to talk about
47:06today is just some local health
47:08statistics specific to Connecticut,
47:09the efficacy of lung cancer screening
47:11and really kind of what I thought
47:13would be important to you or questions
47:16you may have that you know come
47:18down to some nuts and bolts like.
47:20What what?
47:20What is a chest X Ray and how
47:22do I look at it?
47:23Or what's the difference
47:24between that and a chest CT?
47:27Then basically,
47:27Doctor Herps talked a little bit about
47:31his pie chart early on in his talk.
47:34That was for the the significance of
47:37lung cancer for the for the globe.
47:39This is the Connecticut cancer
47:42statistics for 2010 and what you
47:45can see is that long and Broncos
47:48cancers accounts the third.
47:50Leading newly diagnosed cancer.
47:52But it's the most when you look
47:54over at cancer desk back in 2010,
47:57it's the most lethal accounting for
47:59almost a 25% of death from cancer
48:01in 2010 in the state of Connecticut,
48:04you know.
48:05And there's some reasons for
48:07that that we know about.
48:09It's a silent disease.
48:10It's certainly found in more advanced
48:13stages and up until recently we
48:15haven't had an effective screening
48:17tool like there is for breast cancer
48:19like there is for prostate cancer.
48:22That helps to identify patients
48:24at a younger age,
48:25and certainly Doctor Chang
48:26highlighted some of the many novel
48:29therapies that help to combat
48:30the lethality of lung cancer.
48:32But certainly what we're trying to
48:34do now going forward is trying to
48:37identify in those earlier stages.
48:40And now we have the data not going
48:43to go into the weeds with regards
48:46to the randomized control trials.
48:49This pie chart is just to
48:51impress upon you the size,
48:53particularly of one of the studies,
48:55the national lung cancer trial.
48:57Over 53,000 patients were enrolled
49:00in that trial to show that there
49:03was a benefit with regards to using
49:05low dose chest CT to to detect lung
49:08cancer in earlier stage and there
49:11was a 20% mortality reduction.
49:13Using low dose chest CT across
49:15over in Europe, there was another
49:18trial that came out just recently.
49:20Again, more than 15,000 patients
49:22that were enrolled that demonstrated
49:24a similar mortality benefit,
49:25and it's certainly something that
49:28we're at Smilow are working across the
49:31network to have available an is available.
49:35Um, and compared to other known
49:37health screening thing screening
49:39exams for cancer low dose chest CT.
49:41The number needed to screen to
49:44prevent one death is about 320.
49:46When you look at mammography
49:48for breast cancer,
49:49the number needed to screen to prevent
49:52one death is anywhere between 780.
49:55In 2000,
49:56when you look at the literature and Cole.
49:59Colon cancer Screening again,
50:01mammography and colonoscopy are
50:03certainly two screening test you're
50:04familiar with and may have even had the
50:07number needed to screen to prevent one.
50:10Death is about 12:50,
50:12so low dose chest CT certainly has
50:14been shown to be effective as a
50:17screening modality for lung cancer.
50:19Now you know what I've talked
50:22about just now is just a pie chart.
50:24Just some large randomized control
50:26trials an you know term numbers needed
50:29to scream what I really think that
50:31sometimes what happens is that you
50:33know the content delivered is important,
50:35but how we deliver it as doctors
50:38is also important so that you can
50:41understand it and you know how it
50:44applies to you and make decisions.
50:46And I think the biggest thing with
50:49regards to Lancaster Rest is that
50:50I want to drive home today is that
50:53there's two factors that impact it,
50:55want its age and two it's smoking status.
50:57If you just kind of take a look,
51:00I don't know if you can see my arrow here,
51:03but as your pack here,
51:04if you look at your if you're a smoker
51:07as your pack number of pack years
51:09increases and as your age increases,
51:11your six year lung cancer
51:13risk dramatically increases.
51:14And really,
51:14it's the smoking status that we
51:17work to target. With our patients.
51:22Now,
51:22what's the chest X Ray versus a CAT scan?
51:24I know sometimes patients come in
51:26and you know they think they had a
51:28CAT scan and they might have had a
51:30chest X Ray or vice versa that up
51:32to the left is basically what it
51:35what a chest xray looks like it's.
51:37It's pointed at you. You get a ascentia Lee.
51:41You used shadows to try and make
51:44distinctions with regards to the
51:46long or the structures in the chest.
51:48On the right you can see the way
51:50the CAT
51:51scan is arrayed, as it's like you're
51:53laying on your back, you're being
51:55sliced essentially like a loaf of bread,
51:57and we're looking at you from your feet
51:59so that over here where you see my arrow
52:02is your right long over here is your left
52:04lung and the way the radiation beams are.
52:07Essentially, from all different directions,
52:09so that you get as you can appreciate,
52:12you get a lot more detail with regards
52:15to chest anatomy and organs in the chest.
52:21Just some basics for how
52:23to read a chest X Ray.
52:24You can certainly see here that chest X Ray.
52:28Is this a lot of information?
52:30You can see that we can see your airway.
52:33We can see your heart,
52:35we can see the structures
52:36that come off the heart.
52:38We can also certainly assess the
52:40bone structures around your chest
52:42wall where we can see your spine
52:44as well as your upper airway.
52:46And we can even see a portion
52:48of your abdomen,
52:49so it certainly provides helpful information,
52:51but but it's not sensitive,
52:52and it certainly isn't a screening test.
52:55In the past early on,
52:56we want to talk about advances in lung
52:59cancer screening in the 60s and 70s.
53:01They looked it over 180,000 patients
53:03an over 20 years of follow up for
53:06chest X Ray as a way to detect nodules,
53:09and it turned out not to be beneficial,
53:12and I think the reason why that's
53:14important hesitate Co messages
53:16because if you went to the ER and
53:19maybe got a chest X Ray 'cause you
53:21had a cold and you may be someone
53:23who's at risk for lung cancer,
53:25that certainly isn't sufficient in
53:27today's day and age as a screening
53:30modality for lung cancer and.
