Ohio State Wexner Medical Center interventional pulmonologist, Jasleen Pannu, MD talks about a new way to catch lung nodules early.
Interview conducted by Ivanhoe Broadcast News in 2022.
A decade ago, lung cancer was one of those cancers where it just was not caught early because it was so difficult to detect. How has that changed over this last decade?
PANNU: Over the last decade the most landmark thing that has happened is that we’ve found evidence that lung cancer screening through CT scans of patients who are at high risk, can help identify lung cancer early and help save lives and diagnose people with lung cancer at an earlier stage, which is imperative in increasing their survival. I think that’s been a landmark finding in the last decade.
Is that CT screening something that is common knowledge for most patients at this point?
PANNU: I’m not sure it is because it’s not very commonly practiced and that’s the same for patients, as well as health care providers. It is now becoming more and more known through multiple programs for creating patient education, physician education, and health care provider education. It is getting more known; it still isn’t that known yet.
When you say at risk, is that primarily smokers or are there other occupations or conditions or circumstances that would put a person at high risk for lung cancer?
PANNU: There are other conditions like Ridon exposure in patients who are non-smokers, family history of lung cancer that can put you at higher risk if there is some genetic involvement. However, to qualify for screening right now, the U.S. Preventative Task Force describes the criteria of smoking for about 25 pack years over the age of 50 at this time.
Could you remind me what a pack year is?
PANNU: If you smoke one cigarette a day for one year, that qualifies as one pack year. So, If we smoke one pack of cigarettes a day for one year, that qualifies for one pack year. If you smoke one pack of cigarettes a day for 20 years, that qualifies for 20 pack years. Now, if we smoke two packs of cigarettes a day for 10 years, that also becomes 20 pack years.
When you’re talking about a lung nodule program, can you define what that is for me. What essentially do you do?
PANNU: A lung nodule is a small spot, an abnormal area in the lung. It is quite common in the public, and it is not always cancer. In fact, most of the time it is not cancer. But in high-risk individuals or in patients with certain exposures, like Ridon, or even patients without many risks, sometimes a small spot in the lung that we call this lung nodule can represent early-stage lung cancer. This part is less than three centimeters in size, and if it’s by itself, it can present as early-stage lung cancer. It is an opportunity to diagnose lung cancer early and treat it early to increase survival. These are what lung nodules are. A lung nodule program is needed because they are found in high numbers and most of them are benign. However, it is important that we find a small number of cancers which are there. They are about 10,000 lung nodules detected at the Ohio State University system. Approximately 10 percent of them could be malignant in a year, so that’s still 1,000. That is many possible malignancies that could be detected through these lung nodules. It is very important to have a comprehensive program so that we can sift out these high-risk findings and focus our studies and procedures in diagnosing them and treating them early.
If you weren’t looking for lung cancer, under what circumstances could someone flag a nodule that didn’t look right? If someone comes in for an accident?
PANNU: If we weren’t looking for lung cancer through lung cancer screening scans, then most of the times lung cancer can be found accidentally when it is early because it’s not large enough to provide symptoms and one may undergo a CT scan for some other finding. If they’ve had a heart attack, motor vehicle accident, or pneumonia and they undergo a CT scan where this very small nodule, or the finding is found that is suspicious. Many times, that’s not the main issue, why they’re in the hospital, this finding may take a backseat and may get ignored at that point and later be forgotten or not followed up. When this finding becomes larger and creates symptoms like coughing, bleeding, or difficulty breathing, then it comes to light. However, by that time it’s already advanced. The key is to try to find them when these cases present early. That’s where the lung nodule program is geared towards. It is geared towards diagnosing and treating lung cancer early when they are present in the form of these small spots in the lung. It includes when it presents accidentally, when the patient has had a scan for some other reason, or it has been a screening detector nodule. Due to the large volume of such detections, it must be a comprehensive multidisciplinary program. It has four important competences. It has an automatic natural language processing software that we have installed that automatically screens all the CT reports that include lung fields in our system. Every CT report with a suspicious finding is flagged through the software and goes to a special team that is specially created to monitor the system, which includes our lung nodule triage team. This includes one physician, a nurse practitioner, and a nurse navigator. Every day these nodules are looked at to find out which are the most suspicious. Once we detect a suspicious nodule that is not being followed up and has been truly accidental, we contact the primary care provider or the patient and let them know of the findings so we can arrange appropriate follow-up. Then according to the will of the patient, they can choose to follow with us through our lung nodule clinic or locally with their provider if they know that this is a concerning finding.
So, anything that is screened in the lung field and the chest area automatically goes through this computerized screening for flagging?
PANNU: Yes.
Can you describe that?
