Cancer Lungs

[music playing] mika sinanan: so welcome tothe 2016 mini-medical school. i'm dr. mika sinanan. i'm a member of thefaculty, professor in the department of surgery. i'm a gastrointestinalsurgeon working in the area ofinflammatory bowel disease and in colorectal cancer,laparoscopic, minimally invasive surgery, some ofwhich i told many of you

about last year. and i think many of you arecoming back for another year or in fact,sometimes many years. so welcome back. we have a great program. and in fact, i thinkmany of you have seen that we have sold out thisyear for mini-medical school, so that's a great tribute tothe quality of the speakers and to the interestof our community.

let me introducemy co-moderator. virginia broudy: good evening. i'm delighted to be here andto co-host this with mika and to organizethe series for you. i hope you'll enjoy it. i'm virginia broudy. i'm the chief ofmedicine at harborview and the vice chair of thedepartment of medicine. my particular areaof expertise is

taking care of people livingwith hiv who also have cancer. i'm very proud to work atharborview, our trauma center, burn center, and wherethe mission of medicine is always before you. and so mika i wouldlike to welcome you to the series this year. thank you for coming. mika sinanan: so youheard a little bit of a disclaimer at the beginningabout taking photographs

and video and so on. another little disclaimer,just for those of you who are new-- thisseries of six seminars doesn't actually give you alicense to practice medicine, just in case you thought--maybe in the areas that you hear about today,in cancer map and cancer care development, but notgenerally, though we invite your further interest andparticipation in future years. let me tell you a littlebit about uw medicine.

this slide here showsyou all the entities that make up uw medicine,including harborview, uw medical center,northwest hospital, valley, the neighborhoodclinics, uw physicians, of which i have thehonor of serving as the president, theschool of medicine, and airlift northwest. our mission for uwmedicine is to improve the health of the public.

and the specific ways we dothat-- and mini-medical school is a part of that-- are toadvance medical knowledge, to provide outstandingprimary and specialty care to the peopleof our region, and to prepare tomorrow'sphysicians, scientists, and health care professionals. we in uw medicine alsohave a regional network. that's part of oureducational and part of our clinical network.

we serve five states--washington, wyoming, alaska, montana, idaho. and we're the onlymedical school that actually covers amultistate region of this size, just under a quarter ofthe land mass of the us. this program is consideredto be a benchmark for academic models oftraining and especially in primary andrural medicine care. and here's a mapof the wwami states

to just give you an idea aboutthe scope of uw medicine's coverage. there are lots of peoplewho work in uw medicine. 25,000 employeesrepresent the staff-- about 4,500 students andtrainees and about 2,300 employed faculty membersacross all of the entities as i described to you. each year in uw medicine, wehave about 64,000 admissions to our four hospitals and about1.3, actually 1.4 this year,

outpatient clinic visits. so we have a very greatdepth of care regionally, and that's spanningprimary to tertiary care. we are, from aninstitutional standpoint, ranked as one of the topprimary-care medical schools. and this has been a continuousranking as number one since 1994. we are ranked among the topfive to 10 medical centers by us news and world report.

and the school of medicine isin the top two or three funding centers for the nationalinstitutes of health. so we have a mission as partof uw mini-medical school to help fit you intoour training program, to inform you inan interactive way, so lots of qa opportunitiesabout the biomedical sciences, all the way fromresearch to patient care. and you'll hearabout that today. we want to helpyou better develop

an understanding ofwhat medical schools do, what health careprofessionals do, and what the field ofmedicine and medical care, health care, both wellness careand illness care, are about. we want to create a partnership. so we see this asthe first step in it and look forward tobuilding on that partnership over the next six weeks. you've seen theschedule on the website.

we have a great session today. and i'll introducethat in a second. next week, february 9, we have atopic, what's bugging your gut? and three specialists onthe gut biome and about gastrointestinal care, doctorsanita afzali and christina surawicz and dr. ingridswanson, will be speaking. and that's going to bea really great session. so make sure that you setaside time to come back. you can read about theother topics, all of which

are going to be excellent. we have reallyexcellent speakers. both ginny and iare looking forward to learning a lot from them. and more information isavailable on the website. so the presentationswill be available the next day on ourmini-medical school website. it's being taped forlater presentation. many of you have seenpast years shown on uwtv.