53:31You know this is an example of
53:33an X Ray where you do see here.
53:36There's a lesion that was picked up.
53:38Fortunately for this patient,
53:39but the take home message here is the
53:42chest xrays, not a screening test.
53:45And I just.
53:46You know how big is 2 centimeters?
53:50The metric system sometimes comes
53:51up every once in awhile,
53:53and you know 2 centimeter lesion turns
53:55out to be about the size of a penny.
53:58Penny is about 2 centimeters.
54:00Alittle Cheerios about a millimeter.
54:02The pencil erasers about 5 millimeters
54:04in a golf ball sized lesion turns
54:06out to be about 4 centimeters,
54:08just as a reference for some of
54:11you that can go on to my chart
54:14and read some of your image Ng.
54:17Now cieci T.
54:18As you can see is a lot more detailed.
54:21We can certainly see the vessels in
54:23a little bit more detailed structure.
54:25We can see the long certainly
54:27in a lot more detail as well as
54:30the muscles of the chest wall.
54:32This topic is a lot more detail
54:34to be able to detect and what
54:36the studies have shown to detect
54:38lung cancer in earlier stage and
54:40provide a benefit to you.
54:43Uh,
54:43this is just this is just to show
54:45that chest CT isn't effective
54:46screening test and there's a
54:48lung nodule here that ultimately
54:49wound up being respected.
54:53So who's eligible for lung
54:55cancer screening at smilow?
54:56The basically we target high risk patients.
54:59Those are the ones that benefit the most.
55:02It's adults if you're between
55:04the ages of 55 and 80.
55:06If you have a third pack
55:08your smoking history.
55:09Whether you're a current smoker,
55:11if you've quit within the last 15 years,
55:14individuals would typically are
55:16asymptomatic and certainly could handle
55:19treatment with regards to whether
55:21it's surgery or unk logic treatment.
55:24Now what are the risks and these are some
55:26of the things that sometimes come up is,
55:28you know when you get a screening studies,
55:31such as a CAT scan,
55:32it doesn't just look at your lungs.
55:34It looks at everything in your chest
55:36from your neck down to your abdomen,
55:38to your belly,
55:39and one of the things that comes
55:41up is we can sometimes have a
55:43false positive that's identifying
55:44a lesion that may be there.
55:46That's not a cancer.
55:47People often ask about what
55:49the radiation harm is,
55:50and I'm going to talk about that
55:52in the next slide. There's a small.
55:54Much smaller, less than 1%,
55:56risk of biopsy or surgery with
55:58regards to if you identify a lesion,
56:00it needs to be treated and then there
56:03are incidental findings and what that means.
56:07Your sensor scanning from the neck
56:08down through the entire chest,
56:10we look at your thyroid gland.
56:12We look at your esophagus.
56:13We look at your airway,
56:15your chest wall,
56:16and there are lesions that can
56:18sometimes be identified,
56:19such as the thyroid nodule.
56:22What is the radiation risk of the
56:25radiation exposure from a low dose chest?
56:27See T is very low Amila receivers.
56:30How it's measured,
56:31it's less than one and just for comparison,
56:34the background radiation.
56:35If you live in New York City is about
56:383 millisieverts and ascentia Lee.
56:40The radiation exposure from a low dose chest.
56:43See T is equivalent to flying on an
56:46airplane from here to California and back.
56:49Very low risk.
56:52Now let's talk about the
56:54benefits versus the risk,
56:55and that's one of the things that
56:58those studies cut at work to identify.
57:00That and I talked about earlier the
57:03number needed to screen to prevent
57:05a death from lung cancers 320,
57:07the number needed to harm or
57:09the risk to the patients to you
57:11as dramatically higher.
57:13It's close to 4000 patients that
57:15need to be screened to have a side
57:17effect or some sort of harm
57:19from the screening test.
57:23And just to drive home some of the
57:25month main points that the eligibility
57:27criteria and it may not be you.
57:30It may be someone you know.
57:32Adults 55 to 8030 pack year smoking history,
57:34a current smoker or quit
57:36in the past 15 years.
57:37No signs or symptoms of lung cancer.
57:40You can certainly expect if you can
57:42talk to your primary care doctor
57:44about it to see if you're eligible.
57:46If you are, you can certainly expect
57:49to visit reviewing the risks and
57:51benefits to kind of review some of
57:53the things we talked about today.
57:55And really, the important thing
57:56is particular here at smile.
57:58One of the things we believe
58:00it's not just a scan,
58:01it's really a team of experts.
58:03Some on this panel who are involved in
58:07your care from the time you get that.
58:10Are there any questions?
58:13Thanks Vinny, that was that was wonderful.
58:16I'm sure there are some questions.
58:18I have one as we wait for them
58:20to roll in and why wouldn't
58:22everyone eligible get screen?
58:24What's the barriers? Why?
58:25What's keeping people from
58:26coming in and doing this more?
58:28Because the national numbers
58:29that I read say 5 to 10% of
58:32eligible people are screened,
58:33maybe lower. Yeah,
58:35I think there's a. It's a.
58:37It's a great question and the US
58:40Services Preventive Task Force
58:41estimated that if everyone who was
58:43supposed to get screened got screened.
58:45I think in America it's about
58:463 million or 4 million people.
58:49There would be about 128 thousand
58:51people that could be saved from
58:53lung cancer if they were to.
58:54If we were able to Institute this
58:57effectively and it's actually one of
58:59the reasons why, even as a surgeon,
59:01I've been interested in lung
59:02cancer screening,
59:03'cause it's about logistics.
59:04There's a fair amount of logistical
59:07issues that come in with regards
59:08to tracking the patients.
59:10Manageing some of the findings.
