The simple act of breathing is something we take for granted -- until it’s hard to do. As we mark Lung Cancer Awareness Month and COPD Awareness Month in November, and in the face of an expected surge in COVID-19 cases, we focused on smoking and lung diseases in an episode of Baptist Health's Resource Live program on Facebook.
Host, Jonathan Fialkow, M.D. welcomed Mark Dylewski, M.D., chief of thoracic surgical oncology at Miami Cancer Institute and medical director for robotic thoracic surgery at Baptist Health, and Javier Pérez-Fernández, M.D., pulmonologist and critical care director at Baptist Hospital.
Please visit MiamiCancerInstitute.com for more information about lung cancer.
For more information about COVID-19 please visit BaptistHealth-coronavirus.com
The simple act of breathing is something we take for granted -- until it’s hard to do. As we mark Lung Cancer Awareness Month and COPD Awareness Month in November, and in the face of an expected surge in COVID-19 cases, we focused on smoking and lung diseases in an episode of Baptist Health's Resource Live program on Facebook.
Host, Jonathan Fialkow, M.D. welcomed Mark Dylewski, M.D., chief of thoracic surgical oncology at Miami Cancer Institute and medical director for robotic thoracic surgery at Baptist Health, and Javier Pérez-Fernández, M.D., pulmonologist and critical care director at Baptist Hospital.
Please visit MiamiCancerInstitute.com for more information about lung cancer.
For more information about COVID-19 please visit BaptistHealth-coronavirus.com
Announcer:
At Baptist Health, South Florida, it's our mission to care for you when you're injured or sick; and help you stay healthy and fit. Welcome to the Baptist Health Talk podcast, where our respected experts bring you timely practical health and wellness information, to improve your family's quality of life.
Dr. Jonathan Fialkow:
Hello Baptist HealthTalk podcast listeners. I’m your host, Dr. Jonathan Fialkow, I’m a preventative cardiologist and certified lipid specialist at Miami Cardiac and Vascular Institute, and chief population health officer at Baptist Health South Florida.
The simple act of breathing is something we take for granted, until it’s hard to do. So, to bring attention to the importance of lung health, each November we observe Lung Cancer Awareness Month as well as COPD Awareness Month. These 2 diseases take hundreds of lives in this country every day.
“Lung heath: Smoking, Cancer and COVID-19” was the subject of a recent episode of Baptist Health’s Resource Live Program. I had the pleasure of hosting two expert colleagues: Dr. Mark Dylewski, chief of thoracic surgical oncology at Miami Cancer Institute and medical director for robotic thoracis surgery at Baptist Health, and Dr. Javier Perez-Fernandez, a pulmonologist and the critical care director at Baptist Hospital.
In today’s podcast, we’re bringing you highlights of our discussion that included risk factors, symptoms and information about the latest treatments. Let’s listen in:
Dr. Jonathan Fialkow:
Let's start by talking about the scope of lung disease, guys. Again, many different components make up the disease. I want each of you to talk about the lung disease of specific populations. So first, I'm going to ask you, Mark, to talk a little bit about lung cancer, which is very prevalent and the focus of this month's national awareness as well, and then, Javier, we'll turn it over to you about COPD and its relationship to the lungs and Crohn's disease as well. So, Mark, let's start with lung cancer. What can you tell us about lung cancer in 2020?
Dr. Mark Dylewski:
So lung cancer is the third most common cancer in the U.S. and around the world, but it accounts for the majority of deaths both in men and women both in the United States and around the world. So it's a critical issue. We haven't, as of yet, made huge strides in improving the long-term survival and the overall survival in patients with lung cancer. But we're making strides in that effort. The treatment algorithm involves a complexity of treatments such as chemotherapy, radiation, and surgery, and it's often a multidisciplinary approach to managing these folks.
Dr. Jonathan Fialkow:
So it is encouraging to hear about the advancements in treating lung cancer, and we will elaborate on that a little bit later. We'll also give you an opportunity to talk about detecting lung cancer in the community, but we'll start with some preventive components. Javier, speaking of preventive components, let's talk a little about COPD, again, it's level setting for the conversation. What is it? How widespread is it? What are the consequences to our society and our healthcare system?