in fact, it's one of the mostcommonly watched shows on uwtv. please turn off yourpagers and cellphones. settle back, andget ready to learn. today, we're going to be talkingabout creating a cancer care map. and our two speakers arespecialists in this area. i'd like to introduce dr. dougwood, who-- please give him lots of applause and askgreat questions, because he's actually my boss-- is theinterim chair of the uw

department of surgery,professor and chief of cardiothoracic surgery,and the endowed chair of lung cancer research. his special clinicalareas of focus are in the surgical managementof lung and esophageal cancer, as you'll hear about. and he has nationalresponsibilities in terms of guiding thenational clinical care of cancer and esophageal cancer.

he leads a multi-disciplinarythoracic oncology program here where patients can come inand see a group of specialists in multiple areas to comeup with a comprehensive plan for the managementof their illness, including pulmonary doctors,thoracic surgeons, oncologists, and radiation oncologists. he received his trainingat a small school in an eastern city,harvard university. spent a little timethere getting trained,

went to australia andthen came out here. early in the '90s,he had a role also in being the medicaldirector for a number of cruise shipsgoing to antarctica and to other odd places. and i remember some questions. i think he did an appendectomywith a kitchen knife on one of those cruise ships. so anyway, let meintroduce dr. doug wood,

talking about saving lives. [applause] doug wood: well,thank you, mika. and you weren't supposed totell the story about the kitchen knife. it was not a kitchen knife. i actually used realsurgical instruments. but it was in antarctica. this is great.

i mean, i didn'treally know what to expect in terms of howmany people would be here. and it's great to see anearly full auditorium. and i'm glad you pointedout that there's actually no degree granted from this,because i think, actually, over the years, youcould get fairly close to a full medicaldegree if you just continue to come to mini-medical school. and i'm going to talkabout a couple things.

and then dr. martinswill be talking after me. and i'm going to tell,really, two stories. one is a story about earlydetection of lung cancer, why it's important, how welearned about its importance, and how it becamepolicy, and sort of what the imperative is there. and i'm going totell another story about how we improve patientinvolvement in their care and quality andstandardization of outcomes

and care for patients thatwe're treating for lung cancer. so i'm going to tell these twodifferent stories about lung cancer care. but i'd like to start offby telling people what a huge problem lung cancer is. because if we look at thisgraph, you can see at the top it says lung cancer's theleading cause of cancer death in every ethnic group. and that's forboth men and women.

and it's this goldbar on the left. and you can see that if youlook at all the next cancers, more people die of lungcancer than the next four cancers combined, thancolorectal, breast, pancreas, and prostate cancer. if you add all of them together,more people die of lung cancer. and in fact, the sixth mostcommon cause of cancer death is lung cancer in never-smokers. so it's really anenormous problem

and in fact, secondto heart disease, it's the number-twocause of death in the united states overall. and you might say,well, why is that? because we don't paya lot of attention. i know we're notsupposed to smoke, and we've takencigarette ads off the tv. but if you look atother common cancers like breast,prostate, and colon,

those were often detectedat an early stage. and we have screeningmodalities for those to try to detectthose cancers early. and if we look at thegraph that's on your right, you can see that wecan detect cancers of breast, prostate, andcolon at an early stage fairly commonly. and they have muchbetter outcomes when we detect themearly than lung cancer,

which most commonly wedetect at a late stage, at a stage where we're usuallynot able to cure patients, although we're makinga lot of progress, even in late-stage lung cancer. i'm very involved with anational organization called the national comprehensivecancer network, which is really our main organizationin the united states to provide guidelinesfor cancer care that tell doctorsand other providers

what should we do for patientswith different cancer diagnoses and different stages of cancer. and you can see this saidjust five years ago, we do not recommendscreening for lung cancer. so just very recently,screening was not considered a part of thetherapy for patients that would be at risk of lung cancer. and there's a goodreason for that. it's not just because the peoplemaking those recommendations

don't care. they actually care a lot. i'm one of those people. it's that we haddone many studies using a chest x-ray to tryto evaluate for lung cancer. and none of those studiesshowed any effectiveness in early detection thatchanged people's lives. but more recently,with a ct scan, there have beenmany studies that

show that if we do low-dose ctscans, which i'll now just call ct scans, one can oftenidentify early cancers and identify them ata stage where they're treatable and could havesurgery or other curative-intent therapy with a betterchance for cure. but the problem isalthough one could identify that it was possible todetect early cancers, it wasn't actually clearthat it lowered mortality across the whole group ofpatients with lung cancer.

