Pulmonologist Highlights Latest Diagnostic and Staging Techniques in Lung Cancer

Manju P. Paul, MD

Advancements in bronchoscopic techniques have allowed pulmonologists to better diagnose patients who present with lung nodules, explained Manju P. Paul, MD.

“With the advanced bronchoscopy techniques that we have, we are able to achieve [a diagnosis] with a pretty high degree of sensitivity. We can also minimize the risk of complications that [are associated with] other procedures such as transthoracic needle biopsies,” said Paul. “It’s a pretty exciting time for us. The field of bronchoscopy and interventional pulmonology has been rapidly evolving. We have many tools available to help us diagnose and safely treat patients with lung cancer.”

Findings from the NELSON trial demonstrated that the use of CT screening resulted in a 26% reduction in lung cancer deaths in asymptomatic men at 10 years of follow-up (95% CI, 9%-41%). Results presented at the 19th World Conference on Lung Cancer also indicated that the benefit was more compelling in women, who accounted for approximately 20% of the study population.

The population-based controlled trial enrolled 15,792 individuals who were randomized 1:1 to the study arm or the control arm; those in the study arm were offered CT screening, whereas those in the control arm were not. Results of the study demonstrated an 86% average CT screening compliance rate, totaling 29,736 scans. Sixty-nine percent of screen-detected lung cancers were found to be stage Ia or Ib. Additionally, more than half of patients in the study arm were eligible for surgical treatment versus fewer than one-quarter of those in the control arm (67.7% vs 24.5%; P <.001).

OncLive: What are some diagnostic and staging techniques being used in the lung cancer space?

Could you elaborate on the diagnostic techniques that you’re using in your practice?

What is the importance of using a multidisciplinary approach for the diagnosis and management of patients with lung cancer?

In an interview during the 2018 OncLive^® State of the Science Summit™ on Advanced Non—Small Cell Lung Cancer, Paul, assistant professor of medicine at Upstate University Hospital, further discussed these new diagnostic and staging techniques that are advancing standards of care in patients with lung cancer.Paul: Among all cancers in this country, lung cancer is the leading cause of death. The key [to prevent death] is early diagnosis. Pulmonologists tend to see many patients who present with lung nodules. Lung cancer screening has been adopted pretty widely in this country.We have a regular flexible bronchoscope, which we use pretty much every day on our patients. When it comes to peripheral small nodules, we have advanced bronchoscopic techniques, such as navigation bronchoscopy. With our current navigation technique, we can perform a bronchoscopic-guided biopsy and also a transthoracic biopsy, if our bronchoscopic biopsy did not yield a diagnosis. We are also doing Epstein-Barr virus—encoded small nuclear RNA-1 staging of the lymph nodes in the same setting, so we’re able to diagnose and stage lung cancer in a single procedure.Diagnosis is a big part of being a pulmonologist. As part of a multidisciplinary group, we meet every week and discuss and see patients with either a new diagnosis or an established diagnosis of lung cancer. As pulmonologists, we offer diagnostic techniques and staging techniques. By using endobronchial ultrasound, we are able to do a pretty comprehensive mediastinal staging, which is crucial in treating [those with] lung cancer. Interventional pulmonologists provide advanced bronchoscopic techniques to help palliate tumors.

How have screening techniques changed in the past decade?

Has there been an uptake in screening?

What were the main take-home messages from your presentation?

Rigid bronchoscopy, tumor ablation, and other techniques, such as laser, argon plasma, and cryotherapy, are used to help alleviate endobronchial obstruction. We are also are involved in treating patients with malignant pleural effusions by thoracentesis, PleurX catheters, and, if needed, pleurodesis. [Our approach] depends on what best suits [each] patient.Two big randomized controlled trials—the National Lung Screening Trial and the NELSON trial—clearly showed an all-cause reduction in mortality from lung cancer [with screening]. We have incorporated lung cancer screening into our practice. With more scans, we see more lesions. Most nodules that we see tend to be benign. Clearly, we need to have a good multidisciplinary approach for these patients whose nodules are picked up on screening CT scans, so that we know when a surgical biopsy is necessary.Only 2% of patients who are appropriate for screening are being screened. Primary care providers must be educated on the need for lung cancer screening and its benefits, whether that’s through reaching out to the community or otherwise. Educating primary care doctors about the studies that have shown the benefit of screening is [imperative], and then they will talk to their own patients [about them]. The shared decision making is key. Establishing a successful screening program at any institution is [very important].Earlier diagnosis shows a survival benefit, although prevention is better than diagnosing the cancer in and of itself. Lung cancer screening has come a long way. We have 2 large trials that show a mortality benefit. We need to implement lung cancer screening pretty aggressively. As pulmonologists, we have advanced bronchoscopic techniques that help diagnose patients who present with lung nodules. We have tools to help stage lung cancer in a minimally invasive manner. Also, as interventional pulmonologists, we have various modalities available to us to help palliate tumors and help relieve patients of dyspnea from either an endobronchial obstruction or from a malignant pleural effusion.

de Koning HJ, van der Aalst C, Ten Haaf K, et al. Effects of volume CT lung cancer screening: mortality results of the NELSON randomized, controlled population-based screening trial. In: Proceedings from the International Asso- ciation for the Study of Lung Cancer 19th World Conference on Lung Cancer; September 23-26, 2018; Toronto, Canada. Abstract PL02.05.