Podcasts about general thoracic surgery

In the season premiere of Same Surgeon, Different Light, new co-hosts Dr. Cherie Erkmen and Dr. Sara Pereira sit down with Dr. David T. Cooke, professor in the Division of General Thoracic Surgery at UC Davis Health, and Dr. Thomas Varghese, professor and section chief of General Thoracic Surgery at the University of Utah School of Medicine. Together, they reflect on the surprising and inspiring stories shared throughout previous seasons. The episode wraps up with Drs. Cooke and Varghese turning the tables on the hosts, asking about what's in store for the upcoming season of Same Surgeon, Different Light.

Michael Morowitz, MD, is an associate professor of Surgery and an attending physician in the Division of Pediatric and General Thoracic Surgery. Dr. Morowitz's research focuses on Necrotizing Enterocolitis (NEC), a mysterious disorder of intestinal inflammation in premature newborn infants. His lab studies the microbiome, the vast collection of microorganisms that cover our bodies, inside and out.

Doctors Vamsi Velcheti, Sandip Patel, and Michael Zervos discuss recent updates on the management of early-stage non-small cell lung cancer (NSCLC), including the optimization of neoadjuvant and adjuvant treatment options for patients and the role of surgery in the era of targeted therapy and immuno-oncology in lung cancer. TRANSCRIPT Dr. Vamsi Velcheti: Hello, I'm Dr. Vamsi Velcheti, your guest host for the ASCO Daily News Podcast today. I am a professor of medicine and director of thoracic medical oncology at the Perlmutter Cancer Center at NYU Langone Health. On today's episode, we'll be discussing recent updates on the management of early-stage non-small cell lung cancer (NSCLC), including the optimization of neoadjuvant and adjuvant treatment options for our patients, and the evolving role of surgery in the era of targeted therapy and immuno-oncology in lung cancer.  Today, I am delighted to be joined by two renowned experts in this space, Dr. Sandip Patel and Dr. Michael Zervos. Dr. Patel is a professor of medicine and a medical oncologist specializing in lung cancer at UCSD. Dr. Mike Zervos is the clinical chief of the Division of Robotic Thoracic Surgery and Director of General Thoracic Surgery at NYU Langone. Our full disclosures are available in the transcript of this episode, and disclosures relating to all episodes of the podcast are available at asco.org/DNpod. Dr. Patel and Dr. Zervos, it's a great honor to have you on the podcast today. Welcome aboard. Dr. Sandip Patel: Great to be joining you.  Dr. Vamsi Velcheti:  Let's get started with Dr. Patel. As you know, over the last decade we've had dramatic advances in systemic therapy options for patients with metastatic non-small cell lung cancer, in both the realms of targeted therapy and immunotherapy. These have significantly improved outcomes for our patients with metastatic lung cancer. What's exciting is that more recently, we've seen the incorporation of these agents, both targeted therapies and immunotherapies, in early-stage non-small cell lung cancer. Dr. Patel, can you tell our listeners about these exciting recent advances and why do you think it's so important to incorporate these personalized systemic therapy options for our early-stage patients? Dr. Sandip Patel: I think it's a great point and a great question. And so, I think one thing to understand is that non-small cell lung cancer is actually multiple diseases. We give it one name based on how it looks under the microscope, but the vast majority of our advances to improve outcomes for patients have come from our ability to understand specific subgroups.  Many of our therapies have had activity in the advanced setting. We have our patients with metastatic or more widespread disease, which naturally led to the thought that could we utilize these therapies in earlier stage disease and potentially increase the rate of cure for many of our patients, lung cancer being the most common cancer killer worldwide. And so to your point, trying to understand how to best treat a patient really involves personalized medicine, typically driven by understanding the genomic profile of their tumor and two of the genes that have graduated from being tested for in the metastatic setting and now in the localized setting are EGFR and ALK. And these in particular are mutations that confer sensitivity to small molecule inhibitors, EGFR with osimertinib, ALK in the localized setting with alectinib based on the data that we've seen.  