>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> Lung cancer is the number-one cancer killer in the U.S.

But there is hope.

New screening guidelines and innovative treatments are saving lives.

Joining us today on "Second Opinion," primary-care physician from the University of Rochester Medical Center, Dr. Lou Papa.

>> There's five big causes for lung cancer, and three of them are smoking, smoking, and smoking.

>> Immediate past chair of the U.S. Preventive Services Task Force, Dr. Alexander Krist.

>> Every year in America, 280,000 people or so are diagnosed with lung cancer.

>> Pulmonary-disease expert, Dr. Michael Nead, from the University of Rochester Medical Center.

>> Unfortunately, a lot of patients don't develop symptoms until fairly late in the disease, and that's one of the big issues with lung cancer.

>> And here to share her personal story, Cheryll Nolte.

>> I mean, I had a smoker's cough, but it wasn't different from what I had had over so many years.

>> I'm Joan Lunden, and it's all coming up on "Second Opinion."

Thank you all so much for being here.

Cheryll, I want to take you back in time a bit to 2006.

You were at a party, and one of the other guests there, who happens to be a doctor -- actually, he's one of the medical advisers on this program, Dr. Roger Oskvig -- he noticed something.

Tell us what was going on.

What did he notice?

>> He noticed that my fingers were clubbed.

And it was funny because I had noticed this for a while.

But I kind of thought it was because I had psoriasis under my fingernails.

So, I pretty much dismissed it.

My primary never noticed anything, and I used to go to him every three months for a blood-pressure check.

So, it was a little odd, but he told my daughter to tell me to go to my primary-care doctor.

And when I did, I was there earlier than usual, and, more or less, "Why are you here?"

And I put my fingers up like this, and he went, "Oh, my."

>> So, if she had come into your office, Lou, and she would have done that, and you would have seen the clubbing, what would you be thinking?

What kind of work-up?

>> I'd probably say, "Oh, my," as well.

>> Yeah.

>> What she's describing is that appearance of clubbing, which we don't see a lot, but it's where your fingernail has that normal scoop and nail to it, it looks literally like a little club.

It looks like it's getting thickened, like a club.

And there's lots of things that can be associated with it -- lots of pulmonary and cardiac diseases and other diseases that can cause that situation.

But the big concern is, you know, and one of the leading causes of it is lung cancer.

And, Cheryll, I believe, you are a smoker.

Correct?

>> Okay.

>> Right?

How much did you smoke a day at your worst and for how long?

>> At my worst, it was probably two packs a day.

>> Mm-hmm.

>> And I would say for at least 25, 30 years.

>> Yeah.

So, it's a pretty significant smoking history.

>> I mean, all told, I was smoking for 35.

>> Right.

>> Alright, so, that would be like a primary question... >> Right.

>> ...you would be going for because?

>> Because you worry about lung cancer because of the clubbing.

And I'd ask her if she's had any coughing or any shortness of breath or anything that can go along with lung cancer.

>> What other kind of tests you would do?

>> So, I would examine her because one of the things I'd want to look for is to see if her lungs sound different.

>> Okay.

>> Sometimes you may hear a vocal wheeze, or you may hear the lung sounds different on one side of it, or her heart may sound abnormal, which may suggest heart disease.

And I would start with a chest X-ray.

You know, it's a quick, easy test that would look for any abnormalities.

>> So, Cheryll, you went to the doctor.

So, what did he do?

What kind of tests were run?

>> The first thing he did was, he said he wanted to do a CT.

But then he said, "Well, with the insurance, you have to have an X-ray first" because that's the way it goes.

He asked me questions about whether or not I was having pains or anything, and I was totally asymptomatic.

I mean, I had a smoker's cough, but it wasn't different from what I had had over, you know, so many years.

I had the X-ray.

He called.

He said, "We believe it is lung cancer.

I want you to have the CT." And I was sent to a thoracic surgeon.

>> Now, in the end, in order to actually make that diagnosis, it's not made on a chest X-ray.

>> No, there's -- >> Or even necessarily just the CT scan?

>> Correct.

There's a lot of features on the CT scan that can look very, very suspicious for lung cancer and a lot of features that may not look like lung cancer, but it's not definitive.

You need tissue.

You need tissue to get a diagnosis of what you're dealing with.

>> I want to bring Dr. Nead in.