and that might seem confusing. and i'm going to try toexplain it in just a second. so when we're consideringscreening people for cancer or otherdisease, there's several thingswe're looking for. first of all, we'd like it tobe a really sensitive test, meaning we'd like it tobe able to detect a cancer or other illness with ahigh degree of accuracy. we'd also like it to onlydetect the things that

were really important andnot detect other things, what we call false positives. and that's often a problem withany type of cancer detection is false positives, findingthings that don't matter and then doingstuff about it that might actually hurt people. and then in terms ofa social construct, we care whetherit's cost-effective and widely available.

it's not that useful tohave a screening test that costs a milliondollars and it's only available in three centersin the united states, because it's not availableto the general public. so i'm going to actually putout here a couple of really complicated conceptsthat often even doctors don't understand well. because i think it's importantto recognize why there's a difference in screening thatcan appear to be effective

but maybe doesn't have as muchbenefit is you might think. and i'm going to point outa couple of differences. so one is something thatwe call a lead-time bias. that means thatit's an aberration of how we detectcancer in terms of how the outcomes are perceived. so we might have two people,maybe dr. martins and myself, and we're both goingto get lung cancer. sorry, renato.

and one of us gets a ct scanthat identifies it today. and the other onedoesn't get a ct scan, and it's not identifieduntil a year from now. but we both dietwo years from now. it would appear that becausemine was detected today, that i lived two years, twiceas long as dr. martins did from the time of hiscancer being detected. but it's artificial. it was just because we lookedfor it, not because we actually

did any better incaring for that patient. that's often a littlecomplicated to understand, and maybe the bottom one calledoverdiagnosis bias can also be complicated to understand. but there are patientswho will have lung cancer and never die from it. now, one aspect is, i might notmake it home tonight, because i might be in a caraccident on the way home, even if i have lungcancer right now.

but even more importantly,we've learned more and more that there are lung cancersthat grow very slowly. and it may neveraffect someone's life. and what we'd like to knowis if we know those cancers, and we havereasonable confidence that nobody's goingto die from them, they might be something wecan observe rather than treat. so these are theissues that confound some of the early studiesin doing ct scans that make

appearances of improvement. so how we fix those typesof complicated issues is we do a big study. and that means usually anexpensive study, as well. so the nationallung screening trial was a really importantand landmark study that was recently completed. and i won't go throughall of the details, but to tell you that therewere over 53,000 people

in the united states randomizedto either get ct scans or chest x-rays. they're all people thatwere 55 to 74 years old. and they all had smokedat least 30 years. so that's a high-risk populationof patients for lung cancer. and this study wasimportant because it showed when one comparesthe patients that had ct scans from thepatients that just had chest x-rays, the patientsthat had ct scans had

a 20% lower risk of death, lowermortality, from lung cancer, and actually almost 7%lower risk of death overall. so by having a ctscan, these patients died less frequentlythan the patient that did not have a ct scan. but it was a select groupof patients that were at high risk for lung cancer. so this, for the first time,given all the other studies, definitively demonstrated thathaving a ct scan, if you're

in that high risk group,can lower the risk of dying of lung cancer. so a really important finding. and many of you probablyknow about this. you saw it in the news,news about ct screening, news from the new yorktimes, "a cancer battle we can win," from thewall street journal, "deaths from lung cancercurtailed by a screening test." so this was everywherein the press.

so many of you arefamiliar with it. and that results inwork that we then do to create guidelinesof then how should we take this scientific informationand direct it into how we want to recommend care for patients? and this gets back to thenational comprehensive cancer network, or the nccn. and this was thefirst guidelines developed for lungcancer screening

after the publicationof that important trial. and this guidelinesis on a website. it's actually availablefor you, for the public. it's not just for physicians,about lung cancer screening. and i'm going to showyou in a few minutes, there's a part that's even forlaypeople, not for physicians. and i had the privilegeof leading this panel that was made up of specialistsin medical oncology, in pulmonary medicine,in thoracic surgery,

