Smilow Shares Primary Care: Lung Cancer

Transcript

• 00:00Let's get started because we
• 00:02have a lot to go through tonight.
• 00:05Welcome to smaller shares with
• 00:07primary care. Let's see, Renee,
• 00:10do we have the? Slides up.
• 00:17My name is, my name is Anne Chang.
• 00:19I'm a medical oncologist and chief
• 00:22integration Officer, Deputy CMO for SMILO,
• 00:24and this is a series that Karen Brown.
• 00:30And I put together a really focusing on
• 00:36primary care and relationship with smile.
• 00:39Can you advance to the next slide?
• 00:44Thanks. So it's a monthly lecture series
• 00:47that really focuses on primary care
• 00:49perspectives on cancer and hematology
• 00:52and this is really done with Karen
• 00:55together the faculty panel has primary
• 00:57care docs as well as smaller physicians
• 00:59and we we'd like to focus on a a
• 01:02particular region even though our our
• 01:05audiences from across the entire network.
• 01:07So today we're doing lung cancer
• 01:09for lung Cancer Awareness Week and
• 01:12really in Bridgeport and this is.
• 01:14Always the first Tuesday of the month
• 01:16from 5:00 to 6:00 PM and you know,
• 01:19this is really to there's so much going
• 01:22on in cancer and hematology right now.
• 01:25That that we felt that this is
• 01:27really important to share with,
• 01:28with primary care and specifically
• 01:31around questions that you have.
• 01:33Karen, do you want to add anything?
• 01:36Just echo, you're welcome.
• 01:37And we have an expression at NE
• 01:40Medical Group in primary care as we
• 01:43keep trying to work smarter not harder
• 01:46and and that's because we we have a
• 01:48lot to do in the primary Care World.
• 01:50And so sessions like this are
• 01:54invaluable to help kind of guide us
• 01:56in in the collaborative approach to
• 01:59new malignancy and making sure our
• 02:01patients get the care they need.
• 02:02So I'm, I'm thrilled that we're
• 02:04getting this off the ground.
• 02:07Fantastic. So it's very case based.
• 02:11We actually have three cases tonight.
• 02:13I'm going to talk through aspects
• 02:15of screening and locally advanced
• 02:17disease and metastatic disease.
• 02:19We do want to have some some
• 02:21time at the end for open Q&A.
• 02:24So if you have and we encourage you
• 02:26to submit your questions either
• 02:28through the chat you can do that
• 02:31during the the presentation or you
• 02:33can wait till the end or or unmute
• 02:35and and well actually I think I
• 02:37guess it goes through the chat.
• 02:38So, so with the with no further ado,
• 02:43let's get going and introduce our panelists.
• 02:46Karen, do you want to start?
• 02:48Sure. So I'd like to introduce
• 02:51Doctor Steve Benaderet,
• 02:53a Michigan native family
• 02:56medicine specialist in Westport.
• 02:59Under his leadership,
• 03:00patient care and quality scores have
• 03:02been amongst the highest in any MG
• 03:05and he is now the anchor of a new
• 03:08and expanded primary care office.
• 03:09He graduated from New York Medical
• 03:11College and completed his family
• 03:13practice residency at Stanford Hospital,
• 03:15where he also served as chief resident.
• 03:17He has 12 years of EMG practice
• 03:20affiliation and is the Regional Medical
• 03:23director for the Fair Fairfield area.
• 03:25I'd also like to introduce
• 03:27Doctor Daniel Rudolph.
• 03:29Dan is a pulmonologist and Trumbull
• 03:31and Fairfield and has over 40 years
• 03:34of experience in the field and over
• 03:3635 years of affiliation with the
• 03:39Bridgeport Hospital pulmonary group.
• 03:41He has extensive experience in sleep apnea.
• 03:46Pulmonary vascular conditions and
• 03:47a very special interest in lung
• 03:50cancer and developed the bronchoscope
• 03:52program at Bridgeport Hospital to
• 03:54include endobronchial ultrasound
• 03:55for staging lung malignancy,
• 03:58and that's one of the reasons he's here.
• 04:00He graduated from New York
• 04:02University in 1982,
• 04:03attended medical school at NYU,
• 04:05and completed his pulmonary fellowship
• 04:07at Albert Einstein.
• 04:08He has offices in Fairfield and
• 04:10Trumbull and is accepting new patients
• 04:12highly regarded in the community.
• 04:17Fantastic. Thank you.
• 04:18I'll introduce Doctor Sarah Goldberg.
• 04:21She got her MD from Mount Sinai
• 04:23and trained in internal medicine
• 04:25at MGH in Boston and completed
• 04:28her fellowship at Dana Farber.
• 04:30She's an associate professor in medicine,
• 04:33the Division division chief
• 04:35for Thoracic Oncology,
• 04:36the research director for the Center of
• 04:39Thoracic Cancers and Associate director
• 04:41of our Hemlock Fellowship program.
• 04:43Her research interests include
• 04:45personalized medicine immunotherapy.
• 04:47A non small cell lung cancer
• 04:48and a focus on EGFR,
• 04:50mutant lung cancer and brain metastases.
• 04:53Doctor Mike Conundrum is a medical
• 04:56oncologist for Smilow Cancer hospital.
• 04:59His primary focus is lung cancer.
• 05:01He also sees breast cancer.
• 05:04He trained it.
• 05:05He went to Med school,
• 05:07also at Mount Sinai,
• 05:08and did his residency at Brown
• 05:10and his fellowship here at Yale.
• 05:13He participates in the disease
• 05:15affiliated research teams.
• 05:17And thoracic oncology and breast cancer.
• 05:20He has been included on Connecticut
• 05:22magazines Top Doc list for several
• 05:24years and his focus is patient centered,
• 05:27compassionate care and and then
• 05:30finally Doctor Mays Benny.
• 05:33Mays is did his thoracic fellowship
• 05:35at the Brigham and Women's Hospital
• 05:38completed his training as in 2016
• 05:41he's the site director for thoracic
• 05:43surgery at Bridgeport Hospital
• 05:45and Park Ave Medical Center.
• 05:47He has over 24 years of army experience,
• 05:50both active and reserve time,
• 05:52and he's been the leader for
• 05:55lung cancer screening.
• 05:57And and Smilo and Bridgeport in the
• 06:00Bridgeport area and promoting military
• 06:03civilian medical affiliations.
• 06:05Welcome to our very distinguished
• 06:08panel tonight. So fantastic.
• 06:10I'm going to turn it over now
• 06:14to Steve and and who's going to
• 06:17lead us off with case number one.
• 06:21Great. Thank you so much and thank
• 06:22you for the lovely introduction.
• 06:23It is overstated.
• 06:26So as a primary care doc like you all,
• 06:30we run into these things
• 06:32all the time that we.
• 06:35Do one test and find out something else.
• 06:37So the first case is sort
• 06:38of based off of that.
• 06:39You have your 63 year old male patient
• 06:42who's returning for his annual exam.