What are some of the symptoms that people would have with lung cancer, or are there necessarily symptoms?

>> So, unfortunately, a lot of patients don't develop symptoms until fairly late in the disease, and that's one of the big issues with lung cancer.

So, symptoms that will classically go with lung cancer when they start developing could be the chronic cough.

She described a smoker's cough.

So, how do you differentiate a smoker's cough from a cough that's something new and could be cancer?

You know, increasing shortness of breath.

Sometimes when you're coughing, you may cough up blood.

A new chest pain, a funny ache -- I mean, it could be honestly just about anything.

>> But when you get to having all those symptoms, it's probably a little farther along?

Is that the difficulty?

>> It is.

So, unfortunately, once you get to that stage where you're having symptoms, you've often gotten to the point where you've gotten advanced disease, when you're showing up at your doctor's.

>> Lou, what are the main causes?

>> So, I always, when I educate people about lung cancer, I say there's five big causes for lung cancer, and three of them are smoking, smoking, and smoking.

>> Yeah.

>> So, smoking is far and away the biggest cause.

And there are other things.

There's environmental things like radon, and if you're exposed to older means of radiation, asbestos, and some other environmental agents that are related to, but smoking far and away wins that race.

>> Well, and these days, I have to ask, what about vaping?

>> So, vaping is a great question.

You know, vaping hasn't been around enough to know if it increases the risk, because, remember, the majority of people that are vaping, quite honestly, that are being targeted -- right?

-- with bubblegum-flavored and cherry-berry -- it's not for us -- are young individuals.

So, we have to wait and see.

>> So, it's not people who said, "I don't want to smoke anymore because of the damage it's doing to me.

I'll do the vaping."

>> Right.

>> It's new targeted people who are vaping, and it can be any number of things that are in that, correct?

>> Right.

And we do see damage from the vaping, and the concern is, as we look down the road, these individuals that have been vaping for as long as someone like Cheryll has been smoking, that you'll see that.

You know, burning things and inhaling things are not healthy, regardless of what it is.

>> So, that obviously includes, just to say, cigars... >> Correct.

>> ...pipes, anything where you're... >> Right.

Any combustible you're inhaling puts you at risk.

>> So, Dr. Krist, let me bring you in here.

How many people are diagnosed with lung cancer each year, and is it a fair question to say how deadly is it?

>> Oh, yeah, those are great questions.

So, every year in America, 280,000 people or so are diagnosed with lung cancer.

>> Wow.

>> And I think what's really important to know is that 136,000 men and women die every year from lung cancer.

And that makes lung cancer the number-one cancer killer of men and women in America.

It's more -- collectively, lung cancer kills more people than colon, breast, and prostate cancer all combined.

So, it's a devastating disease and something that we need to do something about.

>> Dr. Nead, if a person doesn't have symptoms -- as you say, it's quite often that they don't -- then how do you get a diagnosis early enough in order to have a good prognosis?

>> Yeah, Joan, that's a great question.

So, screening, right?

So, we're very good at screening for colon cancer.

We're very good at screening for breast cancer.

We have screening for lung cancer, but we're not sort of doing that as much as we should be at this point.

>> We actually have Dr. Krist here... >> Yeah.

>> ...because, Dr. Krist, you are on the U.S. Preventive Services Task Force.

And that's the task force that released some new screening guidelines in early 2021.

And that's the first time those guidelines have changed, I believe, since, like, 2013.

So, tell us about how -- how did it change?

>> Yeah, that's correct.

So, actually, the U.S. Preventive Services Task Force started recommending screening for lung cancer with a low-dose CT in 2013.

And 2020 was an update.

And the change is that we started recommending screening at a younger age in a lower number of pack years for people to be screened.

So, the way the guideline works is that we're recommending that anyone age 50 to 80 who has a 20-pack-year history of smoking, who currently smokes, or quit smoking within the past 15 years and is healthy enough to undergo treatment and diagnosis should talk with their doctor and consider being screened for lung cancer with a low-dose CT. >> So, let's just talk about what you mean by "20 pack year."

>> Yes.

Yeah, so a pack year, it's an estimation of how many packs of cigarettes per day a person smoked on average for how many years.

It can be difficult to calculate, but we heard Cheryll say that she smoked for 35-some years and that she smoked somewhere between one and two packs per day.

So, you know, that would roughly be a pack and a half a day for 35 years.

