In the latest installment of our occasional conversations with Fort Worth newsmakers, Dr. John Burk, a pulmonologist with Texas Health Resources, discusses why fewer people are dying of lung cancer.
This conversation has been edited for length and clarity. For a longer version, please listen to the audio file attached to this article.
Alexis Allison: Back in January, the American Cancer Society published its annual report on cancer statistics. Can you just give us an overview of what the report said, specifically about lung cancer?
Dr. John Burk: Well, the good news is the report said, people dying from lung cancer is decreasing. And part of that decrease is due to the improved survival in lung cancer patients, which is awesome news. For decades, we haven’t had very exciting news in lung cancer, but in recent years, it’s beginning to change — and we are seeing significant change in lung cancer care from the beginning to the end. Whether that’s going to be sustained, I don’t think we know. But my prediction would be, it’s going to get better and better and better. We’re in a state of change. Thank goodness.
Allison: It’s nice to hear good news in the health world these days. Can you talk to us about what has changed when it comes to lung cancer care? Why are people surviving longer?
Burk: Well, I think there are three aspects, Alexis. The greatest risk factor for lung cancer is smoking. Some 90% of the attributable risk for the cause of lung cancer is cigarette smoking. And cigarette smoking is actually down. It started decreasing a decade ago. There are some populations, part of our population, where that decrease hasn’t occurred, but generally smoking is down. With time, that will lead to a decrease in the incidence of lung cancer.
The second factor is early detection. We now have the ability for early detection in smokers at risk, ex-smokers at risk, with screening CT scans, where the dose of radiation is similar to a chest X-ray, so that it’s safe. Screened annually, early detection occurs. And with early detection, early treatment is offered. Early treatment leads to a very different outcome. If we wait for lung cancer to be symptomatic, with coughing up blood or shortness of breath or chest pain, it’s usually advanced-stage disease. If you can catch it when it’s the size of a dime as we did the other day, boy howdy, you take it out, patients go home in one or two days, and they’ve had their cancer diagnosed and treated. It’s changing the whole lung cancer journey. The outcomes already are different.
The third factor would be treatment itself. Chemotherapy has been around for years, but in the last decade, we now have immunotherapy. Immunotherapy is therapy directed about the molecular characteristics of the cancer cell itself. And because there are different cells, different individuals with cancer have different molecular types. This is matching an immuno-treatment against a specific cell type of lung cancer. Most of the immunotherapies now are infusions that may need to be given every other week or every month, but have a whole lot less side effects than chemotherapy did. Many of the immunotherapies have the same safety profile as many drugs that have minimal side effects, whereas chemotherapy, as we all recognize, certainly has some side effects for most patients most of the time. Even then, the ability to dose chemotherapy has changed over the years, and side effects have changed. So my oncologist colleagues now can talk about survival in patients that before wouldn’t be with us.
And this survival is not being confined to bed or chair, but being up, living life, doing things. It’s exciting times to be in the field dealing with lung cancer and, I’ll say for at least decades, it wasn’t so exciting. It was pretty dismal at times.
Allison: How would this person that you referenced who had lung cancer the size of a dime have been treated or approached 10 years ago?
Burk: Well, it wouldn’t have been diagnosed. It would have been an accident, an incidental diagnosis. And we couldn’t diagnose it without taking it out 10 years ago. Now we can diagnose it and know, “Oh yes, that little shadow the size of a dime is a cancer and taking it out is appropriate.” Or, “Gee, we now have high-intensity radiation that can target that lesion, sparing most of the lung and the rest of the body and have a cure rate almost as good as surgery.” So we have more choices, we have more ability to treat. It’s impressive. One of the most impressive stories was a dentist who came in on a Friday, we did the bronchoscopy, we did the surgery Friday morning. She was back in the office on Monday. Yes, it’s that sort of exciting.
Allison: Who is at risk of lung cancer?
Burk: The best way to answer that is to say, “What are the screening criteria that are agreed upon and have been issued nationally?” Last year they changed. So now, if you’re 50-80 years old; and you have a 20-pack year smoking history, meaning a pack a day for 20 years or two packs a day for 10 years or half-pack a day for 40 years; and you are actively smoking or have quit smoking within the last 15 years. You meet those criteria, screening CT is insurance-covered and it’s not expensive in the first place. They’ve gotten the price down very low. There are other risk factors that can be considered such as asbestos exposure, family history, hydrocarbon exposure. But the current criteria are 50 to 80, 20-pack year smoking, and being an active smoker or having quit within the last 15 years. That gets you a screening CT scan to be done annually so that you detect and treat early.
Allison: What could you tell someone who maybe falls into that category about what a screening CT scan involves for them?
Burk: A CT scan is a very simple test. Instead of standing up for a chest X-ray, you’re going to lay down on a table that slides into the scanner. They’ll ask you to take a deep breath and hold it for a moment. The scan itself now takes only a few seconds, and it’s done and you’re out and put your shirt on and go about your day. It’s a very short process. There are no needles, it doesn’t hurt and the results are out usually in one to two days that you can talk to your doctor about and say, “It’s normal,” or, “Oh my goodness, there’s a spot on the lung.”
Well, if we go out in the community and do CTs on everybody in north Texas, we think we’d find a spot on the lung in a whole lot of people, but only about one in 300 would turn out to be lung cancer. So we refine it by saying we want people who are smokers or recently quit in this age group that are at higher risk and do our scans in that group of patients. Just because you have a spot on the lung doesn’t mean it’s going to be a cancer. There are other steps that can be taken to say, “Is it necessary to look at?” Little spots that are more like the size of an eraser — the head of an eraser on a pencil — we watch those. May repeat that scan in six months or a year. As they get bigger, we go, “Okay, maybe we need to see if it’s metabolically active or if it’s just a scar. So we do something called a PET scan: Photon Emission Tomography. And it looks at the glucose utilization, the metabolic activity of that spot on the lung, and if it’s metabolically active, well, that makes it more suspicious. So maybe we need a biopsy. And the biopsy can be done under CT guidance from the outside or with bronchoscopy from the inside. Depends on its location, the characteristics of the patient, the other needs.
If you have a diagnosis of cancer, then we talk about treatment choices. Surgery, chemotherapy, immunotherapy, radiation therapy. Oh, and during that screening process, those people who were still smoking, we ask them about their smoking habits and their willingness to consider stopping. Because we know stopping smoking improves the quality of life, even if they have lung cancer. Studies allow me to say that people who quit smoking, even when they’re diagnosed with lung cancer, live longer, have more days out of bed, out of hospital, out of the house than those who continue to smoke.
Allison: Thank you for this, Dr. Burk. Lots of good news overall. I’m wondering if there’s anything else that you’d like to add?
Burk: Well, to those who are eligible, don’t miss the opportunity to get their screening test and consider stopping smoking. It just is so much of the cause. Don’t miss the opportunity to leave it behind. Don’t miss the opportunity to get early detection with a screening CT scan and follow through with any other recommendations that might lead to diagnosis and to treatment.
Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.
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