in thoracic radiology,in family practice, in epidemiology,pathology, so had a wide breadth of specialistsfrom around the country that came together to crateguidelines to help doctors and their patients know how tohandle a risk for lung cancer and whether to be screened. and then this resultsin an algorithm that helps us say whichpatients are at high enough risk so they should have a ct scanand which patients should not

have a ct scan becausethe risk isn't high enough for it to be worthwhile. that is, there could beharms from doing that. and i won't go throughall of that algorithm. it's not important for this. but part of this is toidentify there are benefits but also risks of screening. and i think that we often thinkthat there's only the upside, that we can detectcancer earlier

and that's gottabe a good thing. but there are otherrisks of that. and when we talk aboutconcerns of lung cancer, some of the concerns of thatwe may have overestimated how much benefit is it isfor people or underestimated how much harm there is. when we're considering screeningor other preventive services, often benefits and harms arerelatively close together. so it's a close call of whetherwe recommend something or not.

and as physicians, we'reunder the hippocratic oath of doing no harm. so we care a lot aboutnot recommending something that might harm people. however, when we're talkingabout screening or preventive services, harmcomes in two forms. one of those forms is theunintended consequences of doing the screening. and i'll talk aboutthose in a moment.

but the other harm can be if wedon't screen people that would benefit from being screened. so both of thoseare possible harms. and we'd like to get it right. and there are essentiallytwo philosophies of limiting harmswhen we're considering screening people for lungcancer or for other things. one is limiting howmany people get it. and by doing that, if wereally narrow and are really

restricted about it,we can prevent harms by not exposing peopleto the risk of being screened or having a ct scan. and in a sense, weuse policy to override what we call shareddecision making, which is a dialogue between patientsand their doctors about what is good for them. but there's another wayto minimize the harms, and that's to do thescreening but to improve

how we care for thepatients that are screened and how we do it and makingsure we minimize the evaluation effects, minimize the testingthat might have harms, and that we makesure that there's the appropriate expertise inthe doctors and other providers that are caringfor those patients. so this is one slide ofthe algorithm that shows, ok, somebody gets a ct scan. now what?

they have a littlespot in their lung. is that spot important or not? do they need a biopsy? do they need a surgery? or do they justneed another ct scan in a year to see what happened? and we actually haverecommendations exactly to help doctorsand their patients know when it's this sizenodule and it looks like this,

this one can be observedfor a period of time. it doesn't necessarilyhave to have another test. on the other hand,certain other nodules might be veryconcerning for cancer and need more invasive testing. and the important principleof this is at the title, and the detail that you can'tsee very well is not important. but the americancollege of radiology, which is the large professionalsociety of radiologists,

have developed avery algorithmic way of labeling lung nodules tohelp with that management. and it's called lung-rads. and when we actually lookat that previous study that i showed you, thenational lung screening trial, a vast majority of thespots in people's lungs that were detectedwere false positive. they weren't cancer at all. but if you takethis new information

from the americancollege of radiology, applying lung-rads tothose same lung nodules, we can decrease those falsepositives by about 50% to 75%. so that's the aspect ofimproving management. so that's what iwas talking about. we've learned somethingabout managing those nodules so that 50% to 75%of the time, we're actually not doing othertesting that would potentially cause harms, like abiopsy that somebody

could have complications of. this is the partthat i was relating to that-- a very niceaspect of the nccn is that they also createpatient-friendly guidelines that take the sameguidelines and put it into lay language that'seasy to understand. and those are also availableon the nccn website. so what's happened after thenccn made recommendations to do lung cancer screening?

well, all of thesecolumns are in green because all of theseother organizations have likewiserecommended lung cancer screening in the united statesand canada and in europe. so these are allmajor institutions. there are some of the detailsof what they've recommended elsewhere but major institutionsin the united states and in europe. so that ought to raisethe question, lung cancer

screening, can i get it? and one question is, well,what is lung cancer screening? and it's important torecognize that it's not just getting a ct scan. lung cancer screeningis an involved process. it involves expertise of doctorsand radiologists and followup, so that we do thiscareful management that i just outlined. it's not just gettinga ct scan and saying,

hey, doc, do i have canceror not, and then walking away and saying that all is good. it's really a process. it's not just a single ct scan. is there a program near me? most likely, there is. the programs are developingfairly significantly now, as this has been rolled outand become policy that i'll talk about in a minute.