59:14Opponent, it's those are some
59:16barriers that have prevented us from,
59:19you know, having as much compliance
59:21as there is with regards to either
59:24breast cancer or colon cancer
59:26from mammography or colonoscopy.
59:29Right? What is groundglass?
59:30Someone asks you know,
59:32what do you call it ground glass?
59:34We call it. That's a great question
59:37so I will share my screen again and
59:40see if I can go back to the picture.
59:43Can you guys see my screen again we can.
59:49So please take a look at this lesion.
59:52This lesion is solid,
59:53which means it's filled with cells.
59:55A ground glass lesion means that it
59:58would be essentially fuzzy it would be.
01:00:00You know it wouldn't be as filled with
01:00:03cells because it's kind of amorphous.
01:00:05It's partially filled with cells
01:00:07that hasn't filled in yet,
01:00:08so a ground glass lesion.
01:00:10What we have found is either
01:00:12create precursor or early form
01:00:13of lung cancer adenocarcinoma.
01:00:15That's what it ground glass lesion is.
01:00:17That's a great question.
01:00:18Yeah, we have so many more 30 pack
01:00:21years. You know what does that mean?
01:00:23I guess you know you're listening
01:00:25in the audience, you know. Can you
01:00:28define that a little bit better? Yeah,
01:00:31so a pack of cigarettes,
01:00:33from my understanding has 20
01:00:34cigarettes and I haven't bought a pack,
01:00:36but that's what I that's
01:00:38what my understanding is.
01:00:39It has about 20 cigarettes in it,
01:00:41so if you smoke a pack a day,
01:00:43that's you know an you've been
01:00:45smoking a pack a day for 30 years.
01:00:48That makes you a 30 pack year smoker.
01:00:50There are some people who
01:00:51smoke less than that.
01:00:53They might smoke a half a pack a day
01:00:55if you smoke a half a pack a day and
01:00:58you've been smoking for 30 years,
01:01:00that means you're a 15 pack year smoker.
01:01:03So a pack here is basically the standard
01:01:05is a 30 pack year means you've been
01:01:08smoking a pack a day for 30 years.
01:01:11And how exact are you on this?
01:01:13So if someone is worried about
01:01:15lung cancer wants to be screened.
01:01:17I guess it's sort of hard to sort
01:01:19of know exactly what one smoked.
01:01:21You give them a little flexibility here.
01:01:23Well that's an interesting question.
01:01:25And that's actually one of the
01:01:27challenges for trying to Institute
01:01:28are one of the reasons nationally.
01:01:30Why there's a challenge with
01:01:32lung cancer screening to be
01:01:33implemented is the accuracy of that.
01:01:35What we have found is we try and you know,
01:01:38with regards to that high risk
01:01:40patient population. Put up here.
01:01:4355 to 80 in that 30 pack year.
01:01:46Smoking history.
01:01:46What we have found across the country.
01:01:48That is, if you.
01:01:49If you're a little bit more liberal
01:01:51with that, so let's say it's you,
01:01:54know you say, well,
01:01:55what about if I just smoke 10A10 pack year,
01:01:57smoking history? Or what?
01:01:59If I smoke like, you know,
01:02:00a smoked a cigarette when I was eight,
01:02:03you know, should I get screened?
01:02:05What we have found is when you do that,
01:02:07when you cast a wider net when you
01:02:09talk about the risks versus benefits,
01:02:11the number needed to screen
01:02:13is dramatically higher.
01:02:14So to answer your question,
01:02:15why is we try not to at least
01:02:17for lung cancer screening,
01:02:19we try and stick with what
01:02:20the guidelines are.
01:02:22Yeah, I'm gonna hit you with
01:02:23the lightning round here.
01:02:25A couple of risk factors.
01:02:26Do we screen or not?
01:02:27Radon gas you got rated on the in
01:02:30the basement screening.
01:02:30No screening yet for radon gas.
01:02:32There was another question early on.
01:02:34If their studies with regards to radon gas,
01:02:36an risk of lung cancer and actually
01:02:38there have been some studies
01:02:39and radon gas is a significant
01:02:41risk factor for lung cancer,
01:02:43but it doesn't come fall in the
01:02:44category of some huge screen for it.
01:02:46What about?
01:02:48Smokers do we screen that?
01:02:49Do we screen them? Not
01:02:51today, not with regards to the
01:02:53technology that we have today.
01:02:55Someone with family history of lung cancer.
01:02:57Should their kids get screened? Oh,
01:03:00that's a great question.
01:03:01It's it you wouldn't fall in the
01:03:03criteria 'cause you wouldn't.
01:03:04High risk patient, but that's not
01:03:06typically someone that we screen.
01:03:08Can we read a lot about
01:03:09a I now know the Teslas?
01:03:11You know, sending sending these
01:03:12rockets to the moon's automatically,
01:03:14or using AI right now to help with
01:03:16detecting what's what's a tumor?
01:03:18What's not so that you're going
01:03:19to be doing surgery sometimes?
01:03:21No, it's great.
01:03:22You talked about going to the moon.
01:03:24I just want to go back to Doctor Blasberg's
01:03:26question about the military and the robot.
01:03:28So the the militaries tried to,
01:03:30you know, work to apply that.
01:03:32But one of the challenges is you
01:03:34gotta get the robot into the,
01:03:35you know, into the area.
01:03:37And it turns out that it's easier to send
01:03:40somebody then send the robot right now.
01:03:42But the robot actually was interesting.
01:03:44'cause NASA's been trying to use
01:03:46it because it be great to have that
01:03:48capability when you have put people either
01:03:51on the moon or at the space station.
01:03:53But to answer your question about AI,
01:03:56there is some literature that's looking
01:03:58into using AI to identify these lesions,
01:04:00but it hasn't worked itself
01:04:02into lung cancer screening.
