Medically Speaking #4

Welcome to today's episode of Medically Speaking. Today I have a great guest with us, Dr. Brian Goodman. Brian is one of our thoracic surgeons here at Self Regional, and we have a great conversation today that I look forward to having. So we'll just start with, Brian, why don't you just tell me a little bit about yourself and your background? Sure. I grew up in South Florida, and from there, headed north. I went to medical school in Vermont. I guess at the time, I was really into skiing. I don't know. Spent some time in the north. After completing medical school, I did residency at Allegheny General in Pittsburgh. Then I did a cardiothoracic surgery fellowship at the Ohio State University. And from there, I had kind of the luck of being invited to Harvard, where I did clinical fellowships in minimally invasive thoracic surgery and thoracic surgical oncology at the Brigham and Women's Hospital. And so then after I finished my training, I worked at Geisinger in Pennsylvania and WVU in West Virginia before getting tired of the snow and coming back home, coming back down south. And I've been at Self Regional for about three and a half years, and it's been pretty awesome. Well, Brian, listen, you have really built a great reputation for yourself here in this community. And, you know, I hear often stories from patients where you've really made a difference in their lives. And, you know, we're certainly glad that you're here in Greenwood and serving the community here. One of the neat things that you brought here, maybe we can just talk about this for a minute, is our approach at Self Regional to lung cancer and specifically the pulmonary nodule clinic that you started when you first moved here. Why don't you tell us a little bit about the pulmonary nodule clinic and the types of cases that you see here and a little bit about your practice. Sure. So as far as my practice goes, thoracic surgery is a specialty that deals with essentially the treatment of non-cardiac, both benign and malignant diseases of the chest. And that includes lung, esophagus, chest wall, mediastinum, which is the central compartment of the chest, and the diaphragm. Lung cancer is probably the overwhelming focus of my practice. And when I arrived here, one of the problems or kind of issues that was facing the community was that there were kind of all of these pulmonary nodules that were being found and being sent all over the place. And pulmonary nodules are really pretty common. About actually 50% of people over the age of 50 will have them. 95% of the time, they're benign. They're nothing to worry about. living in the south actually the way that i'll talk to patients about it is it's kind of like you know everybody knows how to deal with moles or things on your skin right and so you know if it's a tiny mole and it's been there forever you're like oh man that's just a mole but if it you know everybody knows all the criteria if you catch your eye you get it looked at and you make sure so most moles are not skin cancer well most nodules are not lung cancer so it's not a perfect correlation but i think it kind of makes sense to people because that's just part of living in the south and um the problem is these things show up all the time um it's estimated that about 30 percent of imaging studies that are performed that image the chest will find a pulmonary nodule and given that there are literally you know upwards of like four to five million chest imaging studies done a year you're talking about over a million incidental lung nodules and so it becomes very cumbersome in uh kind of trying to figure out you know how to manage these particularly if you don't do it all the time you're you know physicians are just looking at you know a report or a study and it says uh you know there's a pulmonary nodule and then what what size matters you know you know some of these as imaging technology has gotten better we can spot things that are one and two millimeters i mean we're talking the thickness of a credit card or two that have almost no clinical significance up to sizes that do matter and although there are algorithms and guidelines for this it's just it's cumbersome particularly for you know uh you know physicians who are already juggling tons of other patient related data and so uh we figured out that uh kind of a central clearinghouse in a central area of expertise that could actually take these things from diagnosis uh or finding them all the way to we're done with them this is what you know this is kind of what needs to be done either you know once or twice and then done or ongoing following it and so that that's been i think um really successful because it's kind of one-stop shopping um doing it kind of managing this as a surgeon you know the majority of these are not surgical issues, but the nice thing is I can own it completely in my practice, can do everything that needs to be done without having to refer a patient to anyone else, and through relationships that I have in the kind of cancer treatment pathway with, you know, pathology, medical and radiation oncology, and interventional radiology, when something does need to happen, it happens very quickly. And so we've really seen a lot of success with that. You know, some of the data that we've reviewed has actually shown that with increased rates of surveillance, and