Episode 60: Does frequent surveillance improve lung cancer patient outcomes?

The Patient from Hell (00:01.438)
Dr. Kozower, I'd love to learn about, so you've done this study, how are you applying it today? So we have patients, essentially the really intense surveillance and the six to 12 months don't seem to make much of a difference. So when a patient shows up early stage, non-small cell lung cancer, they've completed treatment. What are you telling them and how are you working with them to develop a surveillance plan?

Benjamin Kozower (00:28.351)
That's a great question. So surgeons typically have followed patients less frequently than medical oncologists. And so in my own practice, I see patients either every six months or annually. We never see patients every three months following lung cancer unless there's a finding that we want to follow up on. But just the general pathway

is every six months for the first two years and then annually out to five years.

The Patient from Hell (01:02.654)
Interesting. So let's say I'm a stage two, stage three non-small cell lung cancer patient. In that population, given our previous conversation, there is systemic treatment part of the treatment plan. So presumably the medical oncologist is, for lack of a better word, the quarterback for care, and the patient is coming to you for the portion of surgery. Is that right?

Benjamin Kozower (01:30.239)
That's maybe right and it may not. So I have certain patients that I'm their primary doctor. I think in general, patients with more advanced disease, stage three, probably see their medical oncologist more than the surgeon, but not always.

The Patient from Hell (01:48.766)
Got it. And then in stage one is the reverse true?

Benjamin Kozower (01:52.063)
In stage one, typically they don't see a medical oncologist.

The Patient from Hell (01:56.51)
Alright, so they're coming primarily to you and you're essentially quarterbacking the entire experience and then at the end of the two year mark is there a I know it's not formal but like an informal handoff back to the primary care doc or the pulmonologist or is there another clinician that sort of takes over?

Benjamin Kozower (02:16.479)
That's a great question. In the US, there's no great uniform system. We see our patients out for five years. More and more, patients are willing to travel for surgery, but they don't necessarily want to follow up with us here in St. Louis at Washington University for their CT scan. And so,

depends on who is referring the patient, who lives near the patient. If you have a capable pulmonologist or medical oncologist near you, that's totally appropriate to follow up close to home. And so we do that frequently.

The Patient from Hell (02:56.062)
Interesting. Okay. Okay. That is super super helpful. Is there anything about the study that I should be asking you that I have not asked you?

Benjamin Kozower (03:04.575)
A few things, you know, what are the other benefits of surveillance? And this is true with all types of cancers, but particularly for lung cancer, the greatest risk of a new lung cancer is actually a previous lung cancer. So your exposure history, your genetic makeup, you have a high predisposition for lung cancer. And so it's about a 2% risk per year or so

of developing a new lung cancer. And so one of the reasons to be following patients is that you're actually doing a type of lung cancer screening. You're not looking for recurrence of the cancer that was treated, but you're looking for a new cancer.

The Patient from Hell (03:52.574)
There were so many things you just said that I have so many follow-ups to. Okay, can we take just 101? What is the risk of getting lung cancer for the average American? Ballpark.

Benjamin Kozower (04:04.159)
That's a great question. It's a small number. I don't have a great number off the top of my head because that's, you know, it's a very small number. If you think about, you know, 450 ,000 lung cancers, what, you know, we would need a denominator of the U .S. population, you know, to come up with the risk. But it's, you know, per year incredibly small.

The Patient from Hell (04:25.758)
Okay, so the reason I asked you that question is if I heard you write about the 2%, that's in the population that has already had lung cancer, so it's in the survivor population. And the recurrence you're talking about is not a spread, it's a local recurrence. It's not even a local recurrence, it's a new primary, is what it sounds like.

Benjamin Kozower (04:33.887)
Correct. Correct.

Benjamin Kozower (04:46.623)
Correct, correct. And so then the other important question that we didn't talk about is, you know, what's the chance of lung cancer coming back? And that we call recurrence. And so unfortunately, it's a higher number than people like to hear. You know, even for stage one lung cancer, historically, it's about 30%. So the earliest stage of lung cancer, about a third of patients have the cancer come back.

The Patient from Hell (05:08.542)
Oof.

Benjamin Kozower (05:14.623)
And about a third of those come back what we call local regionally, you know, in the lung or the lymph nodes. And about two thirds are systemically, meaning other organs, and they got there in the bloodstream. And...