• 06:44He's been your patient for many years,
• 06:47struggles with weight BMI 32.3 has lacked
• 06:51the motivation to exercise over the years,
• 06:53but he's generally healthy and
• 06:55socially drinks, has never smoked,
• 06:57has no real significant past medical,
• 07:00surgical or family history.
• 07:02Currently is not taking any medicines,
• 07:04doesn't take any supplements
• 07:06during your exam.
• 07:07You know, no complaints.
• 07:09He states he's doing great.
• 07:10He's looking forward to his
• 07:13upcoming upcoming retirement.
• 07:14However,
• 07:14in the past few years has LDL
• 07:17has continued to change and he
• 07:19started off in the low 100 years
• 07:21ago and it's been creeping,
• 07:22creeping, creeping.
• 07:24Now his LDL 158.
• 07:26So you appropriately order
• 07:28a coronary calcium score,
• 07:30which the great news is you get
• 07:32a coronary calcium score of 0.
• 07:34However incidentally found is,
• 07:36and we're going to go over that
• 07:39case now with Doctor.
• 07:43Thank you, Steve.
• 07:48Thank you, Steve.
• 07:50This incidental pulmonary nodule
• 07:53problem is challenging for both
• 07:56primary care and for pulmonologists
• 07:59because they're so common.
• 08:01The FLEISCHNER criteria,
• 08:03which is what radiologists
• 08:04based some of their reading on,
• 08:06was developed to evaluate
• 08:08the risk of malignancy.
• 08:11So when we have cases like this,
• 08:13what the radiologists don't
• 08:15appreciate and what we have to
• 08:17appreciate as primary care providers
• 08:19and sub specialists who deal with
• 08:21this is the risk stratification
• 08:23for these pulmonary nodules.
• 08:25That's part of the FLEYSHER criteria,
• 08:28although the radiologist darn including it.
• 08:31But when you look at the fleischner
• 08:33criteria on the slide that I brought,
• 08:35you can see that it is complicated.
• 08:39Algorithms, but if you simplify it,
• 08:43there is a low risk and high risk category.
• 08:48Which all patients should be evaluated for.
• 08:52And as you probably know,
• 08:53risk includes smoking,
• 08:55chronic lung disease,
• 08:57occupational exposure to pulmonary
• 08:59toxins and family history of malignancy
• 09:02or history of other malignancy.
• 09:04So when we look at these incidental nodules,
• 09:07not only do we have to look at the size,
• 09:10the shape, the morphology, but also have to.
• 09:14Understand the risk profile of the
• 09:18patients that are being imaged.
• 09:21Now,
• 09:21one thing about coronary screening that
• 09:23you probably know is doesn't have a complete.
• 09:26Chest image.
• 09:27It includes only about 2/3 of the lung image,
• 09:30so it's an incomplete image,
• 09:33and it very commonly can have associated
• 09:38incidental nodules that have to be evaluated.
• 09:42So as a pulmonologist,
• 09:43when I deal with this,
• 09:44the first thing I do is,
• 09:46as I mentioned,
• 09:47risk stratify the patient and
• 09:50then look at the nodule size,
• 09:53because size greater than 6 millimeters,
• 09:56if we simplify the algorithm,
• 09:58is the most important distinguishing factor.
• 10:02Larger than 6 millimeter nodules.
• 10:04Need more immediate follow-up.
• 10:08Smaller nodules don't
• 10:10necessarily need follow-up,
• 10:12and unfortunately all the coronary
• 10:15screening of nodule cases very
• 10:17often need a complete CT image.
• 10:20So the question and the
• 10:21challenge is when do you do?
• 10:26Tools which are two,
• 10:27three or 4 millimeters are
• 10:30felt to be insignificant if
• 10:32the risk stratification is low.
• 10:35So unfortunately these are more
• 10:37complicated than a simple size and
• 10:41recommendation from a radiologist.
• 10:44They really have to be looked at
• 10:46carefully for risk size,
• 10:47shape, and sometimes require
• 10:51more immediate follow-up.
• 10:54Now classically the recommendations
• 10:56are six month follow-ups,
• 10:58but sometimes if the risk profile is
• 11:01is significant and the size of the
• 11:04nodule is greater than 6 millimeters.
• 11:06We actually look at a more
• 11:09immediate 3 month follow-up.
• 11:11But the biggest disadvantage is
• 11:12that we don't have a full CT image
• 11:15when we're doing these scans.
• 11:16If you look at the next slide,
• 11:18I try to simplify the FLEISCHNER
• 11:21criteria for primary care doctors.
• 11:25The size of 6 millimeters is
• 11:27a real important issue.
• 11:28Greater than 6 millimeters,
• 11:30the risk of malignancy is much greater.
• 11:32The type of nodule is important too.
• 11:34The ground glass nodules that
• 11:37are reported are less risk for
• 11:40malignant change than solid.
• 11:42Nodules and there's an assortment
• 11:43of other findings that sometimes are
• 11:46included in these reports including
• 11:48calcification would suggest it's a
• 11:50granuloma benign tree bud abnormalities
• 11:52would suggest chronic lung disease.
• 11:54So there's a lot of factors that
• 11:56could be taken into account when one
• 11:59makes a decision about follow up.
• 12:02The risk profile, if I can just emphasize,
• 12:05is really important and that's where
• 12:08the radiologists don't have information.
• 12:10You have to really look at
• 12:12each individual case.
• 12:13This is a patient with a
• 12:15coexisting malignancy,
• 12:16chronic lung disease,
• 12:19exposure to pulmonary toxins.
• 12:22That group has to have more immediate follow
• 12:25up and a full CT image within three months.
• 12:28Others very often that are low risk,
• 12:32less than 6 millimeters or
• 12:34scattered multiple nodules.
• 12:36We can do a longer interval follow-ups
• 12:40and each one of those has to be
• 12:44taken into account individually.
• 12:45Some, if they're very small,
• 12:47two or three millimeters do not need,
• 12:49if they're low risk, a full CT image.
• 12:54So those are the simple fleischner
• 12:57principles that I thought we should discuss.
• 13:02In this particular case,
• 13:03if the risk profile was low and the
• 13:07nodule was less than 6 millimeters,
• 13:10we might not have to consider
• 13:12a full CT image and follow up,
• 13:15particularly if the patient is a
• 13:17younger age group less than 50.
• 13:19If the patient's greater than
• 13:2050 and there was risk factors,
• 13:22then we'd have to do a full CT
• 13:24image within three to six months.
• 13:31We can move on to the next phase or?
• 13:35A discussion of screening CT imaging,
• 13:39Steve, if you want to go.
• 13:51Sorry about that. Stuck on mute.
• 13:54Um, so case number 2.
• 14:02So your 52 year old female patient
• 14:05returns for her annual exam.
• 14:07She's relatively new to your practice.
• 14:09She has a past medical history of
• 14:12controlled hypertension on an ARB pre
• 14:15diabetes that is currently diet controlled.
• 14:18Her family history includes
• 14:20a mother with breast cancer.
• 14:22Fortunately, your patient is up to date
• 14:23with her mammograms, which are normal.
• 14:25She rarely drinks and seems
• 14:27told to watch her sugar.