So, 50, 60 pack years -- that's how that would be calculated.

>> So, this is a pretty significant change, going from 30 pack years to 20 pack years.

That means you're gonna be screening a lot more people.

And you went from 55 down to 50?

>> That's correct, yes.

Basically, there are 14 million Americans who are eligible for lung-cancer screening.

And as Dr. Nead was saying, we don't do very well with this.

So, really, only about 15% to 20% of people who should be screened have been screened.

If you compare that with colon cancer, as a nation we're at 60%, and breast and cervical cancer is more like 70% to 80%.

So, we have a long way to go to try and improve our screening for lung cancer.

>> So, a couple of things I noticed, though, that really kind of stood out to me.

"Despite smoking less, there is evidence that black adults who smoke are at higher risk for lung cancer than white adults."

Like, what accounts for that?

>> Well, we don't know exactly what accounts for that.

Some of that has to do with the exposures to cigarettes.

As Dr. Papa was talking about, it can be related to the environment, family history, lung disease, other factors that can affect things.

We regularly see inequities in the rates at which people get different conditions and then the outcomes they have.

And commonly it is more often that black people have worse outcomes.

So, that inequity is something that we look very closely at.

But one of the good things is that by lowering the age in the pack years, we actually increase the number of black men and Hispanic individuals who would be eligible for screening by 107% and 112%.

So, that goes a little ways towards addressing that inequity.

We also called for more evidence, and we called for action to try and address this, because I think there's a number of factors we need to be thinking about to try and improve outcomes for black people and Hispanic people and women, who all get lung cancer at lower pack years and a younger age.

>> Lou, when you heard these, what was your reaction when you saw -- it was a pretty significant change in guidelines.

It's going to, like, encompass a lot more people.

And then, by the way, how do you try to transmit that, translate that to your patients?

>> Right.

So, it's always good to have something where you can pick up a disease earlier, and, getting to Dr. Krist's point, pick it up earlier, make a difference, that you pick it up earlier.

We know that from the data that's out there.

And the other part of it is, like you said, operationally, how do you do that?

You know, not all smokers are honest with how much they're smoking.

It also needs to be built into what we're doing.

You know, as primary-care doctors, there's a lot of balls we're juggling in the air at the same time.

So, in our electronic record, we now have, just within the last year, in our health maintenance, a red light that goes off that says, "This person is a candidate for lung-cancer screening..." >> Really?

>> "...and they haven't been screened."

>> Is that part of what that's based on, though, if they've told you that they're smoking... >> Exactly.

>> ...and how much they're smoking?

Because people, they don't want to look bad in front of you.

>> Exactly.

And, fortunately, the younger they are, the less likely they are to share it.

The older they are, the more likely they are because they've been with you for a while, and they can feel comfortable sharing that information.

The other plus of it is yes, you're picking up cancer earlier, which is great.

But I got them.

I got them in the office again, and -- >> To tell them.

>> To tell them that, "See?

This is real.

We're actually screening for cancer."

>> Yeah.

>> So, this is not like, "I'm fine.

I'm not having any symptoms.

I'm good, right?"

"No, we actually have to look.

That's how much at risk you are, and this is another opportunity where I've got you, and we need to talk about techniques to quit smoking, because there's huge risk to you."

And I should say that's part of the guidelines are a meaningful conversation about your smoking, if you're still smoking.

>> And then once it's caught, of course, there's treatment.

So, Cheryll, what treatment were you offered?

You had IB, Stage IB?

>> That's what I was originally diagnosed at, and that was after my upper-right lobectomy.

I had to go back for follow-up CTs, and it lit up like a Christmas tree.

And they wound up -- he said, "I need to do a biopsy."

Wound up getting restaged as Stage III.

I went on daily radiation treatments, and I was on weekly Carbo/Taxol.

>> Alright, so, you were taking chemo when you went back, and it came back again, both radiation and chemo.

>> Chemo and radiation, yes.

>> This was in 2006, Dr. Nead.

How have treatments changed since then?

>> That's a great question.

So, treatments have changed dramatically, and I would say from the beginning, from when she was first diagnosed, all the way through to treatment now, I think things have changed dramatically.

So, at this point, when she first would have presented, after that CT scan, she probably would have had a PET scan... >> Right then.

>> ...mediastinal staging at that point, maybe even noninvasively with bronchoscopy just to make sure that everything was clean.