and i'm going to talk more aboutwill your insurance pay for it and how much willit cost when we talk about how these guidelinesbecome health care policy. and this is a littleeducation of your government and your insurance companiesand how they affect you at work. because this is all new,regarding lung cancer screening. so there are private insurers. many of us have them.

and they can make independentdecisions on their own about whether to cover somethinglike lung cancer screening. but the next line, the unitedstates preventive services task force, uspstf for short,is the national body that is assigned the taskof creating guidelines for preventive serviceslike lung cancer screening. and when they decide something,now under the force of law under the affordable careact, that becomes law. and patients are covered byobamacare or by the affordable

care act under law intheir private health plan. but just to make itmore complicated, that doesn't include medicare. and about 70% of patientsthat get lung cancer are medicare patients. and so although the unitedstates preventive services task force creates policy forall private insured patients in the united statesin terms of screening, they do not for medicare, whichis a whole separate process.

so it gets complicated. so those results ofthat national study that i talked withyou about were released in november of 2010. 11 months later, there wereguidelines from the nccn about lung cancer screening. three years later, there wasno decision by the uspstf. four years later, there'sstill no decision by medicare. and that's where policyand advocacy comes in play.

that's where we goto washington, dc and meet with yourcongressman, my congressman, educate them aboutwhat the issues are that affect theirconstituents and patients, meet with administratorsfrom medicare and bring pressure tobear on policymakers about importantpreventive services like lung cancer screening. and this is testifyingin a senate briefing

at the us capitol aboutlung cancer screening. and it works. so on december 31, 2013,the united states preventive services task force also agreedin recommending lung cancer that became effectivejanuary 1, 2015. just a little over a year ago,patients privately insured were covered with no co-pay forpreventive services for lung cancer screening ifthey were eligible. but like i said, thatdid not affect medicare.

and medicare did not follow thatdecision and was evaluating it. this led to a coalition ofprofessional organizations, the american collegeof radiology, the society ofthoracic surgeons, and a patient advocacy group,the lung cancer alliance, banding together to workon educating medicare administrators about theimportance of lung cancer screening for medicarebeneficiaries. and somewhat surprisinglyto us, medicare

brought together an expertpanel to evaluate that. and that expert panelrecommended against lung cancer screening, in conflictwith all other guidelines. and so we went harder to workand worked on educating public. and this is an editorialin the wall street journal, you can see, from abouta year and a half ago. we worked with congress,working with both senators and congressmen, sothat they were applying some of the pressure ofissues regarding lung cancer

but most importantly,we worked a lot to educate themedicare administrators about the importance of lungcancer screening for medicare beneficiaries and addedto this correlation and actually ended up with50 professional societies, major cancer centersaround the united states, and universities thatwere all signatories to this letter advising medicarehow to do lung cancer screening and how to do it responsiblyand in a way that would benefit

medicare patients. and this shows you alittle bit of the data that we gave to them. so interestingly, whenwe talk about screening, we use weird numbers, likenumber needed to screen. and what we mean ishow many people do we need to screen to save a life? and that's a measure of howefficient a screening test is. and it mightsurprise you that you

have to screen a lot ofpeople to save a life. that's ok. it's great to save a life. but you have to screena lot of people. but you can see that you needto screen much fewer lung cancer patients at risk than patientsat risk for other cancers. it's about three- to five-foldless or more effective. and this maybe brings it home. the curve on your left showslung cancer survival rates

within a screening program. that's about 85% long-termsurvival, five-year survival for patients that have lungcancer detected in a screening program. and the curve on yourright is the standard curve of survival for patients withlung cancer, what it really looks like in theunited states today. so you can see thedramatic difference in what we can accomplish ifwe can detect patients early.

