Andrew Becker: Before we start, a quick note. The content in this episode should not be considered to be medical advice and no physician patient relationship is implied.
Dr. Chris Manley: This is the Auris Monarch Robotic Bronchoscopy System and this is the camera that...
Andrew Becker: This is Dr. Chris Manley, Fox Chase's Director of Interventional Pulmonology. He's showing us a machine that is revolutionizing lung cancer diagnosis by spotting the disease much earlier than ever before. It's called the Monarch, and Fox Chase was one of the first three hospitals to get one.
Dr. Chris Manley: ... Out to the nodules. So using them in conjunction allows us to bend and flex in different directions and with full flexibility and mobility to reach nodules and perform the biopsies.
Andrew Becker: The machine itself looks like a tall, skinny box with a computer screen and long arms, but it represents the future and it allows Dr. Manley to embody the mission of Fox Chase Cancer Center, which is to prevail over cancer, marshaling heart and mind in bold scientific discovery, pioneering prevention and compassionate care.
Dr. Chris Manley: I think that this device offers the ability to reach nodules noninvasively or minimally invasively. So the patient gets the diagnosis and the staging and then can move on to treatment more quickly.
Andrew Becker: And that's the whole point. Dr. Manley and his colleagues are sparing patient's pain and saving them precious time. Everyday our waiting rooms, laboratories and clinics fill up with people searching for something. To take care of others. To find the next big breakthrough. Or maybe just to feel like themselves again. This is Connected by Cancer, the podcast of Fox Chase Cancer Center that's all about that search. I'm Andrew Becker and each episode we explore these connections together.
Andrew Becker: In 1905 when the hospital that would become Fox Chase opened its doors, only one out of 10 cancer patients survived longterm. Today that number is two out of three and for some cancers nearly everybody survives. It's one of the monumental success stories of the last century and so we wanted to ask some doctors what it's like to be living in this moment when new discoveries are coming fast and furious.
Dr. Rohit Kumar: One of the things that I've been always interested in is lung cancer screening or picking up cancer really early and one of the things that is new here in the center is a robotic endoscopy platform, or called the Monarch Endoscopy Platform. It really allows us to get to the next level of diagnostics where we can reach tiny, tiny, small, small spots in the lungs which are suspicious for cancer and try to reach them early and diagnose cancer early. Lung cancer, if you pick it up early, you can make a huge impact.
Andrew Becker: Interventional pulmonologist, Dr. Rohit Kumar, believes the integration of both clinical and research disciplines is key to providing patients with excellent care.
Dr. Rohit Kumar: To be able to get to nodules that we weren't able to diagnose before. We weren't able to... We wouldn't even think of attempting them. And now we're really doing that and I think it's changing the landscape significantly. This is certainly going to open the door towards therapeutics by bronchoscopy also. So at the same time when you're doing the endoscopy or bronchoscopy, you can even treat lesions once you find them in all one setting and I think that single setting experience is where the future is. So as it stays right now is that anybody who's in the ages between 55 to 80 and have had a 30 pack year exposure to tobacco, which means they've smoked for example, one pack a day for about 30 years, that's a 30 pack exposure, and they are either current smokers or have quit within the last 15 years, they're eligible to get a low dose CT scan to see if we can pick up suspicious nodules early.
Dr. Rohit Kumar: How it's different for a patient over here is that the whole experience is combined in one day. A patient can come in the morning, be assessed to see if they fit eligibility criteria to get a low dose scan. They go the same time, get the scan and then come back right away to discuss the results of the scan. There is no waiting. They don't have to get the scan, wait for a few days and know what to do after that. And if something is found, they're channeled into the right care process right away. Whether that means seeing a surgeon or getting a biopsy or hopefully, in most situations, it's just getting a followup scan. So that anxiety element, that weight element, that's all taken care of in that situation.
Andrew Becker: He thinks teamwork, in all of its forms, makes a big difference.