Dr. Javier Perez-Fernandez:
Sure. An amazing approach to this. Thanks so much for the opportunity. Certainly, COPD, chronic obstructive pulmonary disease, is a disease that's caused by insult to the airway. Essentially, the most common insult is the smoking. It produces essentially a narrowing of the airway, and it presents that typically after 20 years or so of being a smoker. Certainly, something important is the fourth leading cause of death in the U.S. and accounts for a significant number of people affected. Over 24 million people in the U.S. are affected with COPD, and it's probably one of the most rapidly raising diseases worldwide. That reason is, again, because although smoking has been mostly contained in the U.S., it's certainly not contained in other countries and that's what really, every day we're seeing more prevalence of the disease. So a tremendous handicap for patients and certainly, is a very preventable disease, of course.
Dr. Jonathan Fialkow:
So COPD is emphysema and chronic bronchitis there. Can you describe the symptoms or the recognition of the two components of COPD?
Dr. Javier Perez-Fernandez:
That's correct. What happened is historically, we have divided that into emphysema and what we call chronic bronchitis. Every day, we tend to move more towards just the disease itself because most of the patients contain or have both diseases in one person. Now, the typical emphysema, which essentially is a destruction of the lung inside. The little walls inside the lungs are getting destructed day after day, and it produces, obviously, big balloons inside the chest. The chronic bronchitis, which is mostly the thickening of the airway and the production of mucus blocks and a lot of secretions, but those really are co-existent in most of the patients. Unfortunately, they're very difficult to distinguish one another.
Dr. Javier Perez-Fernandez:
I think the two worst that I really wanted to highlight here are, again, they're both preventable. COPD is a preventable disease, but also, it's treatable. So we do have significant number of tools nowadays to treat the disease and make people life close to normal. Again, this has been very important because for years, we almost always understood that COPD was no cure for it. Again, it's totally treatable, and we can definitely make improvements on quality of life.
Dr. Jonathan Fialkow:
Which speaks to the preventable component because if I read into what you're saying, it's not curable, but you can ameliorate the symptoms in someone who has it to at least establish a quality of life. But they're not going to remove it. They're not going to cure it or get back to normal lungs. Is that [crosstalk 00:05:53]?
Dr. Javier Perez-Fernandez:
Right. But this is also been important, our listeners and our viewers to understand the concept of curable. I mean, hypertension, which is a disease that you're obviously extremely familiar with, is not curable, it's treatable. So you're not going to get rid of the hypertension. You're not going to get rid of the COPD, but you can make life totally normal with the treatment. Obviously, the best circumstances are to prevent it.
Dr. Jonathan Fialkow:
Right. I'm going to wear my cardiologist had a little bit and just say if someone has hypertension from a multitude of factors and they improve those factors, lose weight, exercise, it can go away. But if you have hypertension and don't change a thing, it's always going to be there and you just control it?
Dr. Javier Perez-Fernandez:
That's right. That's right.
Dr. Jonathan Fialkow:
Little sidebar. But with COPD, the damage is permanent that we can mitigate the symptoms.
So, Mark, I'll follow up with you. Can we speak to the symptoms that might make someone seek help to make sure they don't have lung cancer?
Dr. Mark Dylewski:
Absolutely. Everybody's aware of the correlation between using tobacco products and COPD, and emphysema, and lung cancer. Unfortunately, many of the symptoms that are present in patients who've been smoking such as coughing, and shortness of breath, and dyspnea are components of development towards lung cancer. One of the unfortunate things is that the COPD and the emphysema cloud the diagnostic picture of patients who present with lung cancer. Very few lung cancer patients have symptoms other than shortness of breath and a cough. What happens is over time, the tumors in the lungs begin to grow. Then, in very advanced stages when the tumor becomes large enough to start eroding into the vessels and eroding into the airway, you start to get these advanced symptoms such as hemoptysis, which is coughing up blood. You can develop chest discomfort or chest pain when the masses started eroding into critical structures in the chest and the chest wall.
Dr. Mark Dylewski:
So one thing to remember is that patients who develop symptoms in lung cancer, it's often it's in advanced stages, stages that are such advanced that it's hard to treat and cure those folks. So the important thing is to identify patients at risk for lung cancer, and the most efficient and cost-effective way of treating lung cancer is to identify patients with those risk factors and screen those patients. Remember, one point, we do have a cure for lung cancer. It's screening the patients and catching them early in its earliest stages and then offering them appropriate surgical care.
Dr. Mark Dylewski:
So in the last five to 10 years, we've made great strides in identifying the patients at risk for lung cancer and implementing national strategies around screening. So historically, the majority of patients that were diagnosed with lung cancer in United States were in at stage three and stage four. That used to be about 60 to 70% of patients, and that is changing with the implementation of screening with CT scans and we're catching more and more patients in the earlier stages, stage one and two, where surgery can have an impact at curing those patients.