this kind of gets more into screening than actually the pulmonary nodule clinic, that you can just do more and find more earlier. And so the pulmonary nodule clinic is essentially doing that by serendipity you know because these are incidentally found nodules that were imaged elsewhere but what we really want to push for is to continue obviously seeing these patients with incidentally discovered nodules but what we really want to go after are these patients who meet high risk criteria and get them screened so that we can get them in great great points um so uh so that kind of leads me to my next question is uh around lung cancer screening specifically and um so what what are the current guidelines for lung cancer screening who should be screened who should be like considered at a higher risk uh and and should be getting checked out absolutely the uh the risk factors of the definition of high risk have been actually kind of re-evaluated but um Basically, age is probably the most important thing. And so generally we look at people age 50 is kind of what the criteria said. But in these parts, a lot of people will actually start smoking much earlier than that. And so it takes, we think, you know, 30 years of kind of ongoing, you know, 20 to 30 years of ongoing tobacco use. And so, you know, although the criteria for high-risk state age of, you know, 45, if you started smoking at 12, you could absolutely have, you know, 20 to 25 years of constant smoking by the age of 35. And so I think there's a slightly broader definition of high risk here. But as far as the actual, you know, the way that it's defined by the studies and the criteria is age greater than 45 to 50 with 20 years of regular tobacco use. And we kind of at one point said, well, what does that mean? And we use pack years as a definition. So if you smoke a pack a day for 20 years, that's a 20-pack year history. If you smoke two packs a day for 10 years, that's a 20-pack year history, the same thing. Now, you know, a lot of people will, you know, when you ask them about it, they'll kind of nickel and dime you. You know, well, technically for three years I was really smoking only like seven cigarettes a day. But, you know, like we try to encourage people to round up. you know we're not we're not keeping track of this you're not going to get scolded we really would much rather overestimate your risk and your exposure than underestimate it and for those people who are identified as you know quote-unquote high risk and so uh just to summarize that that's age 45 or greater with 20 years of you know smoking history uh it's recommended that they get a non contrast lung cancer screening CT and this is a low dose of scan but very kind of high resolution and these scans are able to pick up very very small nodules and and really lung cancer is very easy to find because it's generally greater than a certain size we think that you know eight millimeters which is just slightly larger than a quarter of an inch is kind of the cutoff and that's very very easy to see what kind of complicates things sometimes when we find the smaller things that you can't really tell what they are yet but then you just kind of follow them and once you know something's there following it is easy it's just there are plenty of people who have never been imaged and so that's what we really want to try to focus on but for high-risk people, getting them in and getting them screened is super easy. I mean, it's literally about 30 seconds of time in the scanner. It's covered by insurance, and it's kind of an in-and-out thing, and we know that in populations that are screened, the incidence or the detection of lung cancer at an earlier stage is much higher. In kind of multiple studies that were done, they showed very clearly that there was up to a 25% increase in diagnosis at early stage. And when we talk about early stage lung cancer, we talk about lung cancer with survival exceeding 60%, whereas advanced stage lung cancer, long-term survival is around 7%. And so the numbers are so bad at the later stages. why when you combine them all together take all comers overall uh you know five-year survival for lung cancer is reported at about 25 still we're making significant improvements uh there's been an improvement of probably over 20 in the survival rates in the last five to ten years um with the you know more and more uh both screening and just incidentally finding things because people get image now more often but um so if you have a 20 pack year history of smoking cigarettes and you are over 45 years old you should get screened for lung cancer and the screening test is a non-contrasted ct scan and just for the audience that requires no iv no pain at all you literally just lay down on the table and they take pictures that's correct and then you get up and you go home that's correct and then you get a report back so it's a very simple screen a much less invasive like colon cancer screening where you have to get a colonoscopy and a whole day out of work and all that you literally can come in on your lunch break get a quick ct and go home absolutely yeah so it's quick and painless screening not to take anything away from screening for other cancers because obviously that's that's really important and uh you know things like mammography and uh and colon cancer screening and colonoscopy