And so, one of the areas that's been particularly exciting is our ability to maximize a patient's chance for durable remissions by integrating these therapies after surgery, after chemotherapy when appropriate, and continuing generally for a finite amount of time, two to three years depending on the agent in the study we're discussing for these patients. Additionally, immunotherapy, which has revolutionized our treatment of patients with metastatic disease, may be particularly well-suited for the localized setting of non-small cell lung cancer as well. Dr. Vamsi Velcheti: Excellent points, Sandip. You're absolutely right, in the metastatic setting, we've all come to accept molecular testing, sequencing, and biomarker profiling as a standard, but unfortunately, that hasn't quite yet percolated into the early-stage setting. Can you talk about some of the challenges that we face as we have these therapeutic options available now for more early-stage patients? Dr. Sandip Patel: So, I think there are 3 flavors of localized therapy in non-small cell lung cancer. One is the advanced, unresectable stage 3, for which the approach is often concurrent chemo-radiation followed by some form of consolidated therapy. We're about to hear the results of LAURA, which is the study looking at EGFR-mutated non-small cell lung cancer.  For other patients, historically, the treatment has been durvalumab, an anti-PD-L1 directed immunotherapy. The other two are operative treatment of localized cancer: adjuvant treatment after surgery, or neoadjuvant or perioperative, in which chemoimmunotherapy begins before surgery. And testing depends on the settings. For the stage 3 patient who's likely getting concurrent chemo-radiation, they may have a very small amount of tissue, and so often these are done by pulmonary EBUS biopsies and that's how we pathologically confirm that advanced stage 3B. There may not be a lot of tissue available for molecular testing. In fact, if you look at the PACIFIC analysis, just looking at PD-L1, which is just an IHC off a single slide, a third of patients weren't able to even get a PD-L1, let alone a genomic result. And so, I think that's one of the areas of LAURA that's going to be particularly interesting to see as we try to implement it into our practice after seeing the full data.  I think in the adjuvant setting, we're lucky because our surgeons, Dr. Mike Zervos here, will get us a large amount of tissue in the surgical resection specimen, so we tend to get enough tissue to do genomics while they're under chemotherapy, there tends to be time to wait for their genomic result. Where this really gets complicated is in the neoadjuvant or perioperative setting, where time is everything.  The most important thing we can do for a patient in the localized space is get them to the operating room, get them started on radiation, their curative local modality, and that's where we have a time pressure but also a sample pressure because that is a diagnostic biopsy. It's a very small piece of tissue. Initially, there are multiple stains that have to be done to identify this lung cancer as opposed to another tumor. And so that's an area that I think we're going to need additional approaches given that cell-free DNA tends to have lower yield in lower stage disease in giving us a result. Dr. Vamsi Velcheti: Great points, Sandip. How do you deal with this issue in San Diego? The challenge is now we have a lot of trials, we'll talk about those neoadjuvant immunotherapy trials, but we know that immunotherapy may not be as effective in all patients, especially those with EGFR or ALK or some of these non-smoker, oncogene-driven tumors. So, we don't want to be giving patients treatments that may not necessarily be effective in the neoadjuvant space, especially when there is a time crunch, and we want to get them to surgery and all the complications that come with giving them targeted therapy post-IO with potential risk for adverse events. Dr. Sandip Patel: Absolutely. It is a great point. And so, the multidisciplinary team approach is key, and having a close relationship with the interventional pulmonary oncs, interventional radiology surgery, and radiation oncology to ensure that we get the best treatment for our patients. With the molecularly guided therapies, they are currently more on the adjuvant setting in terms of actually treating. But as you mentioned, when we're making a decision around neoadjuvant or perioperative chemo IO, it's actually the absence of EGFR now that we're looking for because our intervention at the current time is to give chemoimmunotherapy. Going back to the future, we used to use single gene EGFR within 24 hours, which was insufficient for a metastatic panel, but it often required five slides of tissue input. ALK can be done by IHC, and so some of these ‘oldie but goodie' pathologic techniques, and that pathologists, if I haven't emphasized, understanding what we're trying to do at a different context is so key because they are the ones who really hold the result. In the neoadjuvant and perioperative setting, which many of us favor, especially for stage 3A and stage 2B disease, understanding how we can get that result so that we can get the patient to the operating room in an expeditious way is so important. There is a time pressure that we always had in the metastatic setting, but I think we feel much more acutely in the neoadjuvant and perioperative setting in my opinion. Dr. Vamsi Velcheti: Fascinating insights, Dr. Patel.  