• 14:29She exercises regularly,
• 14:30but notes occasional mild dyspnea that
• 14:33she believes is from deconditioning.
• 14:36She has a history of smoking at least a pack,
• 14:38or maybe more a day through her
• 14:41college years and into her late 20s.
• 14:44She quit briefly when she decided to have.
• 14:50In the past 10 to 50 years.
• 14:52Uh, you do the math. She's a smoker.
• 14:55She's got a 20 pack year history
• 14:58and she is between the ages of say,
• 15:0150 and 80. So you order an initial
• 15:04lung cancer screening test.
• 15:06And the results come back as follows.
• 15:18So let me just jump in
• 15:21about lung cancer screening.
• 15:23There's a another radiologic classification
• 15:25we use called lung rats for evaluating.
• 15:30Pulmonary nodules in this high risk group,
• 15:34it's categorized from one to five.
• 15:37This group includes 20 pack year
• 15:40smokers who are over the age of 50.
• 15:44Of that group, again,
• 15:45I'm going to simplify this.
• 15:47If the nodule is greater than 6 millimeters,
• 15:50we have a much higher concern about
• 15:54malignant potential and three months
• 15:57to six month follow-up is recommended.
• 16:00Above 8 millimeters there is a great
• 16:03concern about malignancy and then
• 16:05further work up with pet imaging
• 16:08and possible biopsy is recommended.
• 16:10Greater than 15 millimeters,
• 16:12which is the highest classification
• 16:14usually is malignant and
• 16:16requires immediate attention.
• 16:17So the screening process a lot similar
• 16:21to incidentals is based on size, shape.
• 16:24However, this group of patients
• 16:26have high risk categories,
• 16:28so they have more immediate.
• 16:30Need for a follow up and all of
• 16:32them need yearly screening scans,
• 16:35low dose screening scans.
• 16:38If I might make a pitch for
• 16:40our pulmonary nodule clinic,
• 16:41because after reviewing all
• 16:43this literature and seeing the
• 16:45challenges of primary care doctors
• 16:47face in dealing with these things,
• 16:49we developed a pulmonary nodule clinic
• 16:52at Smilow and Trumbull to try to deal
• 16:56with the follow up communication
• 16:59and evaluation of these nodules.
• 17:02We have a multidisciplinary clinic.
• 17:06Megan and I karini is the APR.
• 17:09And who's developed it?
• 17:11Who's leading some of the development
• 17:15of this community development?
• 17:18And many Mays,
• 17:20myself and a radiologist at Yale
• 17:22named Doctor Gange is involved in
• 17:25reading all of the scans for us.
• 17:28She's a chest radiologist who's
• 17:31assisted us and allowed us to.
• 17:35Improve the excellence of this
• 17:37clinic so we can give the best care.
• 17:40If you feel that you need help,
• 17:44we have epic link that you can link
• 17:47into at the Montgomery nodule clinic
• 17:49and we will immediately contact the
• 17:52patient and evaluate the patient.
• 17:54Communicate back to the primary
• 17:57care providers and offer excellent
• 18:00care evaluation.
• 18:01If need further staging,
• 18:03we refer directly into.
• 18:06Doctor Macey's office Doctor Mike
• 18:08Cohen Durham also is involved
• 18:11if we have any problems.
• 18:12So this is a great opportunity
• 18:15for those who want to access some
• 18:18specialty help in this expanding
• 18:20group of patients that have incidental
• 18:23nodules or abnormalities on screening.
• 18:35I think we can move on to the third case
• 18:37actually. So Vinny,
• 18:39do you want to Doctor Mays,
• 18:42do you want to talk a little bit
• 18:44about that because you were trying
• 18:45to put some things in the chat,
• 18:46but that doesn't go to
• 18:47all the people who are
• 18:48attending. Can you
• 18:49go, can you go to the next slide, please?
• 18:53But these are the names of the folks that,
• 18:54Umm, you know, in the Bridgeport and
• 18:56Park Ave area that are part of the
• 18:59multidisciplinary team for whether it's
• 19:01lung cancer screening or pulmonary nodules.
• 19:03You know, there's a,
• 19:05there's an effort across Milo,
• 19:07you know, at Greenwich, at L&M,
• 19:10at York Street, you know,
• 19:12to basically these, these.
• 19:15Capabilities, whether it's lung cancer
• 19:17screening or the nodule clinic or or
• 19:20throughout the Smilo Cares network.
• 19:21And there's currently, you know,
• 19:23an effort over the past about
• 19:2518 months to you know,
• 19:26standardize the processes at
• 19:29each at each campus.
• 19:31What I put in the chat was just for
• 19:34folks that do get lung cancer screening
• 19:37or have images on the third Friday
• 19:40of each month from 12:30 to 1:00,
• 19:44all of these folks here we review.
• 19:46All of the CAT scans over the past 30
• 19:48days for a quality control perspective
• 19:50and also any that you might want
• 19:52to be reviewed to look at whether
• 19:54it's your patients or a patient.
• 19:56You ordered a scan on their images to,
• 20:00you know,
• 20:00kind of review and see if all the
• 20:02management's been appropriate.
• 20:03It's also CME event and opportunity
• 20:05over lunch if you're interested.
• 20:07Again, it's the third.
• 20:09Friday of each month from 12:30
• 20:11to 1 via Zoom.
• 20:12Like we review images and kind
• 20:15of talk about them.
• 20:17Thank you.
• 20:24And now we're going to transition.
• 20:26You know we talked about mostly
• 20:28the first two cases where
• 20:30patients with without symptoms,
• 20:31you know it was an incidental
• 20:34finding or lung cancer screening.
• 20:36Historically as patients
• 20:37that don't have symptoms,
• 20:39doctor Conarium is going to
• 20:41talk about this pet scan in
• 20:43particular was a patient that
• 20:45presented with a with a cough and.
• 20:48Gotta work up.
• 20:49That wound up leading to the
• 20:51PET scan that you see here.
• 20:54Hi, everybody. This is Michael.
• 20:56When you're ramp,
• 20:57as I'm sure you've all seen in this
• 21:00probably occurs as frequently as with
• 21:03the cardiac scans and screening scans.
• 21:06Oftentimes you'll have a patient who
• 21:08presents with a persistent cough that
• 21:10are empirically treated for bronchitis
• 21:12or pneumonia that doesn't resolve at
• 21:13which point the next step is to go
• 21:16on to a CAT scan and that's exactly
• 21:18what happened with this patient and
• 21:20this led to a biopsy to the PET scan.
• 21:24I mean obviously you can see a very large
• 21:27left sided mediastinal mass with the
• 21:29tumor very close to the cardiac border
• 21:32and that was really the challenge here.
• 21:35So then I don't know if you want to
• 21:37talk a little bit about how you would
• 21:39view this from the standpoint of a
• 21:41thoracic surgeon and what your thoughts
• 21:43would be about up front surgery?
• 21:46Yeah, thanks. We can go to the next
• 21:48slide and just please I'm I I'm a
• 21:50little chat deficient here and zoom,
• 21:52but if you have any questions just throw them
• 21:55in the chat and see if we can answer them.
