Innovations in Lung Cancer Screenings and Treatment at Orange Regional Medical Center

By: Jennifer Webster
Wednesday, June 4, 2014

Offering low-dose CT screening scans in conjunction with a robust lung cancer management program, Orange Regional Medical Center helps local patients improve their odds in the fight against cancers of the lungs.

With almost 250,000 new cases and leading to 150,000 deaths in the United States each year, lung cancer is more fatal than breast, colon and prostate cancers combined. When identified in the early stages, however, lung cancers can be surgically resected and the disease is often curable. In fact, patients whose lung cancer is identified and treated in stage 1 have a 70 percent chance of living five years, while patients diagnosed in the later stages have five-year survival rates that approach 9 percent. Yet, because lung cancer causes few early symptoms, many patients are not identified or treated until their disease has advanced to the later stages.

“The problem with lung cancer is that it is often identified too late, so patients succumb to their disease,” says Cleveland Lewis Jr., MD, Medical Director of the Lung Cancer Disease Management team at Orange Regional. “Screening allows physicians to potentially start making a difference in the number of people who die from lung cancer.”

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Cleveland Lewis Jr., MD, Medical Director of the Lung Cancer Disease Management team at Orange Regional Medical Center, performs a thoracotomy.

Tumor surveillance resulting in early detection and treatment has proven valuable for other cancers, such as cervical cancer, which have decreased in incidence and fatality since early screening became the norm. However, lung cancer has proven problematic because early screening techniques did not show an increase in lives saved. Sputum cytology and chest X-rays, for instance, have not demonstrated a survival benefit.

In 2011, however, The New England Journal of Medicine published the details of a randomized trial, known as the National Lung Screening Trial, of 53,454 patients at high risk for lung cancer. These patients were randomly assigned to undergo three annual screenings with either low-dose CT or chest radiography. Although both screening methods resulted in a number of false positive results, low-dose CT screening demonstrated a 20 percent relative reduction in lung cancer deaths. The authors’ conclusion: “Screening with the use of low-dose CT reduces mortality from lung cancer.”

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Dr. Lewis and Daphne Garcia, PA, perform video-assisted thoracoscopic lobectomy in the operating room.

Later studies confirmed the findings, while also acknowledging those at low risk would not benefit from the screening. Additionally, a 2013 study published in The New England Journal of Medicine found that accurately estimating whether a lung nodule detected by low-dose CT is benign or malignant is possible, based on characteristics of the patient and properties of the nodule.

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Dr. Lewis speaks with Chris Costello, Orange Regional’s Nurse Director for Same-day Surgery/Endo/PACU, to schedule surgical cases.

Today, the National Comprehensive Cancer Network, the American Cancer Society and the American Association for Thoracic Surgery, among others, recommend annual low-dose CT scans to screen for lung cancer in select patients. These candidates include people ages 55 to 79 who have smoked one pack a day for 30 years, lung cancer survivors and smokers age 50 and older with a more limited cigarette habit who have additional risk factors, such as family history of lung cancer. These guidelines include those who have quit smoking within the last 15 years.

At present, the Centers for Medicare & Medicaid Services does not pay for lung cancer screenings, nor do most insurance plans. However, the United States Preventive Services Task Force (USPSTF) announced in December 2013 that low-dose CT was an important screening tool for lung cancer. This grade B recommendation extended the upper age for screening to 80.

According to the Affordable Care Act, Medicare must pay for USPSTF grade A and B recommended screenings, so lung cancer screenings may soon be available to a wider group of patients. Orange Regional offers low-dose CT screenings as part of a comprehensive cancer program.

Advances in Cancer Diagnosis and Staging

Once a screening test indicates a potential cancer, Orange Regional’s diagnostic techniques help physicians discover the intricacies of the patient’s condition. Endobronchial ultrasound is a minimally invasive bronchoscopy procedure during which a physician introduces a bronchoscope with an ultrasound probe into the patient’s airway. The procedure, guided by ultrasound, involves a transbronchial needle piercing the wall of the airway, allowing the physician to biopsy lymph nodes. The pathologist examines the biopsy tissue in the operating room to make a real-time determination of cancer presence.

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Intraoperative view of a large, fluid-filled pericardial cyst prior to thoracoscopic resection

Swift diagnosis and staging mean patients can begin treatment rapidly. Before surgery, patients receive a call from the lung cancer nurse navigator introducing them to the range of patient-centered programs at Orange Regional, including smoking cessation, survivorship and much more.

Assistance in Smoking Cessation

“We know that smoking is the major risk factor for lung cancer,” Dr. Lewis says. “Before cigarettes became widely marketed in the early 20th century, lung cancer accounted for only 3 percent of all cancers in the United States. Lung cancer trends follow smoking trends; for instance, if you examine the rise in male smoking after World War II and the rise of female smoking in the 1960s and 1970s, you will see that, following a latency period, lung cancer mortality has mirrored smoking trends. As men’s smoking rates have declined, their lung cancer deaths have also fallen.”