Dr. Rohit Kumar: We do a lot of multidisciplinary cancer care. So for our patients, that means that most complex patients can discuss, in a tumor board fashion, where there are pulmonologists, oncologists, radiation oncologists, surgeons and radiologists, plus pathologists, looking at everything together. It really elevates the patient care to a different level. The patient might be seen by a pulmonologist first or by an oncologist first, but when it's discussed together as a team, an easy clear platform or clear work actionable plan gets put into effect. And it's very easy to then channel people into, "You need to get this test done first or see this doctor first." And the plans can change accordingly.
Dr. Rohit Kumar: When I was in a training about 10 or 12 years ago, 12 years ago I would say, and then I would go and see a patient who had advanced lung cancer. I didn't have much to tell them. In fact, I would be very worried about, "What am I going to go say? You just have a few weeks to live?" Now that is completely changed, so I feel really good that now I can go and tell them, "Hey, listen, all that you've heard about the few weeks left, a few months left, that's all out the window. I don't know. It all depends on how you respond to these new therapies." So knowing that just gives us a lot of reassurance as well [inaudible 00:00:05:40]. It's helpful and it's great for the patients.
Andrew Becker: We'll be right back.
Speaker 5: Cancer advice from someone who knows.
Bob Lougheed: I'm Bob Lougheed, pancreatic cancer survivor. The most important thing I've learned in facing cancer is you have to go to a facility that knows what they're doing. The minute I met my Fox Chase team, they walked me through the procedure, told me exactly what they would do. I knew I was in the right place. Turns out I was in a great place. I can't say enough good things about Fox Chase.
Speaker 5: Where you start matters. Fox Chase Cancer Center, 888-369-2427.
Andrew Becker: This is Connected by Cancer. I'm Andrew Becker. Cancer is many different diseases, not just one. And many different disciplines have played a role in turning the tide from early detection to diagnosis to treatment. Recent advances in surgery, for example, are redefining not just how we approach care, but also how we view cancer culturally. Sometimes it seems like even the surgeons themselves can't believe how quickly things are changing.
Dr. David Chen: It is amazing for me to look back at what I was trained to do and the surgeries that I did as a resident and even the surgeries I did as I started my practice, and in 15 years being at Fox Chase Cancer Center, my surgical schedule and the case log as they call it, is completely different than what I started with.
Andrew Becker: Dr. David Chen has been a urologic surgeon at Fox Chase for 15 years.
Dr. David Chen: I'm a specialist in the surgical treatment for cancers of the urinary system, and that commonly is addressing prostate cancer, kidney cancer, and bladder cancer. Those are the three most common that we would see in our field. And then also we take care of less common but also fairly well known issues like testicular cancer, adrenal cancer, penile cancer, things that are more rare but but also serious problems. Most operations really are less invasive that we can do more and more surgery of many types. But especially in urology, in urologic oncology. The great majority of surgeries we do are minimally invasive and sometimes that can be with older laparoscopic equipment, which is still very effective and more commonly using this robotic instrument and being able to do complex surgery through key holes, as they call it, is really, I think a revolution that continues to advance.
Dr. David Chen: And so more and more surgery, which was thought impossible except in traditional ways, can be done with less invasive approaches and that helps the patient to a large degree and is an adjustment for surgeons. But I think for people who have now grown up in the era of this kind of surgery, in this training, it's just looking at things a little differently. The medicine we have and some of that is some of the newer drugs, like immunotherapy, converts something that was life threatening to a chronic disease that you can live with and hopefully live with in a way that's really vibrant and you do what you normally do and you maintain your quality of life and it not be gone forever, but we hopefully can convert it to something where you die of old age, hopefully.