• 21:57And you know for the most part when we
• 22:00think about any of these patients it's
• 22:03really a multidisciplinary approach.
• 22:05You know of those patients that are operable,
• 22:07it's a multi disciplinary
• 22:09multi targeted approach.
• 22:10It's it's really each patient
• 22:12gets tailor made treatment whether
• 22:14they get neoadjuvant treatment.
• 22:16Before an operation or whether they
• 22:19get surgical treatment, you know,
• 22:21after they get chemotherapy,
• 22:23the multidisciplinary setting happens.
• 22:27Across multiple domains,
• 22:28there's a tumor board that meets Umm
• 22:31at Bridgeport Hospital the 2nd and 4th
• 22:33Wednesday where it's a group of the,
• 22:35the thoracic surgeons,
• 22:36the the Radio Board certified
• 22:38radiologist and Thoracic surgery,
• 22:40Umm, the medical oncologist,
• 22:42radiation oncologist, pulmonologist.
• 22:43We review pretty much all the,
• 22:46you know,
• 22:47new cases and complex cases to kind of,
• 22:50you know,
• 22:50come up with a treatment paradigm
• 22:52that's tailored to the patient
• 22:53that typically for these patients
• 22:55like the one that Mike presented.
• 22:58Um, you know,
• 22:59that consists at least of some sort of media,
• 23:02media style staging,
• 23:03whether it's via endobronchial ultrasound,
• 23:05which happens at Bridgeport,
• 23:08or, you know,
• 23:09I have a patient that recently got.
• 23:12Sent to me that has a PET scan similar
• 23:15to that who's going to be getting a
• 23:18mediastinoscopy just for some staging
• 23:19as well as a brain MRI and really about.
• 23:24I would say,
• 23:25you know,
• 23:25probably up front about a third
• 23:27or 2/3 we can wind up doing some
• 23:29sort of surgical management and you
• 23:31know it happens in that manner.
• 23:34And then I think Mike,
• 23:35you're going to talk about the folks
• 23:37that either aren't operable or the
• 23:38neoadjuvant or adjuvant treatment.
• 23:42Clear enough? We have the next slide.
• 23:46Um, I apologize but if to pull this up really
• 23:49close because I have this on my phone.
• 23:52But you know as Vinnie said,
• 23:55there's really not a one-size-fits-all
• 23:58for these patients and it really truly
• 24:02requires multidisciplinary evaluation.
• 24:04I think with the input both of
• 24:06the thoracic surgeon that we have,
• 24:08doctor Mason, Dr Dettelbach, Dan here,
• 24:10we will also very frequently work with
• 24:13some of the thoracic surgeons up on
• 24:16who primarily operate at a New Haven,
• 24:18but really primarily this is through
• 24:20Doctor Mace with the main issue.
• 24:23Being if this is locally advanced,
• 24:26be it stage two or stage three,
• 24:28and that is primarily dictated by
• 24:32the extent of lymph node involvement.
• 24:34Can they be offered surgery?
• 24:37Would they be better off with
• 24:39radiation based treatment?
• 24:41Are they physically able even if
• 24:43the surgery is an easy surgery?
• 24:45And also sometimes it's patient
• 24:47preference alone,
• 24:47sometimes patients have their own
• 24:50inherent biases about radiation
• 24:52versus surgery and that drives us
• 24:54and fortunately we have a lot of
• 24:56options and really the most important
• 24:59thing is you know the vast majority
• 25:02of cases of new lung cancer.
• 25:04Are not chipshot surgeries and with
• 25:07surgery alone still run a very
• 25:10high risk of recurrent disease?
• 25:15One of the options and what we
• 25:17offered the woman whose pet scan we
• 25:19just looked at was to give her up
• 25:22front chemoimmunotherapy in hopes
• 25:24that we could shrink the cancer and
• 25:26then allow her to go on to surgery.
• 25:30And actually I just went back and
• 25:32looked at the time of her surgery.
• 25:34She went from almost a 7 centimeter
• 25:37tumor to out of the 8 centimeter
• 25:39tumor bed that was removed,
• 25:41there was only 0.3 centimeters of.
• 25:44Viable tumor,
• 25:45so 92% of it was all dead necrotic tissue.
• 25:50So pretty close to a pathologic
• 25:53complete response which was seen
• 25:55in almost 1/4 of the patients
• 25:57treated on the Checkmate 816 trial.
• 26:00We don't quite yet know whether this is
• 26:03leading to increased long-term survival,
• 26:06although we have a pretty strong
• 26:08suspicion that it will be.
• 26:10Umm.
• 26:10However,
• 26:10if the patient is better off going
• 26:13to upfront surgery and there is
• 26:15always the concern that if we delay
• 26:18things with systemic therapy or the
• 26:20patient is the unfortunate patient
• 26:23who doesn't respond that we really
• 26:26want to get them to surgery quickly,
• 26:29we can simply offer a similar
• 26:32treatment backbone following surgery.
• 26:33And this is based on the empowered
• 26:3610 study which used a slightly
• 26:38different immunotherapy.
• 26:39It didn't use nivolumab, it used to.
• 26:41Azelis map,
• 26:42but really the hazard ratio in terms
• 26:45of disease free survival was about the
• 26:48same with well over a 30% improvement.
• 26:53Sort of been there.
• 26:53Anything else you want to say?
• 26:56You know, I think you know,
• 26:58clearly there's a lot of detail
• 26:59here and there's some nuances
• 27:01with regards to your patients.
• 27:02You know, one of the things I certainly want
• 27:04to talk about are are things that you know,
• 27:06you may think about hopefully they'll
• 27:07come up in the Q&A section is you know,
• 27:10access to care. You know,
• 27:11at least for you know when we look across,
• 27:14you know, Park Ave and General
• 27:16Access to care is is very good,
• 27:19at least for thoracic surgery.
• 27:20The access to care averages about
• 27:2310.7 days and for the most part it's,
• 27:26it's a lot better.
• 27:27And that there's there's a patient or
• 27:29two that occasionally just stops to you
• 27:31know not come within that week period.
• 27:33So our goal is really you know
• 27:35one was to give you you know some
• 27:37information but also you know learn
• 27:39from you with how we can serve you
• 27:42better and you know any issues that
• 27:45that we can either talk about or
• 27:47learn about from you to help make
• 27:49the patient experience better.
• 27:51You know when they learn that
• 27:52they have a lung nodule that needs
• 27:54to be evaluated which for many.
• 27:56Is unsettling or two for patients
• 27:58that have a recent biopsy where they,
• 28:01you know,
• 28:01they saw in my chart before anyone could
• 28:03reach them that they have lung cancer.
• 28:20So it looks like Doctor Chang just told me.
• 28:22So she put a slide in about next day access,
• 28:24which really I think dovetails nicely
• 28:27with what Danny just brought up.
• 28:30Can't see the actual data.
• 28:32But I do know that relatively
• 28:35recently we built into our schedules
• 28:37save times for urgent cases just
• 28:40like this where they really need to
• 28:43be seen very quickly and we could
• 28:46oftentimes see the patient either that.
• 28:51And many of us are seeing about
• 28:532 cases a week on that basis.