01:04:03At yeah, I just ordered
01:04:05a medical oncologist robot
01:04:06so I can take tomorrow off.
01:04:09And they're working on it.
01:04:10What about, seriously,
01:04:11you know when you know the biggest issue?
01:04:13I guess here is you go in and it's benign.
01:04:16You know it's it's not like a
01:04:18breast cancer screening or a colon
01:04:20screening where the procedures
01:04:21were done usually at the same time
01:04:23or very close to the same time.
01:04:24A little bit easier. You think?
01:04:26That's a different.
01:04:27Why people don't come in and
01:04:29be screened more. I
01:04:30think it is.
01:04:30I think it's I think there's.
01:04:32I think there's a system deterrent.
01:04:34I think there's a patient deterrent.
01:04:35I think that is 1.
01:04:37One of the one of the challenges, yeah?
01:04:39One of the things that were as as
01:04:41the network kinda works to figure
01:04:42out how to continue to grow.
01:04:44It's one of the things that we're trying to
01:04:46sort through. Yeah,
01:04:47there are huge disparities.
01:04:48Of course, it could get screened in,
01:04:50who doesn't?
01:04:51If you look among populations and
01:04:52the socionomic determinants of health,
01:04:53we're actually doing a lot of
01:04:55work right now to go out into the
01:04:57community with navigators to find
01:04:58people in populations where smoking
01:04:59might even be at the highest levels.
01:05:01What are your thoughts on that in Bridgeport?
01:05:03That must be a big issue. Yeah,
01:05:05I think it. Actually it is a
01:05:07big issue and when we dial down
01:05:09I showed you the pie chart.
01:05:10For you know, Connecticut.
01:05:12We've actually we've actually in
01:05:14Bridgeport and Fairfield and Greenwich.
01:05:16We've dialed down to know what
01:05:19the smoking rate is by town.
01:05:21And there are navigators that are
01:05:24going around to local areas as an
01:05:27outreach to try and work to get
01:05:29people to be enrolled her at risk.
01:05:32The smoking. Rae Ann.
01:05:34Granites right now is 7% in
01:05:36the state of Connecticut.
01:05:38It's 11% in Bridgeport's actually 21%.
01:05:40So, to answer your question, we are, we are.
01:05:42We were down to that kind of
01:05:45detail with regards to outreach,
01:05:47incredible.
01:05:47Well, maybe that was an amazing talk.
01:05:49I learned a lot. Sometime thank you and
01:05:52will hopefully have you again at some
01:05:55point in the future on this series.
01:05:58OK well last but not least you
01:06:00know the radiation oncologists
01:06:01are always in the basement.
01:06:04But we're really fortunate they have,
01:06:06you know, talk about radiation
01:06:08oncology and lung cancer.
01:06:09Bruce mcgibbon.
01:06:10Doctor Mcgibbon is an assistant
01:06:11professor of clinical, therapeutic,
01:06:13radiology and medical director of
01:06:15radiation Oncology at Greenwich Hospital.
01:06:17He received his medical degree
01:06:18from UCLA School of Medicine.
01:06:20We also completed his residency.
01:06:23Doctor Mcgibbon treats many forms of cancer,
01:06:25including breast, prostate,
01:06:26lung, rectal, head and neck,
01:06:28and primary metastatic brain cancers.
01:06:30His research interests include
01:06:31a focus on quality of life,
01:06:33improvements in short course,
01:06:35radiation therapy using stereotactic
01:06:36techniques which will explain to us brucea.
01:06:38So glad to have you here tonight.
01:06:41Thank you.
01:06:41Thanks for
01:06:42all the things we have
01:06:44to share my screen here.
01:06:50Maria.
01:06:55Alright, so I'm just going to touch
01:06:57tonight on some of the advances
01:06:59and reduce their long cancer,
01:07:01especially in early stage.
01:07:02I'll talk a little bit about
01:07:04all of amount of static,
01:07:06just a quick look. Just friends.
01:07:08We looked at the robot which is
01:07:10which is really exciting and I
01:07:12just want to show you an internal
01:07:15view of a radiation machine.
01:07:17Since that schematic with tickle
01:07:18machine on the upper left in the area,
01:07:21you can see these Red Arrows show that.
01:07:24Actually electron gun is in the
01:07:26machine that shoots electrons down,
01:07:28accelerates them,
01:07:29which is why the machine linear
01:07:31accelerator they get spun around and
01:07:33smacked into the tungsten target.
01:07:35What comes out are X Rays
01:07:37and those Shinedown patient.
01:07:38You look at the lower right here.
01:07:40The variant is the name of the leading
01:07:43manufacturer of these machines in
01:07:45the world and at Greenwich Hospital.
01:07:47For example,
01:07:48we have true beam,
01:07:49which is another state of the art machine.
01:07:52CNC has that kind of similar
01:07:54summer design idea.
01:07:55And people often ask you about
01:07:57safety and are they going to wear
01:07:59a blanket or are they protected
01:08:00and we don't have led blankets
01:08:02and things like that in the room
01:08:04because they wouldn't really
01:08:05stop the X Rays that were using?
01:08:07Is there too high power?
01:08:08But what we have is something in
01:08:09the head of the machine called
01:08:11the Multileaf Collimator,
01:08:12which is about 3 inches thick,
01:08:14and so it's as if you have a 3
01:08:16inch thick lead blanket protecting
01:08:17you up in the machine.
01:08:19And this is what allows us
01:08:20to create all the shapes.
01:08:22So if I go back to this,
01:08:24imagine the patient lying on that.
01:08:25Black tabletop there.
01:08:26We can manipulate the angle of the
01:08:29tabletop you can go up and down.
01:08:31We can spend the machine around
01:08:33different directions how we can
01:08:35change the shape of the beam and so
01:08:37all those things allow us to create
01:08:40some fancy targeting of radiation.
