 Good afternoon, everyone. Thank you again for joining us for today's webinar, lung nodules and lung cancer screening, understanding, managing and finding clarity with Dr. Kilal Patel from JFK University Medical Center. If you have any questions, you may ask them anonymously by clicking on the Q&A button at the bottom of your screen. But please note that if you type it into the chat, it will not be anonymous and all attendees will be able to see your question and name. We will make sure that all questions are answered at the end of the webinar. This webinar will be recorded and sent to the email address that you registered with along with being uploaded to the Hack and Security and Health YouTube channel. Thank you again for joining us today and I'll pass the floor over to Dr. Patel. Thank you. Hi, good afternoon, everyone. I'm Kilal Patel. I'm the medical director for the lung nodule program for Hack and Security and Health in the central region as well as the chief of interventional pulmonary over here. Today we're going to talk about lung nodules and lung cancer screening, understanding, managing and finding clarity. The objectives which we hope to achieve during the talk would be what are lung nodules and why do they require attention? What are the common causes and risk factors associated with the development of lung nodules? What is lung cancer screening? How is lung nodule detection and diagnosis achieved through screening? And what are the available treatment options for lung nodules and how are decisions made about their management? And in the end we'll have some time for questions if anybody has anything. So what is a lung nodule exactly? It's commonly referred to as a spot on the lung or a shadow on the lung when you get a report and your primary care physician or the ordering physician goes over it. In vague terms, if you're not describing it, it is a small abnormal area on the lung, usually seen as a white opacity, usually less than three centimeters in size. That's slightly smaller than a quarter. This is a chest x-ray for those who are not familiar with it, so that's usually in black and white, as you can see, I just wanted to give you guys an idea about what the spot looks like. On this side, this is the right lung. Lung usually appears black on a chest x-ray because L appears black on it, so it should be completely black. The white lines that you see are your ribs. This is a heart in the center and over here you can see it's not completely black, but there's a white spot that is a lung nodule. Mind you, and when you do a chest x-ray, you're only taking one picture of your chest. The other times, sometimes you might have heard somebody getting a cat scan. And if you get a cat scan, what we are doing in a cat scan is we are taking pictures of your chest and slicing you like a loaf of bread. It sounds a little bit morbid, but that's exactly what we do. It gives us a better idea of what's happening inside of your lungs. Compared to a chest x-ray, in the x-ray you only do one picture, and a cat scan can be anywhere from 100 to 200 or 300 slices or 300 pictures that we take. This is what a cat scan usually looks like. On the bottom part, that's the back of the patient. This is the front. This is the right side and this is the left side. This also, the lung appears black because air appears black when a cat scan and lung is filled with air. The white lines that you see are blood vessels. That's how your body gets the oxygen, gets rid of the carbon dioxide. On this side, as you can see, this is a bigger spot over here and that's what a lung nodule is. So now the question becomes on what are the common causes of lung nodules? So you can broadly classify them into four different buckets. It could be secondary to an infection, secondary to inflammation, or it could be secondary to a scar tissue from a previous infection or inflammation or to some sort of an injury that the lungs got exposed to, like it could be a gas, it could be smoke, it could be chemicals and that caused some scarring. Scar tissue is dead tissue or it could be cancer. That's the most worrisome, obviously. How common are the lung nodules? Nodules are found in about 30% of people who get chest radiographs. Could be an x-ray or a cat scan. They're quite common and majority of them are not cancer. What are the symptoms? Majority of them don't have any symptoms unless it's from an infection then you might have some fevers, chills, some coughing or from inflammation then you can have it from that inflammatory condition. But most of the times they're not symptomatic and it's found on a test done for some other reason. Somebody might go to the emergency room for a belly ache and they get a cat scan over there and when they're taking a cat scan they can get the picture of the bottom part of the lungs and they might see a spot on there. That's called an incidental pulmonary nodule. So most of the nodules are found incidentally or when you get a screening cat scan which we'll talk about in a little bit. So as we just spoke about this nodules are very common per se and most of them are not cancer. Then why are we having this conversation is because of the elephant in the room per se is because of lung cancer. Lung cancer is the second most common of cause of cancer in the United States and it's a leading cause of mortality from cancer both in males and females. The good news is the lung cancer incidence rate is going down as you can see in this graph and males it peaked around in 1985 has been slowly growing down and females it is plateauing out and has been has a slight decrease but not too much. However, the deaths from lung cancer is more than deaths combined from prostate, breast and colorectal combined. That shows the magnitude of it. And the reason for this is because lung cancer usually doesn't present at an early stage because it doesn't cause any symptoms. This slide shows