and medicare agreed. in spite of theirexpert panel, medicare agreed that theywere going to also pay for lung cancer screeningfebruary 5, so almost exactly a year ago, 2015. and this is enormouslypositive news. this is huge news inour world of caring for patients with lung cancer. there's almost 9million patients

that would be eligible forscreening in the united states. and lung cancer screeningis estimated that it would save over 12,000 lives. and if we extend the criteriaas suggested by the nccn, there's another 2 millionpeople that would be eligible and another 3,000 lives per yearsaved by lung cancer screening. it's a huge impact. the number of peoplethat die each year from lung cancer inthe united states

is about the equivalent ofa 747 crashing every day. so it is really adramatic impact. and the ability to save 12,000to 15,000 lives per year is really incredible. so if i just go to thebottom part of this. the aspect of lung cancerscreening, from my perspective, it's the biggest impacton lung cancer management in my career andprobably my lifetime, in terms of our abilityto change people's lives

and save people'slives with lung cancer. so i'm going to takethe last few minutes and talk about, well, whathappens once we find somebody with lung cancer and how do weimprove how they're cared for. and this gets intous recognizing that there's a lot of variationin care in the united states. this map shows differentrates of medicare expenditures in different areasof the country and different rates of heartsurgery in different parts

of the country. and there's too muchvariation to be explained, that people are reallysicker in redding, california than in denver. so we recognize thatthere's variation in how we care for patientsthat we don't even always understand. geisinger clinic is a majormedical center in pennsylvania that wanted to tacklethis and look at it first

with cardiac surgery,with coronary artery bypass grafting,and looked at what we call unjustifiedvariation in care, things that we don't wantto be different in, as well as something you'reall familiar with as patients, is fragmentation of caregiving. you go to thisdoctor and then you go to this doctor and thisdoctor, and none of them seem to talk with each other.

and perverse payment incentivesof how we reimburse for health care, and often thatthe patient's side is a passiverecipient rather than an active participant in care. this led to a pilot projectwith heart bypass surgery that really involved thepatient and their family, identified a number of areaswhere they wanted to accomplish certain aspects of carethe same way every time, and that they wereevidence-based.

everyone agreed upon them. and they wantedto hard-wire them into how they did thingsso that they would never miss on these things. and when they didthat, they found that they decreasedcomplications of patients by 21% and decreasedre-admissions to the hospital, which are somebody gettingout of the hospital but coming backbecause of a problem,

by 44%, really aremarkable outcome. and then we can also look atother maybe less remarkable outcomes but important onesfrom a social perspective. it decreased how longpeople were in the hospital and improved the financialperformance of the hospital. and so insurers andhospital administrators care about that aspect, as well. it not only allowedbetter care of patients but also less expensivecare of patients.

and so geisinger then didthis for many other areas, for cataract surgery, for hipreplacement, for diabetes care. but it was neverdone for cancer. and then they worked with theamerican college of surgeons commission on cancerand said, we've done this in ourinstitution in pennsylvania. can we do it elsewhere in thenation, in multiple centers, for cancer? and the answer is, let'stry it for lung cancer.

so that's where these twostories come together. and we evaluatedthe patients being cared for for lung cancerin the united states and found out that,surprisingly, they did not get care the same wayinstitution by institution, even though we hadguidelines to tell people how to care for people. and we said, there'sroom for improvement. we can do better, in terms ofhow we care for our patients.

and so the goal of this provencare in lung cancer was to say, can we reliably deliver bettercare in many institutions around the country in patientsgetting lung cancer surgery, decrease their complications,improve their cancer outcomes, and decrease the cost of care? and we wanted to take what wehave, very complex systems, and say, could we simplify them? and can we hardwireour workflows? and can we make thepatient and family

be an active participantin how they work with us and align thoseinterests of the patient and the doctors and eventhe insurance companies so that we're all pullingin the same direction? in this move from a firstclinic visit to just before you go into the operatingroom to features that were in the operatingroom that were then immediately afterwards in a hospital andeven in follow-up in clinic, they were differentprocesses that we

had agreed upon wewere going to follow in every patient, every time,for these patients having lung cancer surgery. and a big part of that wasthe involvement of patients and their family, thatthey would be involved in their care, that they wouldbe involved with helping us do better in their managementwhile they're in the hospital. there were six centersaround the united states involved in the initialphase of this study

but then expanded to 12 centers. and you can see themscattered around the united states,university of washington being one of those centersleading lung cancer transformation of care. and this graph shows that atthe very beginning, on the left, we were only perfect--if anybody's ever perfect-- 40% ofthe time, in terms of accomplishing the thingswe said we wanted to do.

but we got better becauseof feedback and because of paying attention andholding each other accountable to the point thatwe're 90% to 100% getting all of these thingsright every time at this stage. there's been now over 1,300patients treated this way. and we're evaluatingthe outcomes of that. and because we're excited aboutthe potential of this improving outcomes for patientshaving lung cancer surgery, we've said, let'stake it even farther.