And then, after that we're collecting tissue, and we're looking for molecular markers to help guide therapy.

So, we no longer just use -- and I'm not a medical oncologist.

I'm a pulmonologist.

But my colleagues no longer administer just straight chemo.

Now we're looking for targetable mutations.

You know, is there an EGFR mutation in an adenocarcinoma that we can target specifically for this patient?

You know, are there immune-checkpoint inhibitors that we can give somebody?

>> Which is the exact cancer that I had.

>> Yeah, see?

So, now -- >> That's the cancer that I had.

But they didn't have all of this back then.

>> Yeah.

>> Right.

>> It was just boom.

You went chemo, radiation.

>> So, I mean, look.

I had triple-negative breast cancer seven years ago.

There are treatments now that didn't exist... >> Right.

>> ...when I was diagnosed.

So, but these are amazing.

These are also kind of, as I'm listening, screenings that you have available to you now.

They're almost like screenings so you can decide which way to go.

Right, doctor?

>> You mean as far as with the therapy.

>> Yeah.

>> Yeah, absolutely.

So, you know, when we go in to do a biopsy now, if we're doing a relatively noninvasive approach with an endobronchologist on camera, it's not just, "Did we make a diagnosis?

It's, "Did we get enough tissue so that the pathologist can run their gene arrays and do all the stains they need to so we can offer the patient the best therapy possible?"

>> Genetic fingerprint.

>> Genetic fingerprint.

>> Genetic fingerprint.

>> Which can tell you so much these days and which can tell you, doctor, what treatments to go with.

>> Exciting.

>> Absolutely.

>> I mean, this is what -- you get to, what, personalize treatment?

Lou, what do you tell one of your patients that comes in, and you can lay all this out, and they just feel that they've smoked for so long, like, what the heck good is it gonna do to stop now?

>> So, one, we talk about screening.

Two, I tell them, "There hasn't been a single study that shows that it's ever too late," right?

A recent study came out that showed that if you had Stage IV lung cancer, and you stopped smoking versus you continued smoking -- if you continued smoking, you died faster.

It's never too late to quit smoking.

And, you know, we're talking about lung cancer, but, remember, smoking, you know, is an equal-opportunity carcinogen.

>> Destroyer, yeah.

>> There's multiple cancers that are associated with it, not to mention heart disease and stroke.

>> Mm-hmm.

>> So, it is probably the single-most critical lifestyle intervention you can make to improve your life expectancy and improve your well-being -- never too late.

>> Absolutely.

>> And, Joan, I'll add -- you know, the task force has a recommendation for clinicians to screen and counsel patients about smoking cessation.

And then, you know, when I'm seeing patients, another thing that I'll often say is the average person who quits smoking has tried seven times before.

So, a lot of times, people come in, and they say, "Well, I've tried, and it didn't work," and they just give up on it.

And they should feel reassured that just because it didn't work before, it doesn't mean that they can't quit now.

>> Right.

>> You know, Dr. Krist, when you make these recommendations, you've looked at lots and lots of statistics.

What do those statistics tell you about racial disparities in lung cancer, both the screening, the diagnosis, and the treatment?

>> The task force, as part of its mission, really has addressing health equity, and we always start each recommendation with looking for the people who are most likely to get and suffer from conditions.

And we always look for evidence to try and find are there things we should do different?

And, recently, we've started to call out that this is evidence of how systemic racism and structural racism impacts health in communities, and we're trying to look, as we look at these different preventive services, for strategies and techniques to try and get better health equity.

>> Well, if the statistics are there, the evidence is there, might there be some merit in making different recommendations for some of the groups that are at higher risk?

>> That was actually one of the things we looked at.

So, one of the steps with the evidence is we look at the primary studies -- the NLST trial and the NELSON trial.

That didn't give us any data that doing something different would make a different outcome, but we also did modeling, where we were able to re-create 1,090 different scenarios.

And we did those differently for high-risk people and average-risk people to see if we did something differently, would we get a different balance of benefits and harms?

That's one of the things with lung-cancer screening.

It is beneficial.

It saves lives.

But it does have some risks.

And so, we're continually trying to look at balancing those risks.

One of the risks is false positives.

In the big trials, one out of four people had an abnormal finding on their lungs that often leads to further testing and diagnosis, which may help them, but it also could expose them to some risks.

>> Alright.