Dr. Jonathan Fialkow:
That's a great trend and good to hear. So screening, if we want to get into that a little bit more, let's talk about screening a little bit. Does someone have to be symptomatic to qualify for screening? Do they have to have a cough or shortness of breath?
Dr. Mark Dylewski:
Absolutely not. The main criteria for screening is whether they are a tobacco user or not, whether they've smoked for more than 15 years, and whether they have quit less than 15 years prior to seeing their doctor. We've limited the age group up to between 55 and 80, knowing that patients who are younger than 55, if they're actively smoking, are less likely to develop cancer until they reach the mid-50s. And patients over the age of 80 are less likely to acquire cancer and have it impact their longevity of survival. So we limit it to a population between 55 and 80, and that's where the cost-effectiveness has the most impact in screening patients.
Dr. Jonathan Fialkow:
What is that screening methodology? What does screening entail?
Dr. Mark Dylewski:
There's a number of methodologies that we've used in the past, but the most sensitive and accurate is using what's called the low-dose CT of the chest, a CAT scan of the chest. Typically, we recommend that being started after the age of 55 if you're actively smoking or if you've stopped less than 15 years prior. That should be done annually as long as the original screening CT scan does not show an abnormality. If there's an abnormality, then those screening protocols may change and they may be implemented to do it more frequently or there may be a trigger to start evaluating the patient for an active, suspicious lesion that may be cancer.
Dr. Jonathan Fialkow:
So a low radiation dose, safe, cheap CAT scan is the screening procedure of choice for that population that meets that criteria to possibly find a cancer early, before symptoms, which would make it much more likely to be curable?
Dr. Mark Dylewski:
Absolutely, absolutely, and to have the biggest impact. Just to make a point, many of our viewers realize that there's a tremendous amount of money spent treating patients with advanced cancer, developing chemotherapy, developing different types of radiation and immunotherapy. There's billions of dollars spent by medical and pharmaceutical companies to this end. The biggest and the cheapest impact that we can have on patients who potentially develop lung cancer is the catch them in its earliest stages.
Dr. Jonathan Fialkow:
Well said. Well said. Prevention. I promise, folks, we will get the smoking specifically because I think tobacco is such an important topic as it relates to lung disease and our awareness efforts. But, Javi, let's take the same tack for COPD. In your practice, what's the level of advanced COPD you see? Is the person at endstage by the time they get to you? Are we successful in picking up early signs and making an impact in the person over the last few years? Tell us a little bit about that trajectory.
Dr. Javier Perez-Fernandez:
There is preventable issues over COPD. Unfortunately, the time that we typically see patients with COPD are when symptoms are well-developed. The typical symptoms are, again, the emphysema, which starts on assertion and goes up to even resting, the significant cough and spasms that affect people with production of mucus, and obviously, the inability to perform most of the normal activities or regular activities. That's the moment people are seeking the medical attention, and they really hunger for air. They really need help to breathe.
Dr. Javier Perez-Fernandez:
That's very unfortunate because then most of the damage, as we mentioned before, it's already done and it's unfortunately nonrecoverable. If we catch COPD in the earlier stages, if we're able to identify, in a similar way, the same population, because, again, it's the same common factor, which is if you are a smoker, if you've been a smoker for over 15 years, whether you have symptoms or not, but if you are a smoker, there is a tool that we can use to identify patients at risk and also patients who develop early stages of COPD is called a spirometry. It's a simple test, does not required any intervention, does not require any punctures, does not required any invasions. It's a simple test. It's blowing into a little machine that most of the pulmonologists have it on their offices and all Baptist hospitals have them, pulmonary laboratory that we can do that.
Dr. Javier Perez-Fernandez:
In those particular events, you can actually do this test. It takes five to 10 minutes to perform and identify whether you have the earliest stages of COPD or at least screen people to determine whether they're affected or not. That's, obviously, an important issue. The second most important factor in COPD is also establish the culture of the smoking cessation. In an hour, we're going to talk about a smoking cessation. But unfortunately, it's well-known that a single question by the doctor or the clinician to the patients when they go into their office and simply engaging into the conversation, "Did you, or would you smoke, or have you smoked?" It's an amazing factor to decrease the number of people who smoke and it's been well-proven. So simple as that, those are two effects.