let's dream big. can we actually do this forall patients with lung cancer, whether they're havingsurgery or whether they're having chemotherapy or whetherthey're having radiation? even if patientsare terminally ill, how well are we caring for themin their last days of life? all of this is in. we want to beperfect in all of it. and that's the next phasethat we are just moving into,

to look through from thebeginning of diagnosis all the way to, unfortunately,death for patients. we want to bebetter and to agree on how we're going totake care of patients optimally and engage themcompletely in that process. so we're trying to expand thosesame principles of reliability to all stages andtreatments of lung cancer. and it's now involving eightinstitutions nationally, with university ofwashington being a key one.

and we're trying to decreaseunjustified variability of care, to improve outcomesfor patients and decrease costs, and to improve valuein lung cancer care. so i'll finish just by sayingearly detection saves lives. it's a real game changer. this really changes theworld of lung cancer. it's newly endorsed. it's covered now by insurers. but it's important torecognize it's a process.

it's not just getting a ct scan. but also reliablecare is important. it's not justexpertise, but it's quality of that carein terms of developing standardized practicesand decreasing variability in how we care for patients thatimproves outcomes for patients and transforms care. that's what wetalked a lot about. can we make carepatient-centered, put patients

really at the center of care? can we be accountable forthat and still financially responsible? often those things are aligned. and in fact, when we get tothe uw medicine mission, which is to improve thehealth of the public, these things seemperfectly aligned with what our missionis here at uw medicine. early diagnosis decreasesthe impact of lung cancer.

it improves thepatient experience. it improves outcomes. and it's cost effective. and it has an impact atthe individual level, obviously, for the individualperson that has better care or has a chance for cure,whether it might not have. but it has an impacton populations as well, because we can affectthousands of people, not just one.

we like to affectone person at a time, but it's alsoterrific to know we're affecting a population at risk. and we want to accomplishit with a better patient experience and at less cost. thank you very much. mika sinanan: thank you, doug. so we're going tohave some questions. i'd like to ask the audiencehow many people personally

or their family or friendshave been touched by cancer? raise your hands. take a look. you can see many hands. how about lungcancer, specifically? still dozens of patients,people touched by this. so questions fordr. wood-- we're going to take some time to askhim a few questions right now and see whether we can answerany specific questions for you.

there are microphoneson both sides. so i'll start while you'rethinking about questions. you talked about lungcancer in patients who smoke and the targeted surveillance. what about peoplewho don't smoke? what's the risk there? and what do people whohave never taken up the habit-- whatshould they care about? doug wood: well, it'sa great question.

and i think it's onethat people worry about, particularly after they listento talk like i've just given. and the news that iput in the second slide shows that it isan important issue, because it's the sixth mostcommon cause of cancer death. but it's very low risk,meaning even though it's a prominent problem insociety, and each individual has a very low individual riskof getting lung cancer if they don't have the riskfactors relating

almost purely to smoking. and because ofthat, those balances of harms and benefits ofscreening-- the harms clearly outweigh the benefitsfor those patients, meaning the potentialof unexpected findings that we would do things thatwould cause harm to patients are more significant thanthe potential benefit of detecting lung cancer in apatient that's never smoked. so we do not recommendscreening for nonsmokers

because the trade-offdoesn't seem to be there. and it's much morelikely we're to hurt them than help them bydoing screening. speaker 1: i've heard that theywere either trying to develop or thinking ofdeveloping a lung cancer screening with the saliva,just from someone's saliva. doug wood: yeah. so the question is are thereother detection methods like saliva.

and yes, there'sseveral methodologies that are considered forlung cancer screening. and sputum or salivais one of them. it's not a very sensitive test. and so it has been usedfor a long, long time. it's actually been usedlonger than a ct scan. but like chest x-ray, it'snot a very sensitive test. interestingly, thereare some very novel ways of detecting lung cancer thatmay be the move for the future

and that relates tothe air that we exhale. there have beenstudies that show that certain dogs canbe trained to detect lung cancer in a human breath. and if we can figure outwhat that is-- and there's definitely researchbeing done in this-- we might be able todetect lung cancer by just exhaling into a machinerather than getting a ct scan. so there are other aspects onthe horizon and potentially

blood tests. but as of yet,they're not available or not feasible fordetecting lung cancer. speaker 2: i wonderedif you could you expand on the othercauses of lung cancer aside from smoking that mightaffect people who don't smoke. aside from that, whatother populations might be at risk,maybe construction workers or other occupations?