you when does lung cancer usually present it? The blue is early stage. The orange that you see is only the cancer has spread only to a regional area. The red is if it has distance spread or stage four disease as we call it. Majority of lung cancers, 57% of this presents at late stage. The below graph shows you what's the survival of it and the survival is very poor when it has spread. Mind you, this slide is based on data in 2010 and cancer therapy has come a long way so the numbers are slightly better for survival compared to that. However, if cancer is caught in an early stage, that's the blue graph, then the survival is very good and sometimes you can even be cured of cancer. This cancer is in a very early stage as we call it. Then you can sometimes cut it out or you can even do some unique radiation therapies. And that's why we come to lung cancer screening. So when do we do lung cancer screening? Lung cancer screening is advised in patients who are in the age group of 50 to 80 years and at least have 20 pack year smoking history. So what do I mean by that? 20 pack year smoking history means if anybody smokes one pack a day for 20 or more years or even if they spoke two packs a day for 10 years, that's when you multiply the number of years smoked into the packs per day and that's the answer. So if anybody who has smoked more than 20 pack years then we should do a screening on that. And they should be a current smoker or quit less than 15 years ago. That the last recommendation, American Cancer Society just came up with a guideline saying that that's not a prerequisite. If anybody meets the top two, they should go ahead and get a lung cancer screening scan. When do we stop screening? We stop screening if they develop a health condition which severely limits their life expectancy then there's no point in doing the lung cancer screening scan. This is a concept just to show you how important it is so to screen. So normally whenever we do any kind of testing in medicine person, we look at how many people we need to screen to save one life from that disease. So the first one is a mammography. So you have to screen about 1,900 females between the age of 40 to 49 to save one life from breast cancer. The number gets a little bit less. We only have to screen about 1,300 between the age of 50 to 59 and only 377 between the age of 60 to 69 to save one life from breast cancer. Compared to colon cancer, you had to do about 817 flexible sigmoidoscopy to save one life from colon cancer. But when you look at lung cancer screening, you only had to do 130 screenings or only 130 patients need to get screened to save one life. That's pretty big discrepancy if you look at it. This slide even shows it even more. This shows you how many patients who are eligible for screening are actually getting screened. The dark blue line is the people who are eligible for breast cancer screening and who are getting screened, which just looks very good. The second one is cervical cancer screening, which wasn't that good early on, but it picked up quite well and now almost everybody's getting screened for it. Holorectal cancer is the exact same thing. It started off at 40% and now it's all on its way to 80%. Lung cancer is all the way down here. So breast cancer, about 76% of patients who meet the screenings, go ahead and get mammograms regularly. Cervical cancer is the same, it's about 72%. Colorectal cancer is about 72, too. However, lung cancer screening is only happening in 4.5%. The various reasons for that and why that happens. There is a stigma attached to smoking, some people think that, oh, you brought it on yourself. That's not true for everyone. There are a lot of non-smokers who also get lung cancer and there are smokers who do not get it, but the whole point being, you need to look out for it. There are screening modalities available which have shown to make a difference and that's why you should encourage yourself or any friends or family members who might qualify for lung cancer screening to go ahead and get screened. You have a long way to go to save lives on that. What happens if at all you get a lung nodule on any of your scans? It could be an incidental finding or it could be from the lung cancer screening. As I said earlier, that does not change. Lung nodules are very, very common and majority of them are not cancers. When we see a lung nodule, we look at the clinical part. What history do you have? What occupation you do? Do you smoke or not? Do you have any family history of any kind of cancers? And then we marry it with what does the nodule look like on a cat's cat? We see the size, the shape, the location, the appearance of it and then marry them together and come up with a pre-test probability or how likely is it that that nodule is cancer or not? Is it high, medium, or low? If it's low, sometimes we don't even need to do anything or we will just get surveillance to repeat its scans, to follow the nodule, to make sure it doesn't change. It doesn't develop any high-risk features. If it's moderate, then we might even do a blood test to see how likely is it that the nodule could be cancer or not. If it's on the high risk category, the high-risk features, then we might go ahead and do a biopsy or maybe a resection or some other invasive modality to confirm it whether it is cancer or not. There are various treatment options for nodules depending on what the cause is. If it's from an infection, get antibiotics and that should fix that and the nodule should go away. If it's inflammation, you get medications for it and that should fix it. If it is scar tissue, unfortunately that does not go away and it stays there for a while. It's like a scab that you get on your skin and it's there forever. However, if it is cancer, then there are various options depending on when we find it, what stage it is. It could be a resection and you could be cured of the cancer if