01:08:43Another thing which is a big advance for
01:08:45us and spent around for some years now,
01:08:47but we keep refining how when
01:08:49you use it is it's called image
01:08:51guided radiation therapy.
01:08:52Ann.
01:08:52As we got more sophisticated
01:08:53with the shape of the beam,
01:08:55we've got to be more careful
01:08:56that we are actually on target
01:08:58oldstyle radiation treat big,
01:08:59Big feels a whole pelvis or whole
01:09:01breast or whatever it is and
01:09:02you don't have to be so refined.
01:09:04And now we do.
01:09:05And so if we look at the gun
01:09:07in the lower right,
01:09:08this is more of a face on view.
01:09:10The machine said it from the
01:09:12side and those little arms are
01:09:13sticking off the side or actually.
01:09:15Imaging arms and so we can spend the
01:09:18machine around the patient before
01:09:19treatment and get an image which
01:09:22looks very much like a CAT scan.
01:09:24So on the upper left is a split view,
01:09:27here where the upper left
01:09:29and lower right are from
01:09:30a real CAT scan done for radiation
01:09:33treatment planning and the lower left
01:09:35upper right are from the cone beam
01:09:37CT and you can see that the image
01:09:40quality is just a little bit different
01:09:43but really quite excellent in red.
01:09:45Circle there, or actually it is showing the
01:09:47tumor that were fired on that on that day.
01:09:50So this way we can set people up have
01:09:52marks on the skin to get them quite close,
01:09:55but then we do the cone beam CT and
01:09:57then we really dial it into your time
01:09:59about millimeter or submillimeter.
01:10:03The other thing we've done with the
01:10:06shaping the beam and manipulating the.
01:10:09Position of the machine itself and the
01:10:11table itself is we've gone from using what's
01:10:13called 3D conformal radiation into joining
01:10:15the left with intensity modulated radiation
01:10:18therapy on the right, and this call.
01:10:20Color wash sounds like a Topa graphical
01:10:22map and you can see on the right
01:10:25that the doses is more constrained.
01:10:27It's really tired,
01:10:28much more in the center of the chest.
01:10:31In this case is its own being treated for two
01:10:34review safaga's like you can see in the see.
01:10:37My cursor will bit.
01:10:39This Gray zone here is the heart.
01:10:41In treatment left is giving a lot more,
01:10:43just the hard.
01:10:44For example,
01:10:44the treatment on the right and this
01:10:46here is the verb rate is fine and this
01:10:49is the spinal cord in the center.
01:10:50You see again that the truth I left
01:10:53is getting a lot more goes to the
01:10:55spinal cord and the one on the right.
01:10:57So we're getting definitely a lot.
01:10:58Lot fans here a lot tighter and
01:11:01what we can do with radiation.
01:11:03One technique on talk more about
01:11:05tonight is called start empty body
01:11:07radiation therapy and this is a
01:11:09technique which is really been around
01:11:11for the better part of 10 or 15 years.
01:11:13But it's really coming into its own.
01:11:16The last maybe 5 to 8 years.
01:11:18A lot more data behind it and what
01:11:20it is is it's it's created a much
01:11:23better in mobilizations were keeping
01:11:24the patient very still position and
01:11:27we are accounting for movement of
01:11:29the lungs or movement of liver or
01:11:31whatever going after an we're using.
01:11:33Imaging like stuff like the cone
01:11:35beam CT Ocean before and getting down
01:11:37to this very accurate treatment.
01:11:39And So what we've done is taking.
01:11:41Treatments are typically go on for
01:11:43weeks at a time and condense them
01:11:45into only one to five treatments,
01:11:47and these are very high powered,
01:11:49refocused and have allowed us to
01:11:51go more aggressively after a lot
01:11:54of tumors that we couldn't before.
01:11:56So I'm gonna touch radiation therapy
01:11:58in the setting.
01:11:59Lung cancer is used for early stage.
01:12:01That's non small cell lung cancer.
01:12:03Locally advanced things like Stage 3
01:12:04where it's written to lymph nodes.
01:12:06It's also good for limited stage
01:12:08small cell lung cancer and extensive
01:12:11stage where it's written more.
01:12:13But we don't have time for all those,
01:12:15so I'm going to talk about the
01:12:17early stage on this.
01:12:18Also,
01:12:19an oligo metastatic oligo metastatic
01:12:20is when the cancer has spread
01:12:22beyond the chest in this case,
01:12:23but only two sites.
01:12:25And this slide is a little busy side,
01:12:28but give you the takeaway which is
01:12:30that we have been using for early
01:12:32stage to stage one lung cancer.
01:12:34Non small cell got a tumor like this one.
01:12:37See this picture here.
01:12:38It's nice rounded tumor and if the
01:12:40patient was not a surgical candidate
01:12:42we were treating him with about
01:12:446 to 7 weeks of daily radiation
01:12:46and the success rate in terms of
01:12:48local control is only about 50
01:12:50or 60% and that's all we really
01:12:52had to offer for years and years.
01:12:55And then we develop these.
01:12:56Through a tactic or his SP arty type
01:12:59of techniques others mentioning and
01:13:01they studied it in this famous Artio
01:13:04Geo 236 study and they saw that the
01:13:07local control rates shot way up and
01:13:09I talked about 97.6% three years
01:13:11and that percent control did drift
01:13:14down overtime but much much higher.
01:13:16So we know that we're really
01:13:18onto something there.
01:13:21At how aggressively we. Trial was done.
01:13:26Patients who either were medically unfit
01:13:28for surgery or had refused surgery and
01:13:30had two words are relatively small.
01:13:33So is a really high powered good local
01:13:36control and very acceptable toxicity.
01:13:39They ultimately more
01:13:40formally compared this SP.
01:13:41Arty to conventional radiation
01:13:43is where we got a new computer
01:13:45historical data that this was better,
01:13:47but they ran out to see an.