>> So, there just wasn't a differential recommendation to make for different racial groups.

>> I have both of you shaking your heads yes.

>> Yes, it's very true.

>> Who wants to go first?

>> So -- go ahead, Mike.

>> Okay, so, right before we went on air, Dr. Papa and I were talking about how we're not certain we've ever had a negative screening test.

>> Right.

>> Something always comes up, whether it's a pulmonary nodule... >> Really?

>> ...which, as was just alluded to, occurs in somewhere between, you know, 20% and 40% of the scans, depending on which study you look at, to coronary calcification, thyroid nodules, dilated aortas.

You're gonna find something.

You're getting so much detail from some of these scans.

>> So, do we need better tests?

>> So, I mean, the problem is, is you probably -- it would be nice to have better tests that you could discriminate.

But one of the things we talked about is the only discriminating factor is the pathology.

And these tests are so good, and these are individuals that have been smoking for decades.

>> Yeah.

>> Their lungs are not gonna be pristine.

They're gonna have mileage on them.

So, they're gonna look abnormal.

So, you end up doing other evaluations... >> Okay.

>> ...which, unfortunately, as Dr. Krist is getting at, now we found stuff... >> Ah, okay.

>> ...and do we really know if we do something just because we found it that they're gonna do better?

So, you end up opening this whole new can of worms, where you end up doing more testing with more radiation, more procedures that have more risks.

So, it is a delicate balance.

>> Okay, go ahead, doctor.

>> You were asking earlier about things that have changed.

One of the other things that have changed is there's new classification systems for long nodules that help doctors to try and differentiate which ones are significant and which ones are not.

It's not perfect, and, you know, as we are hearing, folks who have been smoking for 30-plus years, they're gonna have coronary calcium.

There are gonna be findings and effects on their body from all of the smoking exposure.

And so, sorting that out is really important.

>> Well, I can't end without asking you, Cheryll, how are you now?

How are you today?

>> I'm very happy to be here.

I mean, it's been a rough ride.

I mean, I'm not gonna say that the treatment was a cakewalk by any means.

I mean, I couldn't swallow.

I had severe esophagitis, and my feet swelled up.

I have neuropathy in my feet.

I have chronic shortness of breath from bronchiectasis now, which is resultant from the radiation treatments and the whole thing.

But I'm still here.

>> And, by the way, we should point out... >> I'm still here!

>> ...you stopped smoking -- right?

-- as soon as you heard the diagnosis?

>> Actually, it was -- no, I didn't.

>> Oh!

>> No, I didn't.

>> Cheryll!

>> Okay?

I was diagnosed -- no, I had tried to quit so many times, but what wound up happening was my surgery was scheduled for January 17th.

And I got the final diagnosis.

It was like the beginning of December.

>> And I was coming home from work.

My husband picked me up.

And I had a few cigarettes left in the pack.

And I said to him, "You know what?

Don't buy me any cigarettes tomorrow."

And I quit cold turkey.

>> Oh, so, you did.

That's awesome.

>> That's great.

>> So, let me ask you a question.

The screening guidelines had been available back, you know, when you were diagnosed -- would you have gone for that scan?

>> Of course, of course.

I mean, I go for mammograms.

I go for, you know, all sorts of other preventative measures type of a thing.

If they were available, I would go.

I still go.

I just -- well, I'm now out of the zone, I believe, for the last CT, the low-dose CT.

I had my last one last year.

And it was clear.

>> Yes, doctor?

>> Let me say congratulations, because that means that your risk, after 15 years of being cigarette-free, is low enough.

You don't need to be screened.

>> Such good news!

It's a great way to end, Cheryll, and we wish you much good health.

And thank you, all.

>> Thank you.

>> Thank you, all, doctors... >> Sure.

>> ...for being here.

I also want to thank all of our medical advisers, who are with us every step of the way to ensure that we bring you evidence-based, accurate medical information.

And, of course, to all of you at home, thank you for watching.

From all of us here at "Second Opinion," we encourage you to take charge of your healthcare.

I'm Joan Lunden.

Be well.

♪ ♪ ♪ ♪ ♪ >> Find more information about this series at SecondOpinion-TV.org.

You can also follow us on Facebook and YouTube.

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> "Second Opinion" with Joan Lunden is produced in conjunction with UR Medicine, part of the University of Rochester Medical Center, Rochester, New York.