Thoracic surgeon at St. Joe’s wants more people to get screened for lung cancer—says lung cancer is the most common cause of cancer deaths and causes more deaths than breast cancer, prostate cancer and colon cancer combined
By Chris Motola
Q: You are a thoracic surgeon and I understand you do a lot of lung cancer related surgeries. What do you think of the state’s new legislation on lung cancer screenings?
A: The important thing about lung cancer is that it’s the most common cause of cancer deaths. More cancer deaths than breast cancer, prostate cancer, colon cancer combined. And it’s also the second most common cancer in both men and women. So, the most important thing we can do for lung cancer is diagnose it early. We know that patients who smoke have increased risk. We know patients who smoke and have COPD, especially those who have smoked at a rate of one pack a day for 20 years, have an increased risk of lung cancer. And therefore, we’re allowed to do earlier screenings on high-risk patients and we hope more patients will get the screening. The problem we have with lung cancer screening is that most people, even when they’re eligible to get it, still don’t get it.
Q: Is that because they’re just not aware of it or is it offered and they’re declining it?
A: Well, it’s a combination. Some people are not aware of it. Some patients are not told by their doctors that they’re eligible for it. Sometimes, it’s because of multiple things: because of transportation, because of socioeconomic conditions. Some people say there’s also the stigma of smoking. They have signs and symptoms but still don’t seek care.
Q: What are the signs and symptoms? And correct me if I am wrong, but my impression was that lung cancer generally only presents with symptoms after it’s fairly far along.
A: And that’s correct. Most patients when they have signs and symptoms it is cough, a persistent cough. They may be coughing up blood. They may have chest pain; they may have shortness of breath and it’s prolonged. And so, imagine that a patient goes into the room and has pneumonia, someone treats them like they have pneumonia and then they don’t go back for follow up. And that pneumonia was actually lung cancer trying to tell you something. And if the patient or the physician doesn’t do a follow-up study, then that patient can present later on with more advanced cancer.
I’ve treated a lot of patients who’ve had other studies done for one reason or another. Most times when lung cancer is caught early it’s incidental. So, imagine the patient goes in because they’re having chest pain or a patient has a fall and breaks a breaks rib. And then you find a lung nodule or tumor on the patient’s chest, X-ray or cat scan that you would not have picked up. When I was in Detroit my pastor was having some chest pains. She went in for X-rays, and they were checking for a heart attack. They didn’t find a heart attack, but they did do a cat scan which found her lung cancer. That would have not been picked up if she didn’t go in for chest pain.
Q: So smoking is by far the biggest risk factor. But hasn’t smoking been in decline?
A: So, smoking has declined. But I can tell you that the majority of people who get lung cancer are smokers or people who used to smoke. So, imagine that a patient smoked and they stopped a year ago or two years ago or five years ago; those patients are still at risk for lung cancer. So, if you think that your risk has gone down because you stop smoking and you stop getting studies, then you may miss finding the lung cancer early.
Q: How about the habits that are displacing smoking? Is there good data on vaping so far with regard to lung cancer or is it still too early?
A: So, we don’t know yet about vaping. We know that vaping can cause lung disease. I’ve seen a lot of young patients who’ve come into the emergency room who’ve had a collapsed lung, then we operate on those patients and I’ve seen their lungs and they have significant scarring, fibrosis and lung disease almost as if they’ve been smoking for years and they may have vaped only for a couple of years. But we don’t know yet if there is any connection with lung cancer.
Q: How about marijuana usage? I think that’s on the rise too, right?
A: And we know the same thing. We see young people who smoke marijuana and sometimes you find older patients who are smoking marijuana. But there has been no connection found between lung cancer and marijuana.
Q: How good are the interventions for lung cancer, especially surgical since that’s your area?
A: The interventions are excellent. In fact, they’ve improved and we understand the disease better. Years ago I thought that if a patient had a stage 1 lung cancer, if a patient had a small lung cancer and the lymph nodes were negative, I thought the patients were cured. But we know now that even patients with stage 1 lung cancer may have a recurrence. The good thing is that there have been tremendous developments over the past 10 years in terms of chemotherapy, in terms of cancer-related drugs, which are curing cancer or allowing patients to live longer. I had a patient who had advanced cancer and because we knew her lymph nodes were involved, we knew that patient needed to get chemotherapy. The patient had chemo and immunotherapy; her cancer shrunk and therefore we proceeded to do our operation. And after we finished our operation, we sent a specimen to the pathologist. The cancer was completely gone. That’s not true for everyone, but that lets you know that that chemotherapy, that immunotherapy worked tremendously and killed all the cancer cells that she had. She’s still at risk for recurrence, but the risk of recurrence has decreased because we sterilized the field before we did her operation.
Q: So, in general, the screening is going to be recommended for former smokers. And you said the magic number was what like a pack a day for 20 years, roughly?
A: That’s correct. And so it’s not just for patients who are former smokers; it’s for people who are still smoking. So, who can get lung cancer screening? Anyone from age 50 to 80 who smoked at least one pack a day for 20 years or the equivalent of a 20-pack year history of smoking. So, if you smoke two packs a day for 10 years or any combination of that, you qualify for lung cancer screening. The problem we have is that we know that lung cancer is also occurring in people who are non-smokers. So, the problem is how do you pick those patients up? If you are a nonsmoker and you have increased risk of kidney or lung cancer, unless you have signs and symptoms or unless you get an incidental study, have a study for some other reason, then you may miss a lung cancer. You may miss a lung cancer that could have been picked up early. Unless you have signs and symptoms or unless you end up getting a different study that incidentally detects it, like a CAT scan or chest X-ray. Unless you have reason to believe you’re at higher risk of lung, like mesothelioma from asbestos exposure or a firefighter with a lot of smoke inhalation.
Q: Any practical advice for the general population then?
A: The most important thing people can do is be vigilant if you have signs and symptoms or if you are concerned about it. Make sure you ask your doctor. Make sure to talk to your family members and friends and get tested. I’ve had patients who told me that they asked their doctor, “Do I qualify for lung cancer screening?” And that’s a great question. Why? Because if your doctor doesn’t think about it for one reason or another then that’s great that you take the initiative and do it on your own. And so I’ve had some patients who were screened just because of that. Some patients changed physicians and their new physician may screen them because of that. We’re trying to have our systems be more proactive.
Lifelines
Name: Michael Aaron Parish, M.D.
Position: Thoracic surgeon at St. Joseph’s Health
Hometown: St. Louis, Missouri
Education: Howard University (medical school); Bellevue Hospital Center in New York City (residency); Roswell Park Cancer Institute (fellowship); Howard Universal Hospital (residency), UMass Chan Medical School (fellowiship)
Affiliations: St. Joseph’s Health Hospital, Crouse Hospital, Roswell Park Comprehensive Cancer Center
Organizations: Society of Thoracic Surgeons
Family: Wife, four adult children, 10-year-old yellow Lab
Hobbies: Listening to music, going to plays, skiing.