• 28:56And I think that really offers
• 28:58very timely expeditious therapy.
• 29:00It's a relief to the referring
• 29:02physician and most importantly,
• 29:04a real relief to the patient that they
• 29:06not only have this terrifying diagnosis,
• 29:09but at least now they are under
• 29:10the watchful eye of someone
• 29:12and they have a game plan.
• 29:25And Steve, I guess you're
• 29:26talking about Case 3?
• 29:28Yep. I think it's that we're
• 29:30going to the next one.
• 29:32This is the one that we we primary care.
• 29:35People dread is when people are
• 29:36symptomatic and not feeling well.
• 29:38You're 74 year old male patient returns
• 29:40to your office for a sick visit.
• 29:43He's been your patient for many years.
• 29:44He's very compliant with any
• 29:47recommendations and medication.
• 29:49This past medical history includes
• 29:52controlled hypertension on an ace.
• 29:55Hydrochlorothiazide and routine.
• 29:56He has controlled high cholesterol
• 29:59with statins and he successfully
• 30:01takes allopurinol for chronic gout,
• 30:03which is rarely an issue.
• 30:05His family history includes a maternal
• 30:07grandfather dying of lung cancer.
• 30:09However, he worked in the coal
• 30:11industry and it was blamed on that.
• 30:13His father passed in his 90s of old age and
• 30:16his mother died of a stroke in her age.
• 30:19He is the oldest of four siblings,
• 30:21all of which have high blood
• 30:22pressure and high cholesterol.
• 30:24One brother has survived in MI.
• 30:26He rarely drinks no more than a
• 30:28glass of wine and a family party.
• 30:30He has a very,
• 30:32very remote history of smoking
• 30:33for years in the military,
• 30:35but never that much.
• 30:36He's been in the office in
• 30:38the past for bronchitis,
• 30:40and he even had an ammonia many years ago.
• 30:43He presents today with complaints
• 30:45of some upper back pain and a
• 30:47persistent dry nagging cough that's
• 30:49been around for as he closed a while,
• 30:51which when he questioned him,
• 30:53it's been present off and on
• 30:55for six plus months.
• 30:56You decide to order a CAT scan
• 30:58of his chest and this is where
• 31:00Doctor Sarah gets him down South.
• 31:06So hi everyone. I'm Sarah Goldberg,
• 31:09a medical oncologist and at Yale.
• 31:12And it's really a pleasure to be
• 31:14here and to talk about lung cancer.
• 31:17So this is has Steve
• 31:18said this is a case that.
• 31:21You know as a medical oncologist
• 31:22I I feel like occurs all the time,
• 31:24but I think in in reality it maybe
• 31:26it's not quite as common but it
• 31:28does happen where a patient comes
• 31:29in who's extremely symptomatic,
• 31:31so a cough, severe pain,
• 31:33a lot of times more systemic
• 31:35symptoms like fatigue,
• 31:36weight loss,
• 31:37anorexia and so in this case this is
• 31:40a not exactly the same patient but
• 31:42it's a good example of something that.
• 31:45You know, the,
• 31:46the patient that was presented might
• 31:47might actually have on imaging a lot
• 31:49of times there's much more disease than
• 31:51we even would realize based on symptoms.
• 31:53And so this cat scan here
• 31:55shows multiple lung nodules,
• 31:57really innumerable nodules as well
• 31:59as adenopathy in the hilum and in the
• 32:02mediastinum and bone metastases or
• 32:04bone lesions throughout the spine.
• 32:06After we see this on a chest CT,
• 32:08we often will then get a pet CT
• 32:10that's that's typically the next
• 32:11step in in a work up for this.
• 32:13And you can see here on this pet
• 32:15scan that you see multiple FDG
• 32:17avid lung nodules as well as lymph
• 32:19nodes that are avid and also liver
• 32:21lesions and bone lesions all of
• 32:23which have FDG avidity.
• 32:24So really widespread metastatic
• 32:27disease that we can see on imaging.
• 32:32So I'm going to talk about about how we
• 32:36think about work up and treatment for
• 32:39advanced lung cancer and then we'll go
• 32:41back to the case and I'll follow up on,
• 32:43on what happened with this
• 32:45patient who's imaging we see.
• 32:47So it's actually I think pretty amazing
• 32:50how much we've learned in the last.
• 32:5315 to 20 years about the molecular
• 32:55characteristics of lung cancer and in
• 32:57this in this slide here I'm showing you
• 32:59specifically of non small cell lung cancer.
• 33:02Back in 2004 we were first starting
• 33:04to learn about the the molecular
• 33:06underpinnings of non small cell lung
• 33:08cancer specifically adenocarcinoma.
• 33:11I'm showing you there that that back
• 33:12in in that time we knew about EGFR
• 33:14mutations and care as mutations in
• 33:16lung cancer although we didn't really
• 33:18know much of what to do with it.
• 33:21Over the years and I have another
• 33:23time point of 2009,
• 33:24we started learning about more alterations
• 33:26in non small cell lung cancer.
• 33:28We learned about ALK fusions and
• 33:30B RAF mutations.
• 33:32We were starting to get more
• 33:33familiar with targeted therapies
• 33:35for these mutations which I'll
• 33:36show you more about in a minute.
• 33:38By 2014 we again learned a lot
• 33:39more we should found out about an
• 33:42alteration called Ross One and Red
• 33:43and met and we're really starting
• 33:46to become more advanced with
• 33:47our molecular profiling and DNA.
• 33:50Sequencing so that we can we can
• 33:52find more and more alterations
• 33:54in non small cell lung cancer.
• 33:55If you click again we'll show
• 33:57you where we are today.
• 33:58So this is today I I find it really
• 34:00amazing how many alterations you can
• 34:02find when you look for them in in
• 34:05specifically in lung adenocarcinoma
• 34:07as opposed to almost 20 years
• 34:09ago now where most patients had
• 34:11no known alteration because our
• 34:13sequencing wasn't wasn't so good.
• 34:15We now can find a molecular alteration
• 34:18in almost all patients with lung cancer.
• 34:21And so in the next slide,
• 34:21we'll show you why this is relevant.
• 34:23So it's relevant because now we have
• 34:26some really outstanding targeted
• 34:27therapies that we use for lung cancer.
• 34:30And so this is that same high chart
• 34:31that I just saw on the last slide,
• 34:33but attached to it are all the
• 34:35different targeted therapies that
• 34:37we have to treat lung cancer in
• 34:38this case specifically advanced
• 34:40or metastatic lung cancer.
• 34:42There's different types of drugs
• 34:43that we use for each of these
• 34:45different alterations in the kind
• 34:47of that brownish color.
• 34:48These are small molecule
• 34:49tyrosine kinase inhibitors,
• 34:50they're oral drugs.
• 34:51We have monoclonal antibodies.
• 34:53In some cases you can see that it
• 34:55listed in blue for each year some
• 34:57EGFR mutations and then kind of
• 34:59the the newest class of drugs that
• 35:01we use to target alterations in
• 35:03cancer or antibody drug conjugates.