Smoking is a difficult habit to break — no more than 7 percent of attempts to quit without the use of medication succeed, while only about one-fourth of smokers who use medications to help them quit completely give up the habit. Even among those who were successful, six in 10 tried more than once before achieving lasting smoking cessation.

That’s why Orange Regional’s Lung Cancer Disease Management team offers so much support as patients seek to end their addictions, Dr. Lewis says.

“Quitting is tough,” he notes. “Our nurse navigator works closely with patients to help them stop smoking. Since we can’t counsel each patient every day, we cooperate with numerous groups to bring people the resources and daily support they need.”

Patient-centered Support

Orange Regional also assists lung cancer patients through a range of ancillary resources. These include volunteer navigators who spend time talking with and listening to patients and providing other nonmedical support, a Ride to Recovery program that offers free transportation to cancer treatments, and the Survivorship, Training and Rehabilitation (STAR) Program, which offers comprehensive rehabilitation for each patient. Programs are tailored to meet individual needs and are usually covered by insurance.

The STAR Program Certification confirms that Orange Regional has a proven, systematic method of rehabilitating each patient, from both the difficulties of cancer and the side effects that may come with treatment. Evidence-based rehabilitation programs help patients enter the survivorship phase able to resume activities of daily living with a high level of functionality.

Multidisciplinary Cancer Treatment Team

A multidisciplinary team of professionals collaborates to provide individualized care for lung cancer patients receiving services at Orange Regional Medical Center. The team includes medical oncologists, pathologists, psychiatrists, pulmonologists, radiation oncologists, respiratory therapists, nutritionists, social workers and specialized cancer nurses. Members of the team meet regularly in a tumor board to discuss each patient’s case and identify the best strategies for medical and ancillary care. During surgical procedures, Dr. Lewis is usually assisted by a skilled physician assistant. Orange Regional follows established, evidence-based protocols for treating lung cancer, as well as offering clinical trials for patients whose cancer does not respond to standard therapy. Cancers treated include small-cell and non-small-cell carcinomas, as well as carcinoid tumors and mesothelioma.

The lung cancer management program at Orange Regional Medical Center offers a full range of treatment options.

Dr. Lewis says, “At certain stages, patients may receive surgery, chemotherapy, radiation therapy or some combination of those.” He notes that the fashion in which surgeries are performed has changed significantly.

Minimally Invasive Surgical Options

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Dr. Lewis and Garcia review a patient’s chest CT scan for preoperative planning.

Orange Regional provides minimally invasive video-assisted thoracic surgery (VATS). This approach offers benefits similar to those of traditional, open surgery with greatly reduced postoperative pain, scarring and recovery times.

“Making only three small incisions, we insert a video scope to guide the procedure,” Dr. Lewis says. “The largest incision is typically two inches long at most. We are able to perform most lung cancer resections through VATS, resulting in improved outcomes in terms of less pain, quicker lifestyle recovery and minimal scarring.”

Additionally, radiation oncologists and medical oncologists contribute to patients’ ongoing care. Even non-resectable tumors can be treated with chemotherapy and radiation therapy, Dr. Lewis says.

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Dr. Lewis and surgical nurse make postoperative surgical rounds.

“For patients who have late-stage lung cancer or non-resectable tumors, medical and radiation oncologists have modalities that don’t include surgery yet can treat tumors with varying degrees of effectiveness,” he says. “Some patients can be cured in the late stages with radiation and chemotherapy alone.”

Of course, late-stage cures are far rarer than successful treatments for patients diagnosed with early-stage lung cancer — another reason screening is important, Dr. Lewis says. However, late-stage patients can find many sources of hope at Orange Regional. The medical center has recently developed a robust palliative care team. Additionally, clinical trials offer patients a chance to benefit from newer therapies and contribute to the quest to cure lung cancer.

Options for Clinical Trials

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Dr. Lewis discusses marketing strategies for the Lung Tumor program with a colleague.

“We offer clinical trials because we believe these trials are essential as we continue to decrease the number of lung cancer deaths,” Dr. Lewis says. “All of our lung cancer clinical trials here at Orange Regional are for patients with advanced-stage disease.”

Study topics include experimental chemotherapy, medical adjuvants to chemotherapy, cancer enzyme testing and maintenance therapy after standard chemotherapy. A clinical research coordinator oversees trials and responds to patient questions.

“Typically, patients would have to travel to major cancer centers or academic institutions to access these trials,” Dr. Lewis says. “We offer patients with advanced cancer the chance to participate in groundbreaking trials here in our community.”

Whether patients are coming for a CT screening or attending a support group for long-term cancer survivors, those who visit Orange Regional will find themselves surrounded by a welcoming team.

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The Orange Regional Thoracic Surgery team

“At Orange Regional, we strive to provide a high level of care in all aspects,” Dr. Lewis says. “We want to give patients the same state-of-the-art care they would receive at major academic institutions. Our goal is to provide advanced medical care in the community, close to where patients live and work. This is a multidisciplinary effort involving a team of physicians specialized in lung cancer coming together for our patients.”

To refer a patient for a lung cancer screening, visit