doug wood: yeah, it'sa very good question of other risk factors. and some of them may be obviousto you and others may not. so asbestos exposure isa significant risk factor for lung cancerindependent of smoking. and that can relate tooccupational exposure, for example. secondhand smoke that peopleworry about is harder to judge, because it's very hard to judgehow intense that exposure is.

and so although there'sconcerns about that, it's a little harder toquantify secondhand smoke. radon exposure andother radiation exposure can also increase therisk of lung cancer. none of those by themselves sortof tip the threshold of risk that move that benefit overharm in doing screening. smoking is still byfar the dominant one. but smoking, if you combine itwith one of those other risk factors, may beeven more profound.

speaker 3: that waspart of my question. if you, for example,were a child raised in a household with aparent who smoked nonstop or if you are marriedto someone that smoked and you were breathingin secondhand smoke like that on a regularbasis, not just peripherally, would that put you ina higher risk category? doug wood: it's a good question. and it probably does, butit's hard to quantify.

because it is reallya lot different to be in a roomthat has smoke in it than actually inhalingthe cigarette, if you think about theconcentration of what that is, even if it's overa long period of time. and so for secondhand smokeexposure, like the other risk factors, without beingthe primary smoker, it doesn't seem to tipthe scale towards there being a high enough riskto warrant screening.

mika sinanan: sothis is seattle. and we have liberalmarijuana laws. what about marijuana smoking? they're not goingto ask, but i will. [laughter] doug wood: well, interestingly,i guess i shouldn't say this. but marijuana smoke isnot known as a carcinogen for lung cancer. you can get other things,including infectious diseases,

from smoking marijuana thatcan be very serious as well. so it's not the same aspect. but there are otherthings that it exposes you to that become significant. mika sinanan: soyou're not recommending screening for that problem. please go ahead. speaker 4: i'm notasking you to name names, but as far as that medicareexpert panel that didn't take

the data or input of yourexpert panel into consideration for recommending thescreening for medicare, can you think ofjustifications other than cost that if they were sayingthat it was not beneficial? doug wood: yes. so how could they possiblynot recommend screening is your question, and-- speaker 4: [inaudible]all the doctors who have taken thehippocratic oath.

doug wood: they'rereally smart people. and the fact is, i think allof them's smarter than me. and sometimes you can analyze sowell that you outsmart yourself with something that's actuallyfairly straightforward. but the slide thati showed early on about these aspects ofbalancing risks and benefits and how close they could beand how people are concerned whether the benefits areoverestimated or the risks are underestimated,it relates to that.

they said, well,this was a study. we think in thecountry as a whole, people won't do as wellas they did in the study. so it won't have the sameimpact when it's done broadly in seattle as when it wasdone in these centers that did this study. so it mostly relatesto believing the data but that the data were notgeneralizable to policy. we disagreed with them.

mika sinanan: last question. speaker 5: yeah. i was wondering if therewas any correlation between the chronicuse of bronchodilators and the frequencyof lung cancer. doug wood: no, nonethat i'm aware of. i'm not aware of anyrelationship of bronchodilators and the developmentof lung cancer. so if you have asthma, you'resafe-- safe from lung cancer,

anyway. speaker 6: i have a request. is it possible to dim thelights during the slides? because some of them werevery hard to see back here. mika sinanan: great suggestion. we'll look into it. thank you for raising that. so what you've heard is ascientific question was asked. a study was performed withappropriate statistical

validity to be able toanswer the question. they answered the question. they published that information. but they didn't stop there. they said, this is soimportant to the management of this diseasenationally that it has to be raised to a policyand a guideline level. so first guidelines,then policy, and then escalated even beyond that,so that the government

incorporated it in thepolicies that the government and other payers used to helpdetermine which care is paid for, which care is supported. so that's a progression withlots of patient and advocacy input. and it's a greatdemonstration of how the nih funding, nationalinstitutes of health care funding, actually supporteda change in health care that helps many people.

and it's saved lives. we're going to hearanother perspective on this in about 12 to 15 minutes. we're going to takea break right now. please come backfor dr. martins. thank you.