01:13:50They show that yes indeed the
01:13:52control rate was was much better
01:13:54when I was studying more formally.
01:13:56In this case it was 14% versus 31%,
01:13:59but big picture was stereotactic.
01:14:01When we can use it gives a much higher bill,
01:14:04is much more concentrated.
01:14:06Oxville tried to do that.
01:14:10There have been some efforts, people wonder.
01:14:13Well you know what about
01:14:14surgery versus versus radiation?
01:14:16And the only way to really answer
01:14:18that properly is with randomized
01:14:20trials where people rolling you.
01:14:23Computer flips the coin effectively unused.
01:14:25Yesterday you get radiation,
01:14:26and those trials have been really
01:14:29hard to accrue patients too.
01:14:31And ultimately,
01:14:31they did take two trials that only
01:14:34partially accrued and put them together
01:14:36and publish the results an in that trial.
01:14:39Actually, it made radiation look
01:14:41slightly better than surgery,
01:14:43but it I don't think people fully
01:14:45believe those results because the this
01:14:47wasn't high enough numbers and really,
01:14:50for patients who are still medically fit,
01:14:52our top choices still surgery,
01:14:54but the radiation is not far behind
01:14:57and definitely formations too or
01:14:59recent decline or or medically unfit.
01:15:01Then we know.
01:15:02The radiation is is a great option.
01:15:06Let's look at all going to stack.
01:15:08There were actually two really
01:15:10exciting papers for us.
01:15:11They were published in 2019.
01:15:12The first is verges the Sabre Comet.
01:15:15Now study.
01:15:15And what is it took?
01:15:17Patients were the primary tumor.
01:15:18The tumor in the lung had been controlled
01:15:21and they had anywhere from one to five.
01:15:23Metastatic sites could be
01:15:25in the bone or liver.
01:15:28In another part of the long and
01:15:30they randomize either you got that
01:15:32stereotactic during this party for
01:15:34all the sites or just your standard
01:15:36of care kind of palliative treatment
01:15:39and huge difference was seeing the
01:15:41median survival went from 28 months to
01:15:4341 months just from from doing that.
01:15:46So that was a big win for us and
01:15:48understanding it going more aggressively
01:15:50after this metastatic sites makes
01:15:52sense versus before the ideas.
01:15:54We would only do that if they
01:15:57were causing pain or.
01:15:58Leading or or something will replace defense.
01:16:00Now we say,
01:16:01well we can play with offense here
01:16:03and try to get rid of these spots.
01:16:05The other study that was published
01:16:07in a different Journal.
01:16:09Another great Journal in 2019 seems narrow.
01:16:11This is this is non small cell lung cancer.
01:16:14Not to be clear and these patients
01:16:16had three or fewer metastases,
01:16:18but same idea where there's no real
01:16:20progression at the site in the lung
01:16:22for at least three months after doing
01:16:24chemotherapy or something is targeted.
01:16:27Therapies done channels mentioning and
01:16:28they were offered either what they
01:16:30called local consolidated treatment,
01:16:32which is either that SPRT or surgery,
01:16:34and for the most grounded.
01:16:36Trials,
01:16:37yes,
01:16:37your team or maintenance therapies
01:16:39are not observation and again a big
01:16:41difference in the median overall survival.
01:16:4317 months to 42 months.
01:16:45So we've seen really just in the
01:16:47last couple of years that we have
01:16:50a technique for stereotactic.
01:16:52We see how to safely use it and when
01:16:54to hold back when should have surgery.
01:16:57One should be radiation combination
01:16:59of some patients where one of the
01:17:02regions is a great target for surgery,
01:17:04but another one really isn't.
01:17:06And so make it survey for one
01:17:08and stereotactic for
01:17:09another, for example.
01:17:10And so we just have a better
01:17:13idea of how to apply this,
01:17:15especially in these unique settings where
01:17:16cancer has spread but not very extensively.
01:17:19And so that's very exciting for us.
01:17:22In terms of some future directions
01:17:24and how yells getting involved,
01:17:25one of my colleagues after Henry Park
01:17:27has opened a trial where we've had
01:17:30a little difficulty with radiation.
01:17:31For tumors that are called central tumors,
01:17:34mean ones that are right up
01:17:36against the main airway.
01:17:37Some of the big vessels,
01:17:38and we know that we have to be
01:17:41more careful in the dose there.
01:17:43Those have typically been
01:17:44done with five treatments,
01:17:45and he started trying to see
01:17:47about safely and effectively
01:17:49true that in three treatments,
01:17:50and that was started in New Haven movies.
01:17:53We've opened up in the multiple
01:17:55care center at this point
01:17:58and the other one is is this.
01:18:00Trial where they taking us for your
01:18:02tea and then it's without adding
01:18:04some union therapy afterwards.
01:18:06And actually a few that are going on.
01:18:08But this keynote 867.
01:18:10It has a lot of saving and we
01:18:12could see that has opened.
01:18:14Its about to open and at Yale.
01:18:16And so we're very excited about that as well.
01:18:20Ann, just a brief word in
01:18:23Connecticut and surrounding states.
01:18:24There tends to be a lot of
01:18:27advertising about certain machines,
01:18:28especially the cyber knife machine
01:18:30at the bottom right and sometimes
01:18:32about protons and just talk about
01:18:35this briefly describe machine.
01:18:36If you look carefully,
01:18:38it's really the robot that is used,
01:18:40not the robot.
01:18:41Like Doctor Blocks were talking about with
01:18:44the robot they used for building cars on.
01:18:47The assembly line is the base of that.
01:18:50That machine and the top of
01:18:52it is a miniaturized version
01:18:54of that linear accelerator.
01:18:57An it delivers a little pencil beans
01:18:58out to tumors and it's it's a very good
01:19:01machine for doing stereotactic treatments.
