At the right time and place

Radiologist Lori Watumull, M.D., prepares to perform a CT-guided biopsy. “It’s important we understand lung cancer’s various imaging features (and) the multiple ways to obtain a tissue diagnosis” to help achieve the best possible outcome for patients, she says.
Radiologist Lori Watumull, M.D., prepares to perform a CT-guided biopsy. “It’s important we understand lung cancer’s various imaging features (and) the multiple ways to obtain a tissue diagnosis” to help achieve the best possible outcome for patients, she says.

Low-dose CT clinical tool is boosting survival rates

Low-dose computed tomography (LDCT) screening for lung cancer represents a vital new opportunity to more frequently catch tumors early, when they often can be cured with surgery.

Increased early detection alone could make a difference in survival rates, says Dr. Joan Schiller, Deputy Director of Simmons Cancer Center. Results of the UT Southwestern, published in 2011, found that participants had a 20 percent lower risk of dying of lung cancer if they were screened with low-dose helical CT scans rather than chest X-rays. Before that, Dr. Schiller says, “We didn’t have any proven screening method. Now we do.”

At UT Southwestern, the LDCT screening program is led by Dr. Muhanned Abu-Hijleh, who is one of the interventional pulmonary and critical care physicians at the Pulmonary Specialty Clinic, serving patients with suspected pulmonary malignancies and pulmonary nodules. Screening is available to anyone in the targeted population, even to those who can’t afford to pay. Vouchers are provided by the Roger Williams Fund for CT Screenings for Lung Cancer. The fund aims to spare as many people as possible from the devastation of a diagnosis of advanced lung cancer by promoting early detection.

Roger Williams was a prominent Dallas trial lawyer who died of lung cancer in 2013. “His family wants screening to be barrier-free—if you think this is an issue for you, just do it,” says oncology-certified nurse Maria Grabowski, Program Manager for Patient Education and Community Outreach. “Peace of mind or early detection is priceless. Because of the Williams fund, this opportunity is now available to everyone.”

At UT Southwestern, patients also benefit from cutting-edge technology and faculty expertise. “We have the latest-generation multidetector CT scanners and are continually adding the newest flagship scanners from major vendors,” says Dr. Suhny Abbara, Chief of Cardiothoracic Imaging. Meanwhile, UT Southwestern radiologists are meticulous about radiation dose (a typical dose is about 1.2 to 1.5 mSV for LDCT, compared with 6 mSV or more for a standard chest CT). “We minimize the doses to as low as reasonably achievable clinically,” Dr. Abbara says, “and we do research to further push the limits.”

The targeted population for LDCT screening has been carefully defined to ensure benefits outweigh any harm, adds lung cancer specialist Dr. David Gerber. “When you compare it to breast, prostate, colon, or cervical cancer screening, the number needed to screen to save a life is best for lung cancer,” he says. “This reflects the lethality of lung cancer and the high risk of the targeted population.”

Any center providing screening should offer a full range of follow-up care, he notes. “Screening needs to be done at a place that can guide patients through all the subsequent processes, counsel patients on what a radiographic abnormality may mean, and have an aggressive, comprehensive nicotine cessation program,” tailored to meet individual needs—all services available at Simmons Cancer Center.

Muhanned Abu-Hiljeh, M.D. (left), and his colleague Hsienchang Thomas Chiu, M.D., are a rare breed in their field: Both are interventional pulmonologists who specialize in minimally invasive techniques for advanced diagnosis and staging.
Muhanned Abu-Hiljeh, M.D. (left), and his colleague Hsienchang Thomas Chiu, M.D., are a rare breed in their field: Both are interventional pulmonologists who specialize in minimally invasive techniques for advanced diagnosis and staging.

The team and technology behind the diagnosis

At UT Southwestern, teamwork begins even before a patient is ever told, “You have lung cancer.”

When imaging reveals a suspicious nodule, patients referred to UT Southwestern for follow-up have the benefit of a highly specialized team of interventional pulmonologists, radiologists, and pathologists, all working together to ensure fast and accurate diagnosis by the least invasive means possible.

The team also must obtain enough of a sample so UT Southwestern physicians and scientists—leaders globally in the molecular analysis of lung tumors—can glean important clues about which cancer treatments might work best. For patients whose lesions look suspicious, the goal is to move quickly and safely to diagnosis and staging, says Dr. Hsienchang Thomas Chiu. Dr. Chiu and his colleague Dr. Abu-Hijleh are a fairly rare breed in their field: Both are interventional pulmonologists specializing in minimally invasive techniques for advanced diagnosis and staging.