• 35:05These are antibodies that go after
• 35:06a specific alteration in cancer
• 35:08linked to a chemotherapy is kind of
• 35:09like a smart chemo that finds the
• 35:12cancer and direct directly delivers
• 35:13the chemotherapy drug and we have
• 35:15that now for her two mutations.
• 35:17You could see many of these are
• 35:18small pieces of the pie but when you
• 35:20add them up almost 50% of patients.
• 35:22Um with lung adenocarcinoma,
• 35:24we'll have a targeted therapy that
• 35:26we could consider for use either in
• 35:29standard practice or on a clinical trial.
• 35:31And next slide,
• 35:32actually next part of this slide.
• 35:34So why is this important?
• 35:35Well, it's because it's been shown
• 35:37over the years that targeted therapy
• 35:39can improve survival sometimes
• 35:40quite significantly in patients with
• 35:42advanced non small cell lung cancer.
• 35:44So on the top right,
• 35:45I'm showing you a Kaplan Meier
• 35:47curve for this is really looking
• 35:48at multiple mutations across the
• 35:50board and patients who have a driver
• 35:52mutation are basically those that I
• 35:54listed in the pie chart there and
• 35:56they receive a targeted therapy.
• 35:57That's what TTX is.
• 35:59They have a significant improvement
• 36:00in their survival.
• 36:01Compared to patients who either don't
• 36:03have a driver alteration or even
• 36:05those who have a driver alteration
• 36:07but don't get a targeted therapy.
• 36:08And then on the bottom,
• 36:09I'm showing you one specific
• 36:11example pulling out the patients
• 36:13with EGFR mutant lung cancer.
• 36:14There have been many studies over the
• 36:16last several years looking at targeted
• 36:18therapy in this patient population.
• 36:19This is one of those trials.
• 36:21This is a trial that was published
• 36:23in New England Journal of Medicine
• 36:24a few years ago showing that our
• 36:26third generation drug OSIMERTINIB
• 36:27has a significant improvement in
• 36:29survival over or even our prior
• 36:30generation of drugs or Latin adventure.
• 36:32But I think maybe the most important
• 36:34take away here is that figure on the
• 36:36bottom right which is showing the
• 36:37overall survival for these patients.
• 36:39And you can see this this the
• 36:40follow up in this study at this
• 36:43point ends around 24 months.
• 36:44But you can see well more than half of the
• 36:47patients who received osimertinib were
• 36:49still alive 24 months and and beyond.
• 36:51And so the the prognosis for patients
• 36:54with advanced non small cell lung
• 36:56cancer has significantly improved
• 36:58because of alterations like this and
• 37:01targeted therapies like those summer.
• 37:03Next slide.
• 37:05We've also seen,
• 37:06really sorry about the formatting here.
• 37:08We've also seen significant advances
• 37:10in immune therapy for patients with
• 37:13advanced non small cell lung cancer.
• 37:14I'm just showing you a few examples here.
• 37:16There's many other ones.
• 37:17Basically every trial gets published
• 37:19in New England Journal of Medicine
• 37:21because they're all a significant
• 37:23smashing success when you compare
• 37:24immune therapy with chemotherapy.
• 37:26Overall patients do much better
• 37:28with advanced lung cancer.
• 37:29This is showing you that on the left
• 37:31with that study with pembrolizumab,
• 37:33one of our PD1 inhibitors.
• 37:34On the right, a study with atezolizumab.
• 37:36PDL one inhibitor patients do much
• 37:38better when they receive immune
• 37:39therapy compared to chemotherapy
• 37:41when they have the biomarker which
• 37:43in this case is called PDL one.
• 37:45And so with high PDL one expression,
• 37:47these patients are doing really
• 37:48well with a chemo free regimen.
• 37:50And again you can look at for
• 37:51survival several years out more than
• 37:53half of these patients are still
• 37:55alive and that is a significant
• 37:56difference than just a few years ago.
• 38:00Next slide.
• 38:01So you can kind of click through,
• 38:02there's a couple of animations here.
• 38:04So this is just really showing
• 38:05you an overview of all the,
• 38:07I think there's one more of all the
• 38:09advances that well maybe not all of them,
• 38:10but many of the advances we've
• 38:12seen from non small cell lung
• 38:14cancer in the last 20 plus years.
• 38:15First we got some better chemotherapies
• 38:17but those were never good enough.
• 38:19We then have targeted therapies
• 38:20and you can see multiple of them
• 38:22listed there and now immune therapy.
• 38:23And so we've really seen significant
• 38:25advances and so that that has has
• 38:27changed the way that we think about
• 38:29treating patients with advanced disease.
• 38:31Next slide.
• 38:33I think this is my last slide.
• 38:35So what has this done?
• 38:36Well you know the the we always
• 38:38are every year they come out with
• 38:40overall data for how we're doing and
• 38:43in mortality and other statistics
• 38:45in cancer this is looking at on
• 38:47the top left is looking at men and
• 38:50on the bottom left is is women.
• 38:52Overall in terms of mortality
• 38:54for different cancers,
• 38:55lung cancer continues to be the
• 38:57number one cause of cancer mortality
• 38:58in the US that's that red line.
• 39:00So still the the highest cause of
• 39:02cancer deaths in this country.
• 39:04And worldwide,
• 39:04but you can see and highlighted in blue,
• 39:07there's been a significant decline
• 39:08over the last several decades.
• 39:10And you can see in that table
• 39:12on the right that incidence has
• 39:14declined but mortality has declined
• 39:16even faster than incidence.
• 39:17And so why is that?
• 39:18Well, there's probably a couple of reasons.
• 39:20Reduction in smoking has
• 39:22probably improved the,
• 39:23the incidence has reduced the incidence.
• 39:25I think that's pretty clear cut,
• 39:26but I think also the improvement
• 39:28in screening has helped.
• 39:29But I guess maybe I'm partial,
• 39:30but I think in in large part it's because
• 39:32of our improvements in therapy and.
• 39:34In,
• 39:34in,
• 39:35out,
• 39:35because metastatic disease is so common in
• 39:37lung cancer, the improvements in
• 39:39immune therapy and targeted therapies
• 39:41have really changed the outlook
• 39:43for patients with advanced disease.
• 39:45Next slide. Oh, I have one more slide
• 39:47which is going back to this case.
• 39:48So this is really an amazing case because
• 39:50this patient was very symptomatic,
• 39:52had a biopsy of a liver lesion that
• 39:55showed adenocarcinoma from lung primary,
• 39:56had molecular testing that showed
• 39:58an EGFR mutation.
• 39:59That was one of those pieces of the
• 40:00pie I showed you found in about 20%
• 40:02of patients with lung adenocarcinoma
• 40:04was started on osimertinib.
• 40:06That was at a study I showed you where
• 40:08there was a benefit of osimertinib versus
• 40:11other targeted therapies and he had
• 40:13a significant improvement in in symptoms.
• 40:15Pain and cough even in just a few
• 40:17weeks and we see that quite commonly
• 40:19where even just a couple of weeks
• 40:20people start to feel better when
• 40:22they get a successful therapy.
• 40:23And then you can see on the right,
• 40:25the post treatment scans look amazing.