right um but to put things in perspective those are kind of much more you know uncomfortable screening tools but they're utilized uh pretty significantly overall screening rates for high-risk populations for lung cancer nationally five to six percent for people that meet criteria for people that meet criteria and way under screen well and here's the most striking thing the number of patients needed to be screened to save a life in the in the high risk lung cancer population is about 360. It is by far the lowest of any cancer screening. So the impact of lung cancer screening is greater than the impact of screening for basically like breast cancer, colon cancer, and anything else combined, but utilization is really low. So there's such a opportunity for impact if we can get the word out. Wow. That's, that's, I think that's really meaningful. So I'm just going to say that back too. So for every 360 people that meet those criteria of being over 45 with a 20-pack year history, for every 360 people that get a screen, you'll find a lung cancer and potentially save a life. Big deal. That's a big deal that we push this and really get screening out there. Brian, can you tell me a little bit more about, say, your involvement in our cancer committee? Let's just talk through that process for a minute. So, um, a lot of people don't know how that works. So if, if you were diagnosed with cancer, we have such a phenomenal cancer program and cancer team here that a lot of people probably don't know about. Tell us a little bit about your involvement on our cancer committee. And like, say, uh, if, if someone, if you were to say, do an imaging or you were referred to screening case, and you found a lung cancer, like what's the planning process for treatment for that cancer right here in Greenwood and talk about a little bit of the advanced care that we provide. Absolutely. So, um, so self regional is part of the American college of surgeons, uh, community cancer program. And, uh, that's a pretty rigorous, uh, accreditation process where you have to meet, you know, strict criteria. And, um, for the cancer committee here, I function as the, uh, cancer liaison physician, and so I'm in charge of basically all the kind of quality control measures and reviewing kind of how we perform in comparison to regional and national benchmarks. And so there are, you know, very strict criteria for kind of who we have available, services we have available how we basically see screen and process patients at the time in which it takes and the way things kind of move through according to kind of both national guidelines and the most current and most state-of-the-art treatments and you know self regional has has done a great job of doing this you know kind of on their own but with the oversight of the American College of Surgeons as a designated you know cancer center we have you know this is not just kind of marketing where we say yeah we do this or that there's you know strict criteria and only certain places do it and so one of the things that we or kind of the way that we look at things is is you know how do we perform as far as you know time from initial presentation to diagnosis and then from diagnosis to first course of treatment we're actually constantly looking at this in a rolling fashion and one of my roles is to be constantly reviewing data and I have to report back to the to the hospital the committee and the American College of Surgeons quarterly on this and we're consistently meeting guidelines for this or exceeding them both you know regionally and nationally but in general if someone presents like to kind of walk through it someone gets sent to me in the pulmonary nodule clinic they have what appears to be a suspicious looking nodule they come to see me in the clinic we review the imaging studies together and that's really important to me to always you know put this put the scans up on the screen and explain to the patients exactly what's going on and kind of you know make sure that they leave knowing what I know mm-hmm and we review that and then if it looks suspicious because a lot of times at this time all we have is an imaging study and that's one of the things where I think we really excel is rather than say well you know let's watch it maybe we need to get a PET scan maybe we need to do this maybe we know with with you know 20 years of experience knowing a patient's history and being able to look at something I can say you know what I'm I think there's a real good chance this is a cancer and rather than kind of guess about it or hope let's just let's just move forward you know and so we can very quickly you know pretty much and very often on the first meeting get everything set up with biopsy PET scan pulmonary function testing if they're a surgical candidate determine all these things and then you know within a week 10 days have everything set up and have all that information once we have all that information the patient is then presented at the multi it's called multidisciplinary thoracic tumor board and that's a weekly discussion with pretty much all of the stakeholders who are involved in cancer care and the complete spectrum of cancer care so it's surgeons radiation oncologists medical oncologists Pathology, radiology, nurse navigators, social work, palliative care, basically everyone that could possibly play a