Fortunately, those numbers are starting to change significantly. So there was some great studies, the early lung cancer action project and from patients in the lung cancer screening program, the earlier we find these lung cancers, the better patients are doing.

The Patient from Hell (05:34.558)
Mm -hmm.

Benjamin Kozower (05:47.839)
And so I think the recurrence rates that we see in the future are fortunately going to be much better than they are now. And we see that in the published studies looking at the lung cancer screening population.

The Patient from Hell (06:01.79)
Dr. Kozara, I'm having a bit of a moment of cognitive dissonance. So maybe I can tell you what I'm struggling with and you can help me understand that. At the beginning of the conversation, we sort of segmented patients, stage one, one cohort, stage two, stage three. Like there's differences, but for this question, we're gonna put them together and then you have stage four. So in the stage one setting, patient comes in, primarily do local treatment, right? You're removing the tumor plus some margin.

But then I'm hearing that off that population that has a stage one, a very large majority are getting a recurrence where it has spread. So.

Benjamin Kozower (06:45.951)
Not a large majority, 30%. So two thirds of patients are cured, one third of patients, but it's a larger percentage than you would like, but not more.

The Patient from Hell (06:56.83)
So off the 30% that has the recurrence, there's a one third, two third split of what type of recurrence, right? So it's almost like 66% of the 30% have a sort of stage three, stage four, second diagnosis, it sounds like.

Benjamin Kozower (07:17.279)
Yeah, really systemic. So really stage four. The most common places to spread are the brain to bones, other areas of the lung, liver, the adrenal glands.

The Patient from Hell (07:31.678)
So maybe I can ask you, okay, I think I know the answer to the question I'm gonna ask you anyway, which is if that is true, why are we not doing systemic treatment upfront in that population?

Benjamin Kozower (07:41.471)
That's a Great question. So the issue with that is that historically the treatments we've had for systemic disease have not been that effective.

So that's been a huge problem, okay? And fortunately now we're starting to see the development of targeted therapies for specific mutations. We're starting to see different types of therapies, but not just chemotherapy, but something called immunotherapy, which stimulates the body's immune system to help fight the cancer. And so these things have dramatically changed the paradigm of how we treat lung cancers.

The Patient from Hell (07:59.678)
I see.

Benjamin Kozower (08:26.431)
And there is talk now, so we talked about the Checkmate study earlier in this talk. There are patients with stage one called stage 1B, larger tumors who were enrolled in the study, but there frankly weren't enough of them to see a real advantage. But there's a huge interest. I can tell you the pharmaceutical industry.

The Patient from Hell (08:26.878)
Mm.

The Patient from Hell (08:46.046)
Hmm.

Benjamin Kozower (08:53.183)
And appropriately so, there's obviously a lot of potential benefit for patients if we can identify which of these patients, even with stage one, lung cancer are more likely to recur than what can we do to help them up front. And so those conversations are ongoing. I can tell you there's some studies being designed.

The Patient from Hell (09:13.822)
Thank you.

Got it, got it. Okay, so I'm gonna draw a parallel to breast cancer, because I think there is a nice parallel here, which is in early stage breast cancer, we do have some molecular subtypes, oncotype DX. Right, you have this upfront test that gives you some sort of score on the odds of recurrence. And if you score high on it, that usually is one of the trigger points for the clinician to often offer systemic treatment.

even if the tumor is small and locally available. So it sounds like there is not really today the equivalent of that in lung cancer. Got it. Interesting. Okay, that was fascinating. I just, I learned a lot right now. Thank you. I obviously don't know anything about lung cancer, but okay. I want to go to the future of lung cancer. I think you mentioned a couple of things. I think my specific question there is about liquid biopsies.

Benjamin Kozower (09:55.807)
Correct.

The Patient from Hell (10:15.134)
And I wanted to tie it back to liquid biopsy role in the the the role in surveillance. And I'd love for you to talk about where that is today and where you see it going.

Benjamin Kozower (10:28.703)
That's a great question. I mean, theoretically, if we could take a sample of a patient's blood and be able to identify, you know, very small amounts of tumor, tumor DNA, or whatever the compounds are that we're looking for, it would be tremendous. Unfortunately, despite the numerous companies that are out there and promoting the tests, there's nothing being used in mainstream right now.