it's early stage or you might require some chemotherapy or something called immunotherapy in which we utilize your body's own immune system to fight the infection. So the cancer in this case, our radiation. So there are various modalities what can be done about it depending on what it is. The point we should all consider is we shouldn't be an ostrich and stick our head in the sand. We need to figure out what it is and then just follow it. Kind of nodule care at JFK. So we run, we have a very extensive multidisciplinary program in which we have interventional pulmonary, thoracic surgery, thoracic oncology, radiation oncology, radiology and pulmonary. We all come together and we go over all the nodules and figure out what needs to be done about that. I truly believe in more brains are better than one. Everybody can come up with some sort of an idea and then we decide on what needs to be done about the patient per se and how we can help them. And what's the best way forward in that regards. There are various other new things that I just wanted to give you an example of somebody who was in a lung cancer screening program. If you look at it this is a vertical section of the lungs per se. There is a lot of amphysema and you can see there is a spot on it. And this patient, because of the size of the nodule it's about two centimeters in size so we got something called a PET scan. What we do in a PET scan is we inject some radioactive sugar inside of you then take pictures of your body to see if it lights up. Cancer, infection and inflammation. All three of them love sugar. And if they take up the sugar it appears bright like it does over here. However, it's not too bright. If it's too bright it appears more whitish or yellowish. In this case it is a little bit less. We went ahead and we have a special procedure called robotic bronchoscopy in which we go in with a small camera inside the lungs and we try to biopsy it. So patient had navigation bronchoscopy but think this in this case and was diagnosed with adenocarcinoma. But however there was no lymph nodes involved. What the robotic bronchoscopy does is we take a CAT scan and we use it and put it on computer forms a three dimensional free as you can see over here. Then which works as a GPS. Tells where we have to go and what we have to biopsy. As this was an early stage cancer our thoracic surgeons were able to resect it and have the patient cured of cancer. There are very few times in cancer world that when we can say that we could cure you of a disease. Even high blood pressure, you have to keep on taking the meds. You don't get cured of it, we're just controlling it. So that's why it's very, very important to catch this thing in a very early stage. That's all I have kind of for now. Anybody has any questions for me? All right, our first question. I have two nodules in the lower right lung found on CAT scan for another ailment. I went to a pulmonologist and he said he never wants to see me again. He called me a nodule baby. I smoked but more than 15 years from the time of scan. Do you agree with not having a follow-up scan? My dad has melanoma and his four millimeter nodule grew 1.7 centimeters after six years of scans from original diagnosis. So as I said, it depends on the size, the shape, the location and the appearance of the scan. I don't agree with the other lung doctor who had mentioned to you about that ways. So we don't ignore it for saying that regards, but you have to look at all those things. That's specifically if you are high risk for it because you have a strong family history of the same. So that ways I wouldn't completely ignore it. Even without looking at your scans, you would have qualified for at least one follow-up scan. But if you have any high risk features, then maybe it would be even more. Strongly advise you to have it looked at and make sure somebody takes a look at those scans that gives you right advice about the same. Our second question is, what type of blood test can be done for lung nodules and what do you look for to determine if nodules are infectious slash inflammatory versus cancer? So it's two-part questions. I'll take the second part first about the infection and the inflammation. So we look at the clinical part of it. So if you have signs of an infection like fevers, chills, body aches, or you just had an infection and you're getting over it right now, then the nodule could be most likely from that. In that case, normally if you do a course of antibiotics, if it's appropriate, then repeat the scan a few weeks later. As soon as you're done with the antibiotics, the nodule will not go away because your body takes time to heal itself and for that nodule to disappear. So normally we wait anywhere from six to eight weeks and then we'll repeat the scan and then it should disappear. That's the second part. Going to the first part, so we have various blood tests. The main two ones, what we do is if at all the nodulus cancer, it's not normal. So it has abnormal proteins in it. So whenever it's dividing rapidly, it keeps on the cells, keep on rupturing and releasing protein in your bloodstream. We look for those proteins per senior bloodstream and if you have them present, then we can say that you are higher risk for cancer and then we should proceed with the biopsy. The same token, we know certain proteins which are seen in benign conditions. And if those proteins are found in your bloodstream, then we can lower the risk of cancer and then say that it's less likely that you have cancer. Normally, as I said before, when we look at the size, the shape, the location, the appearance of the nodule, we have calculators which give us a probability on how likely that this is cancer or not. And when we do the blood test, we either increase the likelihood or decrease the likelihood. If we decrease it, then normally we would just go with conservative approach of just repeating gap