role. And we discuss each individual case, discussing national guidelines and what the best way to proceed is for this individual patient. So each decision for treatment is tailored to the specific patient. So if you are 70 years old and have pretty severe lung disease and are already oxygen dependent and do not have a lot of physiologic reserve, then we're going to come up with a treatment that involves probably stereotactic radiation, which is kind of very straightforward, easy to tolerate treatment. And we're very fortunate here at Self Regional to have quite literally one of the most advanced linear accelerators for stereotactic radiation available in the world. And so that's just amazing that we have that. And so if that's the route, we get that sorted out and give those recommendations and then discuss with patients and their family and come to a decision. If we think that someone is a better candidate for surgery and can have their cancer completely resected with curative intent with surgery, we'll present that as our recommendation for them. And if so, then usually within just a few weeks, we'll get everything all the all the required pre-operative testing and lung function everything done go through the details of the surgery with the patient they want to proceed we get them to the or and and get it done yeah so i mean honestly the the multidisciplinary tumor board to me is one of like it's just awesome you have you as an individual you've got radiation oncology medical oncology, a thoracic surgeon for specific to lung cancer or other types of cancers have the specific specialist that's involved in that care. But to me there's no better way to do it. You have all the players like you said in one room looking at that one individual patient and tailoring the treatment to that patient's specific cancer. To me it can't get any better than that. And to have such high qualified medical staff like yourself and the others you mentioned it in a community our size is is really phenomenal and you know I'm very grateful you're here Brian and the work that you're doing is amazing and I know over the last several years we've really had some significant improvements in in our care of lung cancer patients I thought maybe we could talk about that for just a second and kind of how do we do itself regional if you look at like national statistics and like how are we doing in Greenwood with with treatment of lung cancer specifically or whatever like cancers absolutely you know as as I mentioned earlier as the cancer liaison physician for the American College of Surgeons here I I have to look at this stuff and we're constantly being evaluated on it and it's kind of a point of pride for us because not only are we meeting regional and national standards we exceed we're exceeding them we're literally you know outperforming you know much larger centers that have much larger budgets and much more with regard to resources so time from initial presentation to first course of treatment we're outperforming national centers and we are consistently meeting criteria for breast cancer colon cancer and lung cancer which all have kind of the most specific recommendations and kind of are the the keys to accreditation as really kind of the most commonly encountered cancers but the ones that also have kind of the most data of how things should be done and so if you compare you know the treatment of breast cancer or lung cancer at Self Regional to you know you pick the the market or the you know the institution academic so compared to MUSC in Charleston compared to Duke compared to Emory we meet or exceed the performance of those institutions and will provide you know quite literally the same exact care and from a thoracic surgery standpoint the the neat thing is it's a pretty small community nationally and you know so pretty much all of us know each other and particularly in the southeast region and so if someone ever does have a concern and wants to you know get set up to go you know go see someone at Emory or Charleston or or go to do it's an easy phone call because we kind of all know each other and most of the time I can you know I can count on one hand the number of times that someone has wanted to do that since I've been here because honestly I think there's just so much information available now that you know everybody kind of goes home and you know they They don't find it themselves. They talk to their kids, and they're like, oh, you know, we looked up this and that. And, you know, that looks like that's what you would get pretty much anywhere. But, you know, the handful of times that I have had people go elsewhere, they came back and said, well, we were told they would do the same exact thing, and it would make sense to just have it done right here in Greenwood, which for me that's awesome. You know, I mean, I saw that. You know, so when I was in Boston, people came from all over the world uh to get care there i mean particularly because there is a kind of a very strong focus on on treating you know a couple particular cancers there and so for that reason they they came from elsewhere but a lot of times they would uh you know they would come and have their surgery and then we would talk with their their oncology team at you know at home and go over everything with them and uh you know kind of post-op care and everything