In this segment, Katrina Steiling, MD, a physician in pulmonary, allergy, sleep and critical care medicine at BMC, provides details on how the hospital is advancing the early detection of lung cancer for better outcomes that can save lives.
Dr. Steiling is a pulmonologist who sees patients in the multidisciplinary Thoracic Oncology Clinic and the Lung Nodule Clinic. She is also a physician in the Medical Intensive Care Unit at Boston Medical Center.
Learn more about Katrina A. Steiling, MD
Melanie Cole (Host): Lung cancer is the leading cause of cancer related deaths in both men and women. It often goes undetected for long periods, and therefore is diagnosed at an advanced stage when treatments are less likely to cure the cancer. My guest today is Dr. Katrina Steiling. She’s a physician in pulmonary, allergy, sleep and critical care medicine at Boston Medical Center. Welcome to the show, Dr. Steiling. Let’s just talk about the lung cancer screening program and lung nodule evaluation program at Boston Medical Center. How did that come about?
Dr. Katrina Steiling (Guest): Thanks for inviting me to talk with you today, Melanie. The lung cancer screening and lung nodule program at Boston Medical Center came about in 2014 and 2015, and that’s based on some studies that were done that showed that screening people for lung cancer helps improve survival. Lung cancer screening aims to detect lung cancer at an early stage when it could potentially be cured, and that occurs when a patient does not have symptoms. These recommendations are based on the national lung cancer screening trial, which was a large trial conducted in the United States, which compared yearly low dose CT scan to test x-rays for lung cancer screenings. The results of that study showed a 20% decrease in mortality for lung cancer in high-risk cases that were screened with once yearly CAT scans. With the results of that large study mind, several physicians based out of radiology, pulmonology, thoracic surgery collaborated to develop this lung cancer program and lung nodule evaluation program at Boston Medical Center with patients in mind that are at risk for lung cancer.
Melanie: Who is at risk for lung cancer and who should be screened? What are the parameters?
Dr. Steiling: The lung cancer screening is performed on patients that are at the highest risk for developing lung cancer. The primary risk for lung cancer is cigarette smoking, either currently or in the past. A group called the United States Preventive Services Task Force came up with recommendations on who should be screened for lung cancer. Those patients include individuals that are aged between 55 and 80 years old, people that currently smoke cigarettes or previously smoked cigarettes that have quit within the last 15 years, and people that have smoked a high amount of cigarettes that we estimate by a number called “pack years.” For example, 30 pack years is equivalent to someone that has smoked one pack a day for 30 years or two packs a day for 15 years. For patients also undergoing lung cancer screening, it’s important that they have no symptoms of what could be lung cancer, so they should not be losing weight or coughing up blood. Of course, those are serious symptoms and they should have a different kind of CAT scan. if people experience that before screening. They should have no symptoms and people should also be willing to undergo diagnostic testing and procedures in case any abnormal findings are found by the screening scan.
Melanie: What's the screening scan like for patients?
Dr. Steiling: Lung cancer screening is just a simple CAT scan. It’s done using a CT scan that uses a very low dose of radiation to obtain the pictures. It does not require intravenous contrast or an IV – and again, it uses a low dose of radiation, which is approximately similar to what mammograms use in order to do breast cancer screenings.
Melanie: So similar to a mammogram. What happens if something is seen on this CAT scan? What's the next step and how soon does somebody find that out?
Dr. Steiling: The reports for the CAT scans are generally available by the next day. The most common abnormality is something called a lung nodule. A lung nodule is an abnormal or solid area of tissue in the lung that’s present in an area where it should not be. These lung nodules end up looking like shadows or spots on the x-ray or CAT scan. About one in four people that have a screening CAT scan will end up having a spot detected on their lungs. These lung nodules are frequently detected, but less than 5% turn out to be lung cancer – less than five out of 100. It’s the nodules that end up being larger, so larger than about a half an inch or nodules that grow, that we’re more concerned about, and that are more likely to turn out to be cancer.
Melanie: If a nodule is found, or something that might be suspicious, then more testing might be needed. What might that look like?
Dr. Steiling: The evaluation and the treatment for the small lung nodules really depends on what they look like, and importantly, it depends on how they change over time. When a lung nodule is found, usually the next step is to get another CAT scan in a few months or several months to see if it changes in size. If the lung nodule does not change – if it stays the same – then it’s monitored using additional CAT scans. But if the nodule is large or if it does grow overtime, then sometimes a biopsy of the nodule – or removal of the nodule – might be suggested.
Melanie: If this is something that is suggested, what is treatment for either lung nodules that might be benign or lung cancer itself? Just give us a broad overview of treatment.
Dr. Steiling: For nodules that are benign – nodules that are not cancerous and that end up staying the same size – in general, no treatment is necessary. A lot of times, these benign nodules end up representing either small lymph nodes inside of the lungs or small areas of scar where perhaps the body has fought off an infection in the past. For nodules that grow in size or that change overtime or that are particularly large, that end up being concerning for cancer or end up in fact being a cancer, many of these are removed surgically – and that’s using a procedure where a surgeon would go and just take the nodule out of the lung. That ends up being the treatment for early stage lung cancers as well.
Melanie: What do you see on the horizon for lung cancer screening and lung cancer itself? What are you doing that’s very exciting?
Dr. Steiling: I think there's two areas that are really exciting. I think the first area is recognizing that while this new screening is a really important advance in helping people that are at risk for lung cancer by helping to diagnose it in its early stage when it can be cured, that we’re really only screening certain individuals, and it doesn’t encompass everyone that has the potential to get lung cancer down the road. Some of the exciting things I see is being able to develop new tests that serve as adjuncts – or helpers – to the CAT scan to help better stratify or determine which patients are going to truly benefit from having this screening test. Another example would be developing additional tests that can help us decide which of this lung nodules are truly cancer and which ones are truly not cancer. That’s something that’s currently very difficult to do just based on the CAT scan, but we’re hopeful that we can develop additional tests or additional characteristics of these spots or of individuals that can help us distinguish the cancerous ones from the non-cancerous ones.
Melanie: Does insurance recognize lung cancer screening?
Dr. Steiling: That’s a really important question. There's always a lag time between when these important large studies come out and when insurance has potentially covered the exams. The United States Preventative Services Task Force is actually the organization that gives the recommendations about screening tests and they have endorsed lung cancer screenings with what's called a Grade B recommendation, and so it is covered by private insurances. In February 2015, the Centers for Medicare and Medicaid Services – or CMS – also came out endorsing lung cancer screenings, so it’s additionally covered by Medicare.
Melanie: Wrap up it for us, Dr. Steiling, if you would – with your best advice about lung cancer itself – possible prevention, who is at risk and who should really consider having this lung cancer screening, what they should ask their doctor.
Dr. Steiling: I think the most important thing I want to emphasis is that the best way for people to reduce their risk for lung cancer is not to smoke and not to use any form of tobacco. The other thing I want to stress is that as part of lung cancer screenings, it’s important that patients talk with their doctors not only about the importance of quitting smoking and staying quit from smoking, but also about the pluses and minuses of undergoing the screening tests, such as the potential that it detects these spots in the lungs. Patients should always feel comfortable reaching out to their healthcare providers to talk about quitting smoking because that’s the #1 thing that they can do in order to prevent lung cancer.
Melanie: Thank you so much for being with us today, Dr. Steiling. You're listening to Boston Med Talks with Boston Medical Center. For more information on lung cancer screening, you can go to BMC.org/lungscreen. That’s BMC.org/lungscreen. This is Melanie Cole. Thanks so much for listening.