• 40:27So all those lung nodules are
• 40:29either gone or decreased.
• 40:30The bone lesions are better,
• 40:31the liver lesions are better.
• 40:33And this patient had an ongoing
• 40:34response still going on after two years.
• 40:37And again this is something we often
• 40:38will see in clinic where people have
• 40:40significant reductions in disease
• 40:42that can last for many years.
• 40:43It's not a curative therapy our targeted.
• 40:46Therapies and immune therapies when
• 40:47we treat advanced disease don't
• 40:49cure the disease like like binny's
• 40:50able to do when he does surgery or
• 40:52we're able to do with radiation.
• 40:53But we really can see amazing benefit
• 40:56with some of our newer treatments.
• 40:58Next slide.
• 40:59So sorry this is this went a little
• 41:01bit of out of order here but I wanted
• 41:03to just briefly mention some of the
• 41:05side effects because this is something
• 41:06I think in primary care you you'll
• 41:08you'll you either already have seen or
• 41:10you're going to start to see more often.
• 41:12Because as we see the benefit of
• 41:13so many of our treatments we're
• 41:15using them more and more.
• 41:16We use them in metastatic disease
• 41:17to start and now you heard from from
• 41:19the others about how we're using
• 41:21them in early stage disease as well.
• 41:22And so when we use immune therapies
• 41:24we're activating the immune system
• 41:26to fight the cancer but we're it's
• 41:28not specific specific.
• 41:30And so you can see immune related
• 41:32adverse events fairly commonly
• 41:33from our treatments and here's just
• 41:35a summary of all the different.
• 41:38Inflammatory conditions that we
• 41:39cause with these treatments,
• 41:40really any organ system can be involved.
• 41:43It's important to know that the
• 41:44onset can be variable.
• 41:45It could be immediate or a few
• 41:47weeks or months later,
• 41:48but it also could be months or
• 41:50years after therapy is completed.
• 41:51So absolutely something that you
• 41:53should know about when you're
• 41:54seeing patients who were treated
• 41:56with these these drugs.
• 41:57Most of the adverse events
• 41:59are treatable with steroids,
• 42:00but you know sometimes they
• 42:02require a long course.
• 42:03So something to be aware of and to to
• 42:06consider when someone presents with.
• 42:08A new symptom who's been
• 42:09treated with these drugs?
• 42:10So that's all that I had
• 42:11and happy to take questions.
• 42:23So now we are are to the question
• 42:27and answer part of our program and
• 42:31I'm glad to see that we have about.
• 42:3310 or 15 minutes left.
• 42:36Before we do that,
• 42:37I would like to ask those attending
• 42:39to make sure and complete that
• 42:41survey to receive the CME credit.
• 42:43And and we'd love to have you
• 42:46come back again in December on
• 42:48anemia and the first Tuesday in
• 42:51February on gynecologic oncology.
• 42:53So I'm going to turn it over
• 42:57to Karen to to for the Q&A.
• 43:01And so far, I'm seeing only one
• 43:04question and I know people have more.
• 43:07So please type it in.
• 43:08And while you do, I'm going to ask
• 43:12Dan actually a question to tee off.
• 43:15So we use many different radiology
• 43:18services for lung cancer screening
• 43:20and many different radiology
• 43:22services for any imaging where
• 43:25incidental nodules are found.
• 43:29And it is possible that some of
• 43:32the radiologists may give slightly
• 43:35different advice on whether it exactly
• 43:38follows Fleshner criteria or not.
• 43:40Or have you seen that?
• 43:42And how quick are you to kind
• 43:46of overrule a bottom line on a
• 43:50radiologist suggestion for the
• 43:52interval of follow-up imaging if
• 43:54it doesn't match your understanding
• 43:55based on the criteria you outlined?
• 43:59That's the great question.
• 44:02I'll first say for medical legal
• 44:04reasons it's very difficult to
• 44:07overrule a radiology recommendation,
• 44:09particularly if you decide the
• 44:12intervals should be longer.
• 44:14Most important issue is risk profiles,
• 44:17and the radiologists don't really
• 44:19have a sense of what type of
• 44:22patients they're dealing with.
• 44:23And I know that there are different
• 44:27opinions and different radiologists will
• 44:29view different imaging differently.
• 44:32So we're kind of in a situation where
• 44:36you have to seek other opinions unless
• 44:40you feel confident as a primary care
• 44:42provider that you can make that decision.
• 44:45There is a problem in our community
• 44:48with two different radiology groups.
• 44:50Sometimes the imaging from one
• 44:53service is not available to the other,
• 44:56so very often I'm digging through
• 44:58old imaging to see if there's any
• 45:01previous imaging that wasn't compared.
• 45:03Comparison to prodder.
• 45:05Imaging is also an issue if you're using
• 45:08different groups for primary care doctors,
• 45:10so my recommendation to you
• 45:12is to stick with the same.
• 45:15Radiology group as the original scan
• 45:19and I would follow the radiology
• 45:23recommendation unless you have
• 45:25a another subspecialty opinion
• 45:28that supports your decision.
• 45:31Particularly if it's to ignore
• 45:34the frequency or the immediacy
• 45:36of the follow-up imaging,
• 45:38because the last thing you want is to find
• 45:42out that there is a significant change.
• 45:46In a nodule that you have decided
• 45:49was benign at a later date.
• 45:51So I don't overrule radiologists.
• 45:53I do bring patients in to to make
• 45:56certain of the risk profile and then I.
• 46:00Very often take command of of what
• 46:03I do in terms of follow-up imaging.
• 46:08If that helps.
• 46:10Well, I think end of life and you know,
• 46:12life expectancy and informed decision
• 46:14making around that is probably something
• 46:17we could also justify you know,
• 46:20with or without specialty consultation
• 46:22with very explicit discussion that I,
• 46:24I, I do see your point.
• 46:27I think they're older folks.
• 46:28I mean I have you know 90 year old
• 46:31patients that have incidental nodules
• 46:32and at that age the real question
• 46:34they have other medical issues.
• 46:36Do you really need to go through
• 46:38the process of follow up and that's
• 46:41that's where the primary care doctor
• 46:43can be instrumental in dictating what
• 46:45the patients wishes are and needs.
• 46:47But when you're dealing with a younger
• 46:49age group it's a different challenge.
• 46:56And then Steve, you've unmuted.
• 46:58I thought maybe you had a question.
• 47:02I do have a question and I
• 47:04would say I put this up to.
• 47:06Any of the other panelists.
• 47:08So as primary care one of our
• 47:11concerns is is sometimes we just
• 47:14want to know how to get the
• 47:17attention of of the of you guys.
• 47:20So we know we can sort of
• 47:23arbitrarily enter or referral into
• 47:24epic and we click a send button.
• 47:27But sometimes you don't,
• 47:29you don't know everything and
• 47:30and sometimes we want to just
• 47:32type in the in the box that
• 47:34says help because we want to.
• 47:36Thank you.