Those techniques include linear endobronchial ultrasound (EBUS), which visualizes body tissues that then can be sampled by instruments passed through the bronchoscope. EBUS is used to access central sites.

Electromagnetic navigational bronchoscopy (ENB) is deployed for harder-to-reach lesions. ENB uses CT scan data to build a virtual reality representation of the lung. Then, as the patient lies on a plate that generates an electromagnetic field, the bronchoscope is tracked within the field and an airway map is generated. A computer combines that map with virtual reality to guide the probe.

Dr. Chiu often is referred patients whose previous biopsies didn’t collect relevant tissue—even when cancer is evident on scans—or who were told erroneously that the tumor is too small to biopsy. “We can deal with these challenging cases,” he says.

To investigate very peripheral lesions, a radiologist is enlisted to perform a CT-guided biopsy. While the procedure is not without risk—most commonly lung collapse—“if it’s done in the hospital, we are prepared to deal with any potential complications,” says radiologist Dr. Lori Watumull. “It’s a safer environment, especially for high-risk patients.”

Meanwhile, cytopathologists with expertise in lung cancer are always on hand to provide rapid on-site evaluation as samples are collected. “They can tell us on the spot, are we actually getting cancer cells?” Dr. Chiu says. Also, adds Dr. Watumull, they can ensure a sample isn’t composed of necrotic tumor tissue, or, if the lesion is an infectious site, ensure enough tissue is gathered for culture and antibiotic sensitivity determination.

“We work together as a multidisciplinary team,” she says. “It’s important we understand lung cancer’s various imaging features, the multiple ways to obtain a tissue diagnosis, and the various treatment alternatives—the whole process—to obtain the best possible outcome for the patient.”

Extinguishing smoking—one patient at a time

For smokers aiming to kick the habit, UT Southwestern’s Simmons Cancer Center won’t quit until they do.

Yet some patients referred to the center’s nicotine cessation resource just aren’t ready. In that case, program educators—all of whom are American Lung Association–certified in nicotine cessation—can act as a telephone resource to help patients prepare.

This resource also helps lung cancer patients get smoke-free before surgery. “When we get that referral, we stay close,” says oncology-certified nurse Maria Grabowski, Program Manager for Patient Education and Community Outreach. At no cost, educators will help the patient set a quit date and offer telephone or in-person motivational and educational sessions as well as regular check-ins.

The cessation resource has a medical director, Dr. David Balis, and an advanced practice nurse from the lung cancer team, Sharon Hoskin, who are highly experienced in pharmaceutical support for smokers trying to quit. That team makes varenicline or bupropion available and provides the close management advised for patients using varenicline.

Also available to the public is a weekly class, the Lung Association’s Freedom from Smoking course, whose only cost is $35 for the companion book. Classes meet on campus at noon on Tuesdays. Participants can range from people struggling with quitting to those who are smoke-free but tempted to resume. Patients ready to quit but who miss the course’s start receive catch-up tutoring. Class participants also have access to the rest of the resource’s services and may return to classes anytime in the future.

Referrals come from within UT Southwestern and from the community. Smokers are also encouraged to explore other resources aimed at screening and early detection of lung problems, including UT Southwestern’s low-dose CT lung cancer screening program.

Some smokers are so relieved that their screening revealed no lung tumors that they are then raring to quit, Ms. Grabowski says. “They are grateful. They feel as if they can get out alive.”

Lung Cancer Screening

The U.S. Preventive Services Task Force recommends annual screening with low-dose computed tomography for asymptomatic patients who:

  • Are between 55 and 80 years old;
  • Have a 30-pack-year history of smoking*; and
  • Now smoke, or quit within the past 15 years.

Screening should be discontinued when the patient:

  • Has not smoked for 15 years; or
  • Has developed a health problem likely to significantly limit life expectancy or ability/willingness to undergo curative lung surgery.

*Pack-year history is calculated by multiplying the number of packs of cigarettes a person smoked per day by the number of years the person has smoked.

Source: uspreventiveservicestaskforce.org/uspstf/uspslung.htm

Diagnosing Lung Cancer

Low-risk lesions:

  • Regular CT monitoring Moderate- to high-risk lesions
  • Bronchoscopy and endobronchial ultrasound (EBUS) for lesions accessible in or by the airway
  • Electromagnetic navigational bronchoscopy (ENB) for lesions not directly in the airway
  • CT-guided biopsy, for more peripheral lesions
  • Surgical biopsy, when appropriate
  • Rapid on-site evaluation of samples

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