but the i mean the traveling and everything was it's just so cumbersome you know and so that was one of the things that was really attractive uh for me and coming here was being able to do that kind of stuff here you know in greenwood to see the insight that you know self regional and the the board and and uh the the people who kind of think about these things you know they they realize that there was a real need for this in the in the region and uh you know it it's very satisfying for me to be able to offer you know this kind of world-class care that you may have thought you needed to travel someplace else to go get right here and and that's that that that pretty much keeps a smile on my face every day you know i mean it's it's it's very satisfying that's awesome Well, you're doing a great job, and like I say, we certainly feel fortunate to have a, gosh, Harvard Fellowship-trained thoracic surgeon right here in Greenwood, South Carolina. That's one of those things that, you know, you don't, like, you know, I don't make a fuss about that. No, I know you don't brag on yourself. I appreciate your humility as well, but it is awesome to have that level of expertise and training right here in Greenwood and to be able to offer, you know, your skill set to the community for folks that need it. I did want to just maybe change the subject just a little bit. You know, so we've talked about lung cancer screening and kind of who meets the criteria. You know, when we think about kind of looking at lung cancer kind of through a health equity lens, just for just a second, I know you've been involved in our health equity advisory task force. And can you talk about that for just a minute, the health equity task force, and also specific to lung cancer and disparities nationally around perhaps different races maybe not getting the same level of screening or treatments as others? And then specifically, how are we handling that in Greenwood? Absolutely. I think that the Health Equity Task Force is a great initiative that Self Regional has undertaken kind of with an awareness of of kind of our community and trying to uh address uh specific issues that uh may have uh been kind of uh either less obvious or just kind of raise awareness to things and so particularly here where we have a large african-american population there are certain issues that really um uh you know contribute to kind of increased uh both morbidity and mortality in black communities and really interestingly for me uh is uh tobacco use contributes actually to the three leading causes of death uh among black americans and so cardiovascular disease stroke and cancer and it really disproportionately affects the black community um the one of the most striking things i've uh statistics i've seen is that tobacco kills more african americans each year than aids alcohol car accidents drugs murder and suicide combined that's that's how significant uh these disease processes are in the black community and um it's uh it's interesting because even though african americans generally actually smoke less than non-african-american smokers they have higher rates of death from smoking related disease so the thinking on this is it is is an issue with access to care or access to screening kind of medical literacy and education and and things that we probably can move the needle on and so making sure that we do something to increase community education about this improve access to screening and care make it easier for people in our community to get in and get to see someone make it easy for them to get on medications and get titrated make it easier for them if they want to quit smoking to get access to things that can help them because the the data is very clear that these things are really kind of not taking advantage of it as much and so we you know as a whole as an organization there are other issues as well but obviously this one is very near and dear to me so the the Health Advisory Task Force is really trying to focus on you know what can we do to improve disparities in care that really have a significant effect on our community and and and we're like i said hoping to with initiatives kind of improve access that over time will will help avoid some of this basically excess mortality brian so if one of our viewers feels like they meet criteria for needing lung cancer screening in other words again just as a summary it sounds like over 45 with a 20 pack year history of smoking cigarettes that's correct um how do they go about getting a screening test the easiest way is probably just to ask their primary care practitioner to go ahead and refer them for that and once the screening test is done if there's no findings that really you know doesn't really need to go any further and if there is anything that needs to be looked at then they'd most likely be sent to me for review and if they don't have a primary care provider they can certainly just contact the thoracic surgery office 725-7900 and we'd gladly help them get it set up perfect perfect brian thanks for being with me today and telling the audience about your practice thoracic surgery or cancer care in greenwood in general and specific to lung cancer and lung cancer screening, and a little bit on healthcare disparities. So appreciate your time today. Thanks for joining us. Thank you. Thank you for having me. Excellent.