• 47:37So how would you recommend with these,
• 47:39you know people on the on the
• 47:41line here who are primary care
• 47:43physicians that that we sort
• 47:44of say well is this the urgent,
• 47:46urgent case is this is there,
• 47:48is there certain things that
• 47:50you might want us to look at
• 47:51differently so that we can raise
• 47:53that red flag a little differently.
• 47:54You know,
• 47:55I was fortunate when he came into
• 47:56my office and literally sadly
• 47:58a week later I had somebody he
• 47:59did you know lung cancer surgery
• 48:01and I happened to seen him and
• 48:03I got his phone number and so I
• 48:04called him and he got someone in
• 48:06the next day for me and that was.
• 48:07Catholic but but not everyone on
• 48:09this has each others phone numbers.
• 48:11We don't all see each other and
• 48:13we also primary care.
• 48:14We don't want to raise the red flag
• 48:16for someone who's not a red flag,
• 48:18but we also don't want to to be
• 48:20the 10.4 days when it should
• 48:21have been the next day visit.
• 48:23Any advice you could give us on
• 48:25how to sort of let you guys know
• 48:27whether that's a a my chart message
• 48:29is that how do we let you guys
• 48:32know that we might be worried?
• 48:40Steve.
• 48:44I'll, I'll comment that you know I think.
• 48:47Any one of us I will maybe speak
• 48:50through would be happy to help
• 48:51guide you if you reach out.
• 48:53You don't need a phone number to e-mail
• 48:56us or to you know, epic message us.
• 48:58I and I often get calls or texts
• 49:01or emails from people saying,
• 49:04well this is what's going on,
• 49:05what are you suggested?
• 49:06I actually think it's helpful
• 49:08for a few reasons.
• 49:09First of all we can help get the
• 49:10person in if it really is urgent or
• 49:12even if it's not urgent but the person
• 49:13just really wants to be seen right.
• 49:15Sometimes even if it's not medically urgent,
• 49:16it's like emotionally urgent
• 49:17that the patient is seen and
• 49:19that's really important too.
• 49:20But we could also suggest some
• 49:22maybe some work up it you know to
• 49:24get things going while the while
• 49:26the appointment details are are
• 49:27processing you know we I might say
• 49:29oh you have a CAT scan that's great.
• 49:31We would also probably want a PET
• 49:32scan and a brain MRI you know
• 49:33like let's get that started. So.
• 49:35So I I think it's actually great
• 49:37to reach out to us and.
• 49:39Um, I think,
• 49:39I think any of us would be happy
• 49:41to help with initial guidance
• 49:43and and expediting appointments.
• 49:46Yeah, and I think, Umm, I asked Renee
• 49:48to put my cell phone in the chat too.
• 49:50You can call, you know, call me anytime.
• 49:54Just what Sarah said is sometimes
• 49:56that quick phone call we can say,
• 49:59well, I'll see them and if you're
• 50:01OK ordering a pet, we're getting
• 50:03enough a different kind of a CT.
• 50:04It helps when we see them.
• 50:06What I try and do is typically
• 50:09what happens is when you call us,
• 50:11you know, it's likely that you know,
• 50:13you're in the room with the patient and.
• 50:16Should I try and do is Umm,
• 50:18you know touch base with them
• 50:20hopefully either that night or
• 50:21the next day myself just so that
• 50:23they know that we've talked and at
• 50:25least for me you can always give
• 50:27my cell phone to the patients.
• 50:28I'm happy to have them text
• 50:29or call me directly as well.
• 50:34Great. And I am seeing right here
• 50:408 O 27344231 especially for those
• 50:43of you in the Bridgeport region.
• 50:45I think the the other thing that
• 50:48probably bears repeating again is
• 50:51access to you know the pulmonary
• 50:54nodule programs and how that
• 50:55looks in the various regions.
• 50:57It looks like Bridgeport has
• 50:59a great one built out.
• 51:00What what's the status of that
• 51:02in other regions?
• 51:03Where we have any MG and and
• 51:05other primary care clinicians.
• 51:10And do you want to take that?
• 51:13Yeah, I was trying to get the the
• 51:16so Renee actually put into the the
• 51:19question and answer and I'm not
• 51:21sure that everybody can see that.
• 51:24But that's the link to the lung
• 51:26screening that's across the network
• 51:28and it actually shows you who the
• 51:31contact person is in New Haven,
• 51:33Lynn, Tenui, Polly, Sather,
• 51:35who the contact person is in Bridgeport
• 51:39and then in Greenwich, etcetera.
• 51:41And so that's probably the best way.
• 51:44And somebody also asked for the epic link.
• 51:46And I guess, Renee,
• 51:48there's also if we go back to,
• 51:50for example, I think the the slide deck.
• 51:54Dan had provided the.
• 51:56The epic referral to pulmonary nodule clinic.
• 52:00So that
• 52:02actually bears putting up again because
• 52:04it's not intuitive when you search for it.
• 52:07You have to kind of know the name.
• 52:11So I don't know, Renee,
• 52:12you can share that again.
• 52:16Megan, I think if you
• 52:19search pulmonary nodule.
• 52:20On the Epic order platform, it'll come up.
• 52:24It says Jan was in my office with
• 52:26Megan and he actually just tried it.
• 52:28I just opened up a patient's chart and I
• 52:31typed in the word poll nodule and the that.
• 52:34It came up quite easily actually.
• 52:36So it was it was pretty similar.
• 52:39And if you keep on going, oops, go back.
• 52:45There's ambulatory.
• 52:47Referral to pulmonary nodule clinic,
• 52:49you know I think we've done a really
• 52:51great job of of creating a whole
• 52:54network for lung screening that's
• 52:55actually work that's done that's
• 52:57been headed by shavir Laurent and in
• 53:00genetics prevention and screening.
• 53:02And we have regular meetings of all
• 53:05the medical physician leaders but
• 53:08also of all the the the coordinators
• 53:10just to make sure that we're learning
• 53:12from each other and and doing things
• 53:15in a standard way across the network.
• 53:21Hopefully that answers the question.
• 53:24Yeah. No, I think we've actually
• 53:26addressed all the questions.
• 53:28Are there on Steve or anybody else?
• 53:30Do do we have any questions
• 53:32for each other or should we?
• 53:34Call it a successful program. Give everybody
• 53:39back 4 minutes.
• 53:43Yeah. So, so thanks everyone for coming.
• 53:46Again we we have anemia
• 53:48that's teed up for December.
• 53:51Please send us every send us some
• 53:53some feedback about this program.
• 53:55Again, we're really trying
• 53:58to to dial into questions and
• 54:01perspectives from primary care.
• 54:03I think the the overall
• 54:05picture for lung cancer.
• 54:07I'm also a thoracic medical
• 54:09oncologist as Sarah said and
• 54:11Mike said folks on the screen.
• 54:13Is that there really has been an
• 54:15amazing amount of research and people
• 54:17are living longer and longer for
• 54:20something that previously was really a
• 54:22terminal sentence of a year or less.
• 54:25People, not everybody,
• 54:26but there are many people who are doing
• 54:29much better and living longer life.
• 54:32So we're really excited about that.
• 54:33So thank you very much everybody
• 54:35and have a good, have a great night.
• 54:37Thank you.