scans to make sure that it's okay. However, if it increases it, then we would proceed with some sort of a biopsy to just confirm the diagnosis so we can treat it before it spreads anywhere else. Our next question is, I was diagnosed with breast cancer at 39 years old. During tests, it was found that I had numerous pencil eraser size nodules in my lungs. I never smoked. Should I have some type of surveillance testing and or monitoring? Yeah, so it's a complex question per se. So whenever you are diagnosed with some sort of cancer, they must have been staging for it at that time. If you have that conversation with your oncologist, they would be able to answer that question more because if this was present at that time and it was deemed related to your breast cancer and then you are in remission right now, then the nodules should not increase in size. So most of the times we do a repeat surveillance scan, not just for the nodules itself, but just to make sure there's no increase in it if it was related to your original scan. If it is really thought to be because of something else, then that's a different ball game altogether because we want to see why it's there and it's not changing per se. So just because of the breast cancer diagnosis, I would strongly recommend to speak with your oncologist and they would have access to all your historical data so that they can compare it and then advise you accordingly. But a quick answer would be yes, there would be a follow up scan about it to see how quickly you have to do it. It depends on what the original scan showed and how many of them were there. Our next question is, should you look at vaping the same as smoking? Vaping is actually worse than smoking in a way but I have a personal bias about that. So if you think about vaping people who are not familiar with it, it's an electronic cigarette. Usually it comes as capsules or ampules per se or cartridges, what they put in it. One cartridge of vaping is equal to roughly about 100 cigarettes, 100 packs of cigarettes or so per se. Some, most people don't realize it in that regard. And now when you add vaping with flavors which is very addicting like lollipop or whatever bubblegum with sugar in it which is very addicting by itself, it gets even worse per se. So what's happening right now is initially vaping was introduced saying that people can get off cigarettes and which works, but however the amount of smoke that they're taking in is exponentially higher because people don't realize what's equivalent of. Like when they were smoking a pack of cigarettes they would just stop at the end of the pack because they think, okay, I finished a pack. It's a material thing which I can look at. Whenever you do the electronic cigarette they don't realize it. They just take a puff every now and then and it keeps on going. And that's why we're seeing a lot of young people who vape quite a bit who has lungs which are like they're 20 years old but the lungs are 60 years old per se because they have got so much damage in them. But the same token, if you use it as a tool to quit smoking, yes it works in that regard but I would use more caution in that. Vaping usually still has nicotine in it which is the addicting part per se and depending on what the other things that they put in the vaping, that's what if you get exposed to because what happens in vaping is you're not burning anything it's basically suspending it into small droplets which you breathe in and that's how it works. And so that's why I would say like no vaping is sometimes actually even slightly worse but if you use it as a crutch to quit smoking then yes it's worthwhile. Our next question is my mom had nodules and PET scan however she was 91 and we left it. However she did pass about two years later. I feel that we could have done something we were going to get an NFA however the pulmonologist said that she could get a collapsed lung. So you're absolutely correct about that so it depends on how we biopsy it. There are multiple ways if you have a nodule which appears high risk so you do your homework about that size, shape, location, appearance and then the clinical part and if it appears that it's high risk per se then we talk about different modalities on how you can do a biopsy. One is we can give you some local numbing medication to go from the outside. And the other one is we go from the inside that's the robotic bronchoscopy what I was talking about. So depending on where the nodule is actually located we choose the modality. The risk of lung collapse is roughly about 20 to 24% when you go from the outside and it's only about four to 6% when you go from the inside. But the downside of going from the inside of the robotic bronchoscopy is you need general anesthesia so you should be stable enough to get that. So there are a lot of caveats in it. Yes, lung collapse can happen and but there is more to it than that. Sometimes most of the times it can be done in the same manner per se. Personally, we have if it depends every 90-year-old is not the same. We have apseed 88 or 1992 is my highest which who look like they're 70 years old they're pretty vibrant and living life per se then you go ahead and do that in those cases because you want to preserve the quality and the quantity of life as much as you can in that regard. So it's a mixed bag. It depends on a lot of variables per se. Yes, it can cause lung collapse but we have various strategies to mitigate it or reduce it but it doesn't go all the way down to zero. Our next question is are you finding COVID instead of cancer within these nodules? So let me reframe the question a little bit. So are we finding other diagnosis? So we cannot find COVID on biopsies per se because it's a virus usually and by the time we do that it will be gone by we can we don't we cannot culture it that well the virus doesn't survive that long. But as I said earlier or early on in