Dr. David Chen: I see a lot of patients who come in and they've heard about their diagnosis and they are mentally really at this state of confusion that they're worried about dying and that's a natural reflex. And yet at the same time, they're paralyzed on what to do because the idea of cancer and they're having cancer has just given them this new look that they don't know how to react to it. And having more and more cancer survivors really gives, at least I think the opportunity for people to understand cancer isn't a death sentence. Cancer isn't always going to wreck your life and change how you live in a huge way.
Dr. David Chen: It certainly sometimes can, but the ability to have newer treatments and minimally invasive surgery and these therapies that can make it a chronic disease, I think there's going to be an adjustment in how we culturally view what cancer is and what it means to have cancer. But I think it's all a good thing that we can learn to live with life having cancer as much as people have learned to live with life with kidney failure and dialysis and that was a huge issue many years ago and remains a huge issue. But people are able to resume their life even if they need dialysis or need treatment like that.
Dr. David Chen: I think being at Fox Chase every day, I really see it as a privilege that I get to be at a place that has had groundbreaking discovery and also doesn't forget about the patient. And so patients come here and they remark on their being treated at a personal level as an individual and not being part of some bigger system or some dataset or some point on a curve. And that's an important priority that everyone here has. And being able to think the two come together because we are moving forward with developing new treatments and extending how we take care of patients to make progress in treating the cancers and hopefully, as much as we can, curing people and as much as we can, extending their life and as much as we can, if we can't do either of those things, allowing them to enjoy and have a better quality of life for what days they have.
Dr. David Chen: And I think what remains to be exciting in the future is there probably will be more and more opportunity to treat cancer with this whole approach of what's referred to as de-escalation. We're used to throwing the kitchen sink and doing everything and doing chemotherapy and radiation and surgery and multiple things get done. And hopefully the more we understand the specifics of the problem and we are able to see improvements in imaging and being able to say where these tumors are, we're able to really more directly treat the area and avoid normal parts of the body. And that's getting done with surgery and being more precise with surgery. And we don't have to take out a whole kidney if we can take out a portion. And in the future, we're looking at not treating the entire prostate because we can treat the area with cancer. And so more and more developments are right around the corner, which I think is really exciting.
Andrew Becker: Dr. Martin Edelman, Chair of Medical Oncology and Deputy Director of Clinical Research at Fox Chase has also been pleasantly surprised by the rate at which cancer care is evolving. In fact, he says it can be challenging for doctors to keep up.
Dr. Martin Edelman: At a place like Fox Chase, we're very specialized and I think that's a great advantage. Somebody comes to Fox Chase, they're not seeing a general oncologist. I think general oncologists do a great job, but these days it's hard to even stay up with narrow areas. The field has progressed a great deal. There are many nuances to various treatments. And so we rely that if it's a breast cancer patient, we have specialists in breast cancer. If it's a bladder cancer, genitourinary cancer patient, we have specialists in that area. My own field is lung cancer. And it's been actually very difficult to stay up because the amount of progress the last few years has been dramatic.
Andrew Becker: Edelman says that one of the quantum leaps that have occurred around cancer treatment is the idea that the latest breakthrough, whatever that happens to be, doesn't replace the previous breakthroughs. It actually joins them.
Dr. Martin Edelman: So during the chemotherapy era, the drugs that we had were pretty unpleasant to people. And you'd have a lot of hair loss, a lot of other problems. So some years ago, I played a significant role in development of a regimen, carboplatinum gemcitabine, which is now, people say, "Oh, that's ancient." But at the time, it was relatively easy for people to take. They don't lose their hair. I played a small role in development of the anti-nausea drugs that have transitioned treatment from the inpatient to the outpatient basis. So this was a well tolerated, effective regimen that, in its day, was quite excellent and is still utilized today in a large number of patients. Still has a role and where we're going today is to further develop so-called targeted therapies, where we can specifically identify who will benefit usually on the basis of a specific mutation or protein abnormality.
