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OHSU interventional pulmonologist Peter Lee, M.D., M.H.S., helps people with lung nodules using the Ion robotic navigation system (nicknamed Rosey). Under Lee’s direction, the system guides a thin probe through a patient’s lung to examine nodules for signs of cancer. He is one of the medical co-directors of OHSU’s new lung cancer screening program. (OHSU/Chris Lydgate)
Lung cancer is a notorious killer. According to the American Cancer Society, the disease fells more than 125,000 Americans every year — more than colon, breast and prostate cancer combined. For many years, the prognosis was bleak and survival rates were distressingly low.
But it doesn’t have to be that way, clinicians and scientists at the OHSU Knight Cancer Institute say. Lung cancer is treatable and curable — so long as it’s caught early.
Armed with innovative technology, teams at the OHSU Knight Cancer Institute are launching a project to change the way lung cancer is treated. The initiative could save thousands of lives and dramatically ease the burden of the disease in Oregon.
The initiative, which will launch Nov. 11, National Lung Cancer Screening Day, has four components:
- Catching cancer earlier through annual screening
- A high-tech robot that peers deeper inside the lung, where most tumors start
- More support for patients, including nurse navigators
- More tools to help people quit smoking — anyone can get lung cancer, but people who smoke, or who have smoked, are at highest risk
Innovations like these mean that lung cancer is more likely to be caught at the earliest stage, improving patients’ five-year survival rate to more than 90%. That’s in stark contrast to outcomes when the cancer is caught late, where survival rates are 10%.
Chara Rydzak, M.D., Ph.D. (OHSU)
“Annual low-dose chest CT scanning is a fast, easy and painless screening test for lung cancer,” says radiologist Chara Rydzak, M.D., Ph.D., one of three co-directors of the new program and an associate professor diagnostic radiology, OHSU School of Medicine. “It allows us to diagnose lung cancers quickly and at the earliest stages possible. This improves survival and cure rates for patients, giving them more time to enjoy life and spend time with their loved ones.”
The program’s other directors are Katie Putnam, M.D., M.P.H., resident physician in family medicine, and Peter Lee, M.D., M.H.S., associate professor of medicine (pulmonary and critical care medicine), OHSU School of Medicine.
“We can make a huge difference if we catch this early,” says nurse navigator Ann Spencer, RN. “Thousands of people in Oregon could benefit from screening.”
Screening saves lives
In the early stages, lung cancer has no symptoms — there’s no lump to feel or mole to spot. That means it is often not discovered until it has reached an advanced stage and spread through the body. Only 25% of all cases are caught at stage I, according to figures from the National Cancer Institute, a branch of the National Institutes of Health.
Katie Putnam, M.D., M.P.H. (OHSU)
However, low-dose CT scans can detect lung cancer long before patients notice any symptoms. Patients had to pay for the scans themselves until 2015, when Medicare began to pay for screening — now most insurance plans cover screening for people at high risk.
In 2021, the United States Preventive Services Task Force issued new guidelines on who would benefit most: anyone age 50 to 80 with a smoking history of 20 pack-years — meaning a pack a day for 20 years — who is still smoking or who quit within the last 15 years. The new recommendations doubled the number of Black people and women who are eligible for screening.
Uptake has been slow, however. In Oregon, just 7% of the eligible population was screened in 2022. Researchers have identified two barriers in particular: accessibility and “therapeutic nihilism,” or the mistaken belief that lung cancer isn’t treatable.
To overcome these barriers, OHSU has launched an ambitious program to get more people screened.
“Smokers and ex-smokers should absolutely get screened,” says nurse navigator Eliza Kaiser, RN, B.S.N., CCRN. “Early detection is a game-changer.”
Nurse navigators like Kaiser and Spencer help patients sign up for screening, schedule their appointments, quit smoking and coordinate their care among the different specialists they see. “We’re here for you every step of the way,” Kaiser says.
A low-dose CT scan typically takes about 15 minutes. If a scan shows something suspicious, nurse navigators also help patients take the next step: figuring out if they really have cancer.