PANNU: This computer software has a natural language processing system. It goes through CT scan reports that are reported through a radiologist and reads through what they’ve written. In these reports, if there is a radiologist that has reported a lung nodule of a sudden size, these can be flagged and followed up. The next component of the program includes a lung nodule clinic. Any suspicious nodules once they are detected, if the patients or their providers would like us to manage these nodules for them, we have long experts, surgery experts, and radiologists that are part of this clinic, to expedite and help diagnose the ones that may have malignancy and help to follow what would likely be benign. We also include a step that’s called a multi-disciplinary lung nodule board. This is a unique meeting that we have where before we see the patient, we meet. This includes interventional Pulmonologist, thoracic surgeons, radiologists, even oncologists, and we reveal the imaging ahead of time and come up with a comprehensive multidisciplinary plan depending on whether the patient would need surgery at this time, biopsy first, or a follow up. That helps to create an expedited plan even before the patient is seen so that we can truly have a fast-track for the patient’s management. This way, if this is cancer, we can help to expedite taking care of it early.
You had mentioned that with this software reading program and the lung nodule program in place, 10,000 nodules a year are flagged for potential screening?
PANNU: We will see how many are flagged. But we performed the study in 2018 where we looked at the CT scans that were being done in the Ohio State system, and through those CT scans, about 10,000 nodules were detected in the reports through our study that was separate from this software. Based on this study, we went ahead and invested in this program to try to take care of these findings.
And you mentioned a statistic. Most of those are not cancer, but there’s a percentage that are?
PANNU: Yes. In the general public, which includes everybody, the risk of malignancy in these nodules is in about four to 10 percent of cases. If this is a high-risk population and the patient has a lung nodule, the risk could go up to 25 to 50 percent.
What is the potential impact Doctor, of having a program like this then?
PANNU: We’re hoping to make an impact in early lung cancer detection through this program, through nationally available data and our data also majority of the times follow up off and incidentally detected nodule can be missed because of other priorities that are taking place at that time. Through nationally available data, we are only able to follow 30 percent of these findings and we can miss about 70 percent of them. Our own studies as we were missing close to 60 percent of them. There are many nodules findings that can be missed that way. If we are trying to push on screening on one side to detect lung cancer early. This is another avenue where if the patient is accidentally presenting himself or herself to the hospital system with this concerning finding, we should make it a priority to follow it up as soon as the immediate issue is taken care of. That’s why this lung nodule program was created.
What are the statistics, the life expectancy of a patient when lung cancer is caught this early as opposed to the later stages?
PANNU: The overall survival of lung cancer patients is just over 22 percent over a period of five years. However, if the patient is detected in early stages, that is stage 1 or even stage 2, the survival can be more than 60 percent. This is a huge impact that we can make in improving lung cancer survival.
Are you able to talk a little bit about Steve? How did you meet him?
PANNU: Steve was referred to our program because he had a very small lung nodule which was not even solid. It was part solid. It was a very thin nodule and that was found in his lung. He came through as a referral for lung nodule clinic. In our multi-disciplinary lung nodule board, we discussed his finding. It was concerning but it was too small to operate on to find this small nodule, thin nodule reliably during the surgery. What we did was in his biopsy itself be implanted small pieces of metal, a small piece of gold which can mark the spot for the surgeon so that when they went in for surgery, they knew exactly where the spot was, and they were able to accurately resect this nodule. It did come out as an early-stage lung cancer. It was fortunate that we were able to get to it that early.
Do you remember Steve having any symptoms at that point?
PANNU: Not at all. He did not have any symptoms. He did have risk factors because he had smoked for a long period of time, and he went through lung cancer screening as a routine preventative effort in his care and that’s how he found out. Otherwise, he may not have found it out for a long time.
Is there anything I didn’t ask you, Doctor that you would want to make sure people know?
PANNU: Patients being more aware as well as providers. I think it’s important to have more awareness regarding this effective test that is available in funding lung cancer early and in knowing that lung cancer now has several more treatment options open, early detection of lung cancer is now possible, just like breast cancer, just like cervical cancer. There is no shame or stigma attached to it in knowing about it. In going for your regular test, just like you go for your other tests. The same for both patients as well as primary care providers as well as lung doctors to be open to talking about this with the patients. If there is a finding, we do not have to be perplexed about what to do about it. There are avenues like lung nodule programs, lung nodule clinics, pulmonologists that work exclusively with lung cancer that can help detect and treat lung cancer early.
What are the implications of having a program like this?
PANNU: Having lung nodule programs is still a state-of-the-art early effort. There’s not much data available, but the data that I can give you is more practical data. If we’re missing 60 or 70 percent of findings that are found accidentally, then the implications can only be that. If we can follow 100 percent of these accidental findings that we are missing, we are likely to triple our detections of lung cancer and make huge impacts in early detection, creating a healthy life for the patients, as well as the biggest support system from the hospitals. I think implications are wide-open there. As more of these programs will be created, more solid data will come out from this in terms of lung nodule management as well as increasing lung cancer screening.
Is it any CT scan that would have been of that region?
PANNU: Yes. Any CT scan that would involve the lung fields.
Would it just involve the longest way from the neck to the abdomen?
PANNU: Correct. There are several CT scans of different areas that may involve some part of the lung. If you did a CT of the neck that may involve the upper part of the lung. If you did a CT of the abdomen, that means sometimes catching the lower part of the lung. CT chest obviously catches the whole chest. Cardiac CT is cats, some parts of the lung. They are not mainline tests for lung cancer screening, but they can detect these accidental findings.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Amanda Harper
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