Dr. Martin Edelman: As well as the immunotherapies which are broader. And there's overlapping aspects. So for example, immunotherapy tends to work best when combined with chemotherapy and it may even be that the targeted therapies, we're readdressing this question now, may work best when combined with the older chemotherapies. So there's no... It's not like one treatment is exclusionary of the other. And we also work very closely and combine these treatments with radiation and surgery and individualizing therapy to the right patient is very important.
Andrew Becker: And while decades old treatments are still relevant in modern care, Edelman says immunotherapy has been a game changer.
Dr. Martin Edelman: I'm a medical oncologist, so we treat cancer with drugs. So for example, for patients with advanced lung cancer, when I started in medical oncology, you know more than 30 years ago, when your life expectancy was probably in the 10 to 20% range and that's now the five year life percentage of patients.
Dr. Martin Edelman: So that's really a pretty dramatic change. And some of those patients come along and it's not just that they're sick all the time either they're living full, normal lives. And so this has been a dramatic change and the cure rates at every stage of disease have gone up, durability of response, tolerance of treatment. So I think we've made substantial advances. Still a lousy disease and still a long way to go. I think what we're doing in new technologies is how do you take the advantages that we're seeing in a subset of patients and extend them both to a larger set of patients as well as for the patients who do not get durable benefit, how do we extend the the length of time? So that's our big questions. We have numerous trials that address these issues.
Andrew Becker: But despite all the recent advances in care, he cautions against abandoning the basics in search of the cutting edge. For instance, the idea that in the future we might treat cancers by their biology rather than where they appear in the body.
Dr. Martin Edelman: There's no question that for certain diseases, having a particular mutation, regardless of the tissue of origin, makes it responsive to a particular drug. And probably the poster child for this was something called TRK mutated cancers, TRK mutated disease. But at the end of the day, it's a very small number of patients. Yes, they'll all respond to the same drug. But the reality is that even in many cases where patients disease has the same mutation, their responses may be very much dictated by the tissue of origin. So I think that it's going to be a mix. There will be clearly certain diseases with certain mutations where the presence of that mutation would indicate that they will respond to a drug that might have originally been developed in a different setting. Or alternatively where yes, you've got that mutation, but if you have this tissue of origin, it's more likely to respond to treatment.
Dr. Martin Edelman: So I don't think that the older approach or the existing approach of deciding what you do or originally doing assessments by tissue of origin is going to go away. Furthermore, I think it's important to recognize that even if you had the exact same drug, there are differences in the patient populations. So, for example, in lung cancer, while we certainly have a large number of patients who say never smoked and are relatively young with lung cancer, that may be 10 to 15% of non small cell lung cancers, just 20,000 to 30,000 patients a year in the United States who are fairly significant number though, dwarfed by the number of smokers. The overwhelming majority were former smokers, their median age is 70, so you're dealing with a very different population, a lot of coexisting cardiovascular and pulmonary disease. And being familiar with the population is extremely important as well.
Dr. Martin Edelman: So I think it's like with everything else, it's going to evolve over time. And I think it's a mistake to always be chasing after, the latest shiny object. And I think it's very important to always keep traditional principles of doing the basic things, a history, a physical, evaluating the individual, their studies, and all the latest technology, the molecular biology, et cetera, in a larger context. So you can't just say, "Oh, this patient, her tumor had a [inaudible 00:19:35], and we're going to treat it with this." It's not going to be so easy.
Andrew Becker: Connected by Cancer is a podcast of Fox Chase Cancer Center, and it's produced and edited by Joel Patterson and me, with help from Jonathan Pfeffer. Thanks to Doctors Chris Manley, Rohit Kumar, David Chen, and Martin Edelman for sharing their stories with us. Thanks also to Blue Dot Sessions who provided us with music and to Rocket Summer Productions. Subscribe to Connected by Cancer in Apple Podcasts, on foxchase.org, or wherever you listen. And remember, the content of this episode should not be considered to be medical advice, and no physician patient relationship is implied. I'm Andrew Becker. Let's stay connected.