01:19:03It doesn't have the flexibility to do other,
01:19:05larger, more traditional
01:19:06treatments like the true beam does,
01:19:07so it's a little bit pigeonholed
01:19:09and what it does,
01:19:10but it is excellent at what it does.
01:19:14In the problem really,
01:19:15for those use it is that you know
01:19:17there's no particular reason
01:19:18to travel for that machine.
01:19:20When you have other machines that
01:19:22can do just just as good job
01:19:24and are much closer to home,
01:19:26so was something was quite
01:19:27exciting some years ago.
01:19:28Now it's a little less exciting because
01:19:31other genes we do do just as well,
01:19:33but you do hear bout on the radio a lot
01:19:36for long and even more for prostate.
01:19:38And the other side is there on the protons,
01:19:42protons is spitting out a totally
01:19:44different particle national proton
01:19:45particle instead of an X Ray and
01:19:48tremendous advertising their very
01:19:49expensive machines to build yales is
01:19:51looking into whether I might want to
01:19:53be involved in having one of those
01:19:56are signals or collaborating with someone,
01:19:58and it does seem to have.
01:20:01Here advantages in certain tumors
01:20:02and other tumors not at all.
01:20:04Lung cancer is one of those ones
01:20:06where it's much less certain
01:20:08whether there's an advantage to it.
01:20:10So we get some trials to see if
01:20:12it's better or actually worse.
01:20:14Eventually,
01:20:14there have been some studies have shown.
01:20:18Trial for breast cancer.
01:20:20For example, it showed little
01:20:22bit higher risk of rib fracture.
01:20:24The same protons instead X Rays.
01:20:26So protons are something that are
01:20:28really starting get more popular in the
01:20:31country miss anymore machines but mode.
01:20:33The vast majority of the treatments
01:20:35going down the US are being
01:20:37done with the traditional linear
01:20:39accelerators that have been refined,
01:20:41refined like the true beam
01:20:43shown in the top there.
01:20:46And so that's it for me to be
01:20:47happy to take questions as well.
01:20:51Thank you very much.
01:20:53That was that was wonderful.
01:20:54Let's see what questions we have.
01:20:58Here's a couple.
01:21:02Who's I marquita treated tumor that has
01:21:05become resistant to immunotherapy in the
01:21:07hopes of reducing or illuminating it?
01:21:09Even though you're in late stage.
01:21:12As a great question, so yeah,
01:21:14so that that's been one of the that ties
01:21:16into the spirit of those two articles
01:21:18that was mentioning, you know, the.
01:21:20The one of the paradigms in medical
01:21:23oncology from before I think have
01:21:24been you know if there are one or
01:21:27two spots that weren't responding
01:21:28and the other ones were that maybe
01:21:31it's time to change drugs entirely.
01:21:32And now that we have better more
01:21:35focal treatments like against party,
01:21:36we know that you may not be
01:21:38the best with go back.
01:21:40Maybe since you're controlling let's say 8A.
01:21:43Treat the two that are acting up and which
01:21:46may have a slight different mutation
01:21:48or something that's going on with them
01:21:51and level the playing field again so
01:21:53that that has been very successful.
01:21:55Lot more that in the last last few years.
01:21:58You know there's some interest as to
01:22:01whether immune therapy and rating play
01:22:03particularly well together because
01:22:04there's a thought that radiation
01:22:06therapy is breaking up the tumors
01:22:08and exposing more of the pieces.
01:22:10If you will to be immune system
01:22:12and therefore.
01:22:13Stopping at Supercharger in system can do.
01:22:17And it's unclear when that happens or
01:22:19to what degree and and so that's why
01:22:22some of the trials like that key trials
01:22:25timed out our our great interest.
01:22:27We've seen even some cases where
01:22:29we've treated one or two spots.
01:22:31An additional spots that we did
01:22:33not treat got better and they call
01:22:35that the Scoble.
01:22:36In fact and it's another one
01:22:38that we're only beginning to
01:22:40understand certainly doesn't happen.
01:22:41All the time,
01:22:42but there's something special
01:22:44that happens sometimes between
01:22:45radiation immune system
01:22:46so radiation activating.
01:22:47Immune system, you know?
01:22:49So you see affects at other sites
01:22:51even where you did not radiate.
01:22:53Yeah, and we've seen that we
01:22:55see that lung cancer for sure.
01:22:57We've seen that and ice trials
01:22:59with prostate cancer recently.
01:23:01Yeah, I think we'll see.
01:23:02See more, but it's as we're seeing it,
01:23:05but we haven't fully realized how
01:23:07about harness that potential or or
01:23:10when it's going to happen versus not.
01:23:12So
01:23:12that's where some of the trials
01:23:14are coming. Here's an interesting
01:23:16question about the Nice.
01:23:17What's the difference between cyber knife
01:23:19and Gamma Knife?
01:23:20That's good question.
01:23:21So both were were designed by.
01:23:24Marketing geniuses were good with good
01:23:26with names and words and Cyberknife,
01:23:28so it's surely that machine against that
01:23:32miniaturized robot on top of dimension size.
01:23:36What? And that machine is for
01:23:38stereotactic treatment only.
01:23:40It can treat in their brain the neck
01:23:42to buy really anywhere in the body.
01:23:45It contentedly get to because
01:23:47of the gamma knife machine.
01:23:49Let me go cybernetics also.
01:23:51It's it's fundamentally shooting out X Rays.
01:23:54Gamma Knife Machine is looks
01:23:56like 1/2 Dome really and it's
01:23:58for treatments in the head only.
01:24:01It's usually for brain metastases
01:24:03and a helmet is bolted to the heaven.
01:24:06Patient is put into the Dome
01:24:08and in the Dome there are.
01:24:10There's a constellation of
01:24:12radioactive pieces of COBOL that
01:24:14all Shinedown into into one spot.
01:24:16So you move the head around so that spot.