They are becoming available. Certain insurance companies are more likely to pay for them than others. And it's because the data is reporting them. They're also very expensive. And so, you know, our healthcare system's not doing particularly well on, you know, the kind of efficiency of our...

healthcare utilization. So before we use these really expensive tests, we have to have good data that they are reliable, that they improve outcomes, and we're just not there. In the future, it makes a lot of sense that they're going to be out there. Currently, people look at CT DNA. Can we look at the amount of DNA in the blood from the cancer, and can we understand what's going on, and can we use that as a marker of treatment and recurrence?

And what we're finding is, for example, in stage one lung cancer, it's really not been helpful because typically, CT DNA is undetectable. But as the burden of cancer goes up, then it's more helpful. And so there's all these things in play. So I do think in the future, these things will, molecular testing is really just at its beginning.

The Patient from Hell (12:17.374)
I'm watching the clock doctor and I am, I'm going to try and wrap up, but my question for you on the wrap up is more, it's more on the emotional side for you. And the reason I asked that is we had a, we've had a few guests come and talk about lung cancer recently on our, on our show. And one of the themes I have been hearing is it sounds like lung cancer is sitting at this funny inflection point.

where so far the story has been largely sad. Patient gets diagnosed with lung cancer and the odds are just not in your favor. But now with the advent of molecular diagnostics, targeted therapies, immunotherapy, the story and the narrative seems to be shifting. I'd love for you to talk about that. Do you see more hope and optimism for lung cancer?

today and the future, or is it from your perspective, kind of the same story that played out for years?

Benjamin Kozower (13:20.351)
and you're taking a step back, right? Like our government, our insurance companies have not paid for any lung cancer screening until this decade. So it's a little crazy, but if you think about it in general, smokers have not been a very sympathetic group. And I'm sure that comes into play.

The Patient from Hell (13:31.486)
Wow, it did not look like... What?

Benjamin Kozower (13:44.511)
But now we're also seeing it used to be that over 90% of lung cancers were in smokers. And unfortunately, we are seeing a rise in non-cancers developing lung cancer. 15%, 20% and rising, particularly in young women. And so it changes how people look at that. But...

Right now, lung cancer screening is available to everyone. It's available to private insurers, Medicare, most states, Medicaid, but the utilization of lung cancer screening is awful. So for people who do it, it is extremely effective. It's actually the most effective type of cancer screening.

It's better than colonoscopy for colon cancer, better than mammograms for breast cancer. But if you're a primary care doctor and you've got to talk to a patient, it's really difficult because you've got to screen for all these types of cancer, you've got to manage blood sugar and their weight and everything else. And now if you start ordering these scans, about 25 % of patients will have a nodule. They'll have a spot on their lung. One out of four.

The good news is fewer than 5 % of them are lung cancer. But a lot of people have spots in your lungs. So, you know, I'm getting off track a little bit, but I'm making this plea that people need lung cancer screening.

That is the single best thing, particularly if you're at high risk. You're over age 55, you have a 20 -pack year smoking history. The best thing you can do for yourself is quit smoking, but at the same time, you want to get lung cancer screening. Okay, so that will save a lot of lives because the vast majority of patients will be found at a very early stage and highly treatable, likely curable.

The Patient from Hell (15:48.766)
Wow.

Wow, okay. I think you just blew my mind at the very end. I had no idea that the cohort where there is a rise happening is young women.

Wow.

Okay, I'm going to reinforce your last statement as the summary of our podcast today, which is lung cancer screening is the most effective way of screening for any type of cancer, which I also did not know. And of course, if you have risks, you should get screened. So on that note, doctor, anything else you want to add to that?

Benjamin Kozower (16:30.911)
No, thank you very much. I appreciate it. You'll see for those patients listening who do have lung cancer, there are going to be many different algorithms and will depend on your personal risks and also on kind of the practice patterns where you are. But I think it's very reasonable if you have questions, you could ask the physician caring for you.

The Patient from Hell (16:57.342)
Thank you so much. We really appreciate your time for coming on this episode.

Benjamin Kozower (17:01.343)
My pleasure, thank you.