Dr. Javier Perez-Fernandez:
But again, even in those patients who have severe diseases, we can treat them. If we catch them earlier on the disease, we definitely can make the lifespan significantly higher. Mortality of COPD has been reduced. There's no question about it. There's no single treatment, other than oxygen, that reduces mortality for COPD patients, but the treatment itself reduces mortality. Again, this might look like a little bit of a game of words, but it's not. It's just no single drug or no single medication will really reduce mortality. But if we treat patients with significant different factors, whether it's medications, exercise, activity, oxygen, whatever is needed, the mortality's significantly reduced. We know that for the last two decades. So good news for that.
Dr. Jonathan Fialkow:
Let's now start getting into the 800-pound gorilla, which is tobacco and smoking. What does tobacco do? How dangerous is smoking to our lungs?
Dr. Javier Perez-Fernandez:
So smoking has two components. One is the habit-creating component, which is the nicotine. The other is really the toxic products are delivered by the smoking or the smoke inhalation. The nicotine addiction is one of the strongest addictions that we know in pharmacology. It is a very potent drug, and the delivery system goes directly to your brain. So it is a very, very, very direct interaction between the drug and your brain, producing even more habit, as we know, by other drugs.
Dr. Javier Perez-Fernandez:
Second aspect is the toxicity caused by the smoke inhalation. The products delivered through the smoking byproducts, I will say, are as many as 6,000 different chemical toxics that are included in the smoke that is eliminated by a cigarette. For those who believe then, well, then the vapor or the (vaping products) they might be good. Well, it's certainly not. We already know that those also produce significant number of toxic elements because of the high temperatures that are initiated to deliver the [inaudible].
Dr. Jonathan Fialkow:
I think it's very important, the nicotine gives you pleasure when you first take it. But as your brain becomes addicted, you have a plateau with nicotine and you feel terrible when you don't have it, which produces the nicotine. Also, you said directly to the brain, it goes right through your cheeks. As a cardiologist because, of course, smoking and nicotine is very bad for our cardiovascular system, "Well, I don't inhale a cigar." That nicotine is going right through your cheeks into your brain. You don't need to get it into your lungs. So, again, a couple of points now. So, what does nicotine do to our lungs in terms of its relationship to lung cancer, Mark?
Dr. Mark Dylewski:
One of the most important issues nowadays is the use of vape pens. As Dr. Perez-Fernandez indicated, nicotine is highly addictive, and these vape pens produce more nicotine per puff than a routine combustible cigarette. That's important for the viewers to realize. Our young folks are thinking that these vape pens are safer, less addictive, and it's absolutely untrue. So if someone is using these vape pens, you need to realize that it's a highly-addictive device. If you go eventually to combustible smoke instruments, then you're going to be smoking combustible cigarettes at a higher rate and a higher frequency that's going to deliver these toxic chemicals to your lungs.
Dr. Mark Dylewski:
Now, nicotine itself, we do not believe that it has any relationship to lung cancer. Lung cancer develops in patients as a result of the 6,000 to 7,000 co-carcinogens and carcinogens that are released from the tobacco leaf. Tobacco smoke is not the only thing that is necessary in the alignment of the development of lung cancer. You have to have a genetic predisposition or some other element of viral infection that allows your genes to alter and grow unimpeded and grow exponentially into a tumor. So not everybody that smokes gets cancer, but a certain percentage, 10% to 20%, we know are predisposed to developing cancer if they are smokers. So it's very important to realize that.
Dr. Mark Dylewski:
The other issue is that not all non-smokers don't get lung cancer. There is a significant percentage of people in this country, particular women, between the ages of 50 and 70, that are developing lung cancer for some reason that we're not quite sure why. So just because you're a non-smoker does not mean that you can't develop lung cancer.
Dr. Jonathan Fialkow:
Smoking, again, bad, affects all parts of our body, addicting. What resources do we have, or what do you connect smokers to to help them quit smoking? Javier, can I ask you that?
Dr. Javier Perez-Fernandez:
Sure. Sure. Actually, at Baptist Health System, we have two different smoking cessation programs that our patients can go and definitely attend to different problems of education that we know. So when you look into the historical data shows that when patients try to quit smoking, they have significant difficulties doing so. We know that the average number of attempts before successful quitting attempt is seven. That's actually the magic number that we know historically by all literature. Now, when we add to our counseling in the office, as a physician, as a clinician, the ability to provide the patient help with nicotine addiction, such as any nicotine substitution or any other medications that might help with that, and this is very important that you need to address this with your clinician.