01:24:20Is overlying the tumor,
01:24:21and you kill the tumor that
01:24:23way with radiation.
01:24:24But because the Dome effect in the
01:24:27constellation there's only so far,
01:24:28you can put someone into the Dome,
01:24:31and so it's really only practical for
01:24:33it's one of the earliest and best of the
01:24:36radiosurgery machines for rain taxis.
01:24:38And so you see,
01:24:39certain programs like Yale's it doesn't
01:24:41very robust remote access program
01:24:43where you'll have a dedicated team
01:24:45that just does tons of treatment very,
01:24:47very well with that machine.
01:24:49That's all they do.
01:24:51She's so Doctor Veronica Chang is
01:24:53the neurosurgeon, for example,
01:24:55in charge.
01:24:55Then she works with our radiation
01:24:58doctors to do those treatments.
01:25:00So that's how that's handled in New Haven
01:25:02at some satellites Laika Greenwich Hospital,
01:25:05we actually use the linear
01:25:07accelerator treat brain metastases,
01:25:09But anyway that's doing cyber defense.
01:25:13Very helpful,
01:25:14maybe one
01:25:15more question. Proton therapy?
01:25:17Is it more effective than some of?
01:25:20Code and where is the
01:25:23nearest proton therapy? And
01:25:24so, as far as you know,
01:25:26in lung cancer is not more effective.
01:25:28You know the first chance in terms of
01:25:31effectiveness really comes down to
01:25:33dose is is this something where we
01:25:35can put more dose into an area and
01:25:37for most cancers we can think of it.
01:25:39That's not the case. We're not.
01:25:41We're not putting more dose in with
01:25:43X Rays than protons or photons then
01:25:45expertise we're really referring
01:25:46to the same set of data and trials
01:25:49that have established proper doses.
01:25:50Here are some very, very limited exceptions,
01:25:53but but not many.
01:25:55The hopes and dreams of you know
01:25:57around protons really has deal with
01:26:00side effects because under optimal
01:26:02circumstances proton will will part.
01:26:03I mean goes into the body.
01:26:06Suddenly deposits build status,
01:26:07super point and then stopped.
01:26:10Person X Ray goes into the body
01:26:12deposits and bills,
01:26:13but then pops out the other side.
01:26:15So you have like a track of dose
01:26:17and so protons for,
01:26:18let's say treating a child spine
01:26:20to me are clearly better because
01:26:22you can take one being from the
01:26:24back and treat it and you're not
01:26:26treating any of the abdominal organs.
01:26:29But if you're treating prostate long,
01:26:31most breast treatments you know most
01:26:34things in the head and you just
01:26:36don't have that same advantage yet,
01:26:39meaning multiple beams.
01:26:40You're still going through through things,
01:26:42so the protons aren't magic,
01:26:44they're just very helpful in
01:26:46certain situations.
01:26:47And what happens because they are in
01:26:50part because they're so expensive.
01:26:53To develop and run and build,
01:26:55then you know the number of protons
01:26:57in the country for many many years
01:27:00was really small.
01:27:01You're talking about two or three
01:27:02units in the entire country,
01:27:04and not many outside the US.
01:27:06And it's really just in the last
01:27:08maybe 5 to 10 years that with
01:27:10collaborations between academic centers
01:27:12or sometimes between that consumers,
01:27:14private centers and venture capital groups.
01:27:16You're seeing more of these pop up,
01:27:18and so we're just beginning to run some
01:27:21trials to really be able to figure out.
01:27:23More more academically,
01:27:25more scientifically, which is better,
01:27:28anwen,
01:27:28and so the nearest proton centers to us?
01:27:33Boston new jerseyan.
01:27:34Recently one opened up in East Harlem area.
01:27:37It's a collaboration site between
01:27:39some centers and Yale is is in talks
01:27:42about whether to develop their own
01:27:44and participate in research and
01:27:47everything that goes along with it.
01:27:49But for most people now that we see a time,
01:27:53you lose this not many occasions where
01:27:56you really need or should travel for protons,
01:27:59but certainly in very interesting
01:28:01machine and is going to have
01:28:04its advantages and stuff.
01:28:06Some situations,
01:28:06right?
01:28:07I hear rumors we're going to
01:28:09have one soon, but, you know,
01:28:11at least in lung cancer, sounds like
01:28:14we have state of the art equipment.
01:28:16That is what's needed at this time.
01:28:20I have some particular challenges
01:28:22in lung cancer because they're
01:28:24they're a little bit fussy about
01:28:25what tissue they're going through,
01:28:27and moving tissue and accounting for that,
01:28:29so I think there's you know,
01:28:31excited about everything,
01:28:32but not not as much about
01:28:34lung cancer this time.
01:28:35So yeah, I'll definitely has all the
01:28:37all the state of the art radiation
01:28:40machines for lung cancer really
01:28:41is incredible, and so all of you,
01:28:44as it's been a great panel tonight,
01:28:46I really appreciate everyone who's joined.
01:28:48I want to make a few announcements that.
01:28:50Out this will be posted.
01:28:53The recording will be posted on
01:28:56yelpcancercenter.org so you can
01:28:58go and you can hear this again.
01:29:00And if you have additional questions
01:29:03you can reach out to cancer answers at
01:29:06yale.edu at anytime, so that's cancer.
01:29:09Answers at yale.edu.
01:29:11Bruce Vinny just in an I think Renee good,
01:29:14who's our coordinator for these programs?
01:29:16Thank you very much for exactly on time and
01:29:19it's my pleasure now close the evening.
01:29:22Thank everyone who was on line.
01:29:24Please reach out to us with any questions.
01:29:26I know I've learned about tonight.
01:29:29It's been a great evening.
01:29:30Have a good night.
01:29:32Be safe.
01:29:32Everyone, thank you.
01:29:33Thanks for coming.