my talk most of the nodules are benign. So if you biopsy let's say everyone we find get 100 people with scans which have nodules in it only 4% of that would be cancer. So forget about the risk factors and everything. So if you think look at it most of the other stuff is either an infection inflammation that's why the push is to really look at the nodule itself in a multidisciplinary manner. You look at it from multifaceted approach we look at the size, the shape and location that sound like a broken record you marry all of them together and when somebody who's like has looked at it all their life and that's what they enjoy doing then they will be able to tell you you don't have to put a needle in each and every nodule that regards to try to figure out which one is higher risk and then you do it that way. So yes to answer your question majority of them are not cancer but and no we cannot we have not detected COVID there is no way for us to detect COVID in that because the virus would not survive processing. Our next question is my lung cancer was caught at a very early stage and I had a low back to me. There was no spreading and I've just completed two years of CT scans. Do I still fit into the 54% survival rate that I saw on one of the slides? It's actually much higher now so if you're an early stage cancer the rates are if I'm not wrong and you went between the high 70s to low 80s per se. So as I said, that slide was a little bit older but I liked the graphic representation it was from 2010. So yes, if you're very early stage cancer then you fall in the 80% range per se in that regards and if it has not anywhere else congratulations on that that it was found at an early stage and you could cure cancer. Our next question is can a scan be used to diagnose the specific kind of COPD a non-smoker has? I've been told I have COPD that it's not emphysema but not which specific disease it is. So there is a condition in which non-smokers can get COPD. There are a lot of genetic conditions that you should be looked at depending if you have a European descent per se. So that there is more that goes into it you will require some sort of a workup I would strongly urge you to do it sooner than later because what happens in most of those conditions is that you can have progressive damage of your lungs properly that's what's happening right now and that's why it showed up on the scan and you need to figure it out what it is so you can arrest it and reverse it as much as possible per se. You need your lungs to breathe and you need to breathe to live so there's no other way around that. So yes, there are conditions about it you are able to usually say whether you have lung damage or not from the CAT scan but you cannot say how much the damage is because it doesn't tell you anything about the functionality of it. It's just a picture of your lungs. Our next question is can we get a screening from our regular doctor? How can we go about it? Yes, you should be able to go to your regular primary care physician and they should be able to order the lung cancer screening scan. I can share if you can shoot me an email my email address is right there and I can share the fire where your primary care has to share. Send the paperwork to but most of places do it and we do it at JFK and all the central region hospitals do it the lung cancer screening scan. So your primary care should be up to date about it but otherwise shoot me an email I can share the data with you. I believe this next question is in reference to the previous question on vaping. They asked cartridge equals how many cigarettes? So there is a flyer on FDA's website which I'm quoting for a sake that shows that 100 cigarettes one cartridge is equal to 100 cigarettes. Our next question is have two or three nodules for over 20 years also have emphysema how often should I get CT scans? So if you're not smoking right now or have quit smoking for more than 15 years then you don't need to get scans for the nodules itself. However for emphysema if that is progression then your lung physician might order a CAT scan to look for other treatment modalities. And our last question is if one sees a pulmonologist affiliated with JFK are those clinical findings discussed in your department? Majority of the times they are so usually they bring up the nodules in which there is a clinical question which they cannot answer or they are not comfortable with. We encourage all pulmonary physicians to bring their cases over there and talk about it as much because everybody can then chime in. All of us bring in cases at that time if it's a straightforward case then usually no but otherwise yes. We had one more question slip in. On a CAT scan and subsequent PET scan it was confirmed that I have several small nodules but also bronchial status. What is your advice? So most likely your nodules appear that they are from an infection. Bronchial cases means you have damage of your breathing tubes per se. This is usually secondary to a chronic infection or some kind of injury that keeps on happening over you. Months to years at a time per se. I would strongly advise you to get that infection under control so that you don't have progression of your bronchial cases in that regard. So you would not need CAT scans to follow on the nodules but at the same token if you have high risk behaviors as if you are smoking or you have cancer industry then that's a different question but other than that no, you don't need CAT scans to follow on those nodules because you have a cause which appear most likely from an infection. Are there any further questions before we end the webinar? All right, if there are no other questions thank you again everyone for joining us virtually here at Hycon-Security and JFK University Medical Center and thank you again to Dr. Kilal Patel for sharing your expertise on this topic. I hope you all have a wonderful rest of your day.