GPS for the lung
Deep inside the maze, in a glistening tunnel mottled with burgundy reds and rosy pinks, the passageway branches into two. Over the gentle whirring of fans and chirp of biomonitors, Lee, program co-director and an interventional pulmonologist, checks his coordinates. He’ll take the left fork. Using trackball and scroll wheel, he expertly navigates forward. It looks like a scene from Star Wars, but Lee and his team are in an operating room at OHSU, guiding a super-thin scope through a patient’s lung with the help of a robot.
Sometimes a scan will show a spot on the lung, known as a lung nodule. Most nodules are inconsequential; small ones are usually the result of scar tissue from an old infection and pose no cause for concern. A bigger nodule is more likely to be cancer and can be treated with surgery if it’s caught early. But first the team needs to be sure whether it’s cancer or not. That requires a bronchoscopy, a procedure where Lee and team reach deep into the lung to take samples of worrisome nodules, using the Ion robotic-assisted navigation system, affectionately nicknamed “Rosey.”
Bronchoscopy is a challenging procedure because the airway is an intricate labyrinth of forking paths that grow progressively narrower and more convoluted as they branch deeper and deeper inside the lung. To chart a course through the maze, Rydzak, a thoracic radiologist, examines a CT scan and pinpoints the exact location of the nodule. Rosey uses sophisticated technology to create a detailed, three-dimensional roadmap of the best route — like GPS for the lung.
“It’s a powerful tool,” Lee says. “The Ion is far more accurate than older navigation systems and very safe. We can reach nodules in corners of the lung that other tools can’t reach.”
After the patient is comfortably sedated, Lee gently guides the scope through the twists and turns of the airway. Rosey uses optical-fiber technology to steady the scope and keep it on track. When the scope finally reaches the nodule, Lee deploys a cryogenic tool to freeze and remove a small sample of the nodule for the pathology team to analyze. If it turns out to be cancer, the team can run more tests to see which type of treatment will be most effective. In some cases, they can tailor the therapy to the precise genomic profile of the cancer.
Breathing room
In the early days of lung cancer treatment, surgery usually meant removing an entire lung through a large incision. For many years, thoracic surgeons at OHSU have been removing early-stage lung cancers with very small incisions, using minimally invasive techniques, which preserves more of the patient’s lung. With increased early detection, these life-saving techniques can be used to help more people.
“We know how to do big, complicated lung surgeries for advanced lung cancer, and when it is needed, we are here,” says Paul Schipper, M.D., FACS, FACCP, professor of surgery (cardiothoracic surgery), OHSU School of Medicine. “With early detection, however, we finally get the chance to cure lung cancer in a lot more people and spare more healthy lung tissue so they can get back to their lives.”
“Identifying lung cancers earlier allows us, as surgeons, to surgically treat the cancer effectively while preserving lung function for our patients,” adds Ruchi Thanawala, M.D., M.S., FACS, assistant professor of surgery (cardiothoracici surgery, OHSU School of Medicine.
Catching lung cancer early also opens the door to powerful types of radiation therapy.
“Over the past two decades, advances in imaging, radiation delivery and computer modeling have significantly advanced radiotherapy for lung cancer,” says Josh Walker, M.D., Ph.D., assistant professor of cell, developmental and cancer biology, OHSU School of Medicine. For some patients, that means curing early-stage lung cancer in as few as three radiotherapy treatments.
“We can use these precision techniques in patients who are not good candidates for surgery, and we are able to cure early-stage lung cancer in more than 95% of cases,” Walker says.
Immunotherapy is also beginning to help more patients. In January, the Food and Drug Administration approved the immunotherapy drug pembrolizumab, known by the brand name Keytruda, to help patients who have already received surgery and chemotherapy for certain types of lung cancer, and studies are now investigating if it can be helpful earlier in treatment.
Lung cancer isn’t always caused by smoking, but people who smoke are at much higher risk. OHSU’s tobacco treatment specialists offer counseling, medication and follow-up to help people quit, offering the support that significantly boosts quit rates and cuts the risk of cancer and other conditions.
Overall, the OHSU team is optimistic that the new initiative will encourage more people to take charge of their health, get screened and breathe easier.
“We want to partner with patients and communities to be champions of their health journeys,” says Putnam, program co-director resident in family medicine. “A robust lung cancer screening program will help us to detect cancer earlier and empower folks to get back to doing what they love sooner.”
Find more information on lung cancer screening at OHSU.
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