Dr. Javier Perez-Fernandez:
Do not take anything over the counter because we know that's not successful, that it's only going to do more harm than help. As you already mentioned, nicotine is not exempt of cardiovascular effects. The problem with the substitution is that you substitute the nicotine of the cigarette with another product, whether it's a gum, or whether it's a lozenge, or whether it's whatever, that the problem is that those people who do not quit smoking, they're using a significant increased amount of nicotine because they're using the substitution plus the cigarette. And that produces then problems that cannot be pressing on patients. So you always need to be oriented about this. You always need to be assessed by your clinician.
Dr. Javier Perez-Fernandez:
So when we add to that the ability to perform through the smoking cessation program with education, sometimes group chats, sometimes very hand-to-hand evaluation, the success rate for quitting can be as high as 40%. That means for every two patients that go into this program, one person is already smoking free after one year of being in this program. So it is very important that we address that, and they can go to the website and they can look into the information how to access, how to communicate with our smoking cessation program as well. We offer that ability and that facility as well in our Baptist System.
Dr. Jonathan Fialkow:
The best way to avoid tobacco-related lung disease is to not smoke in the first place. If someone smokes, we recognize the addiction, no one has to be judged because you smoke. But don't give up. There are lots of resources available to work with you to help you quit smoking. I want to finish up with a couple of COVID comments or at least points. We know that we know it affects the lungs. We saw the early data and the images of people on ventilators, which I think we have different ways of approaching it. What do we know about COVID in the lungs, Javier? What have we learned? You were at the forefront of the Baptist Health System in the early days of preparing, and treating, and communicating worldwide. Give us a little bit of where we're at with COVID related to lung disease. Are there long-term consequences? Whatever you want to tell our viewers.
Dr. Javier Perez-Fernandez:
Sure, sure, sure. So I think it's important to summarize a little bit of a COVID experience over Baptist. At Baptist, we had over 7,000 patients that were treated with COVID since the beginning of the pandemic in the hospital. We had over 14,000 patients that we were able to manage at the emergency departments, [inaudible 00:25:25], and refer home safely through actually very sophisticated technology that we've used to follow those patients and monitor them at home. We have a system set up for that, and we have telemedicine also to attend.
Dr. Javier Perez-Fernandez:
Let me tell you a little bit about the experience with the patients in the hospital, and it's been an amazing learning curve for a lot of us. COVID is a viral disease that affects significantly, mostly the lungs. Those patients who get complicated, the first organ failure that they have is the lung organ failure. So it's very important to realize that, and we all learned [inaudible 00:26:01]. Now, what we have not really completely mastered yet is the decision whether this could be a chronic disease or not for some people. We learned, we heard, and we read some stories about people who, after a few months of being with COVID, they still have significant problems. But that's not enough to guarantee a chronic disease.
Dr. Javier Perez-Fernandez:
We think that COVID affects people in a subacute way. It tends to weaken a little bit the respiratory system and that might be there for significant weeks or months. And in some cases, it might have actually highlighted problems that were baseline on those patients. But there's no certainty that the really COVID produces chronic lung disease at this point.
Dr. Mark Dylewski:
I have one other thing to add, Dr. Fialkow, is that when someone's told that they have an abnormality in their chest, it's so important that you seek proper advice. Every medical professional is not as experienced as Dr. Javier Perez, or yourself, or myself. If someone's told that they have an abnormal finding on an x-ray, don't settle on one opinion. Get multiple opinions until you are absolutely certain that you've got the best opinion and you've received the best care. It's extremely important when it comes to lung cancer.
Dr. Jonathan Fialkow:
Very helpful. So to summarize, don't smoke if you're not smoking. Work to stop smoking if you are smoking. Don't vape. Similarly, stop if you are. Exercise, get your flu vaccine and your pneumonia vaccines, practice healthy distancing, eat a healthy diet, get checkups with your primary care doctor, get the CT screening if you're eligible, as Dr. Dylewski eloquently informed us, and there are smoking cessation programs available if you need to.
Dr. Jonathan Fialkow:
If you’d like to watch the full episode of Resource Live, there’s a link in the notes for this podcast.
As always, if you have any comments, questions or suggestions for topics for the podcast, email us at BaptistHealthTalk@baptisthealth.net
Thank you for listening. Stay safe and mask up!
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