Turning to Dr. Zervos, from a surgical perspective, there has been an evolution in terms of minimally invasive techniques, robotic approaches, and enhanced recovery protocols, significantly improving outcomes in our patients post-surgery. How do you see the role of surgery evolving, especially with the increasing complexity and efficacy of these systemic therapies? How do you envision the role of surgery in managing these early-stage patients, and what are the key considerations for surgeons in this new era? Dr. Michael Zervos: Thanks, Vamsi. Thanks, Sandip. Thank you for having me on the podcast. Obviously, it's an honor to be a part of such a high-level discussion. I have to say, from a surgeon's perspective, we often listen to you guys talk and realize that there's been a lot of change in this landscape. And I think the thing that I've seen is that the paradigm here has also changed. If we were having this discussion 10 years ago, a lot of the patients that I am operating on now, I would not be operating on. It really has been amazing. And I think the thing that stands out to me the most is how all of this has changed with neoadjuvant chemotherapy checkpoint inhibition. I think, for us as surgeons, that's really been the key. Whether it's CheckMate 816 or whatever you're following, like PACIFIC, the data supports this. And I think what we're seeing is that we're able to do the surgery, we're able to do it safely, and I think that the resectability rates are definitely high up there in the 90% range. And what we're seeing is pretty significant pathologic responses, which I think is really amazing to me.  We're also seeing that this has now shifted over to the oligometastatic realm, and a lot of those patients are also being treated similarly and then getting surgery, which is something that we would not have even thought of ever. When you look at the trials, I think a lot of the surgery, up to this point, has been done more traditionally. There's a specific reason why that happens, specifically, more through thoracotomy, less with VATS, and less with robotic. Sandip, I think you guys have a pretty robust robotic program at UCSD, so I'm sure you're pretty used to seeing that.   As you guys have become so much more sophisticated with the treatments, we have also had to modify what we do operatively to be able to step up to the plate and accept that challenge. But what we are seeing is yes, these treatments work, but the surgeries are slightly more complicated. And when I say slightly, I'm minimizing that a little bit.  And what's complicated about it is that the treatment effect is that the chemo-immune check inhibition actually has a significant response to the tumor antigen, which is the tumor. So it's going to necrose it, it's going to fibrose it, and wherever there is a tumor, that response on the surgical baseline level is going to be significant. In other words, there are going to be lymph nodes that are stuck to the pulmonary artery, lymph nodes that are stuck to the airway, and we've had to modify our approaches to be able to address that.   Now, fortunately, we've been able to innovate and use the existing technology to our advantage. Personally, I think robotics is the way we have progressed with all this, and we are doing these surgeries robotically, mainly because I think it is allowing us, not only to visualize things better, but to have sort of a better understanding of what we're looking at. And for that matter, we are able to do a better lymph node dissection, which is usually the key with a lot of these more complicated surgeries, and then really venturing out into more complicated things, like controlling the pulmonary artery. How do we address all this without having significant complications or injuries during the surgery? Getting these patients through after they've successfully completed their neoadjuvant treatment, getting them to surgery, doing the surgery successfully, and hopefully, with minimal to no morbidity, because at the end, they may be going on to further adjuvant treatment. All of these things I think are super important. I think although it has changed the landscape of how we think of things, it has made it slightly more complicated, but we are up for the challenge. I am definitely excited about all of this. Dr. Vamsi Velcheti: For some reason, like medical oncologists, we only get fixated on the drugs and how much better we're doing, but we don't really talk much about the advances in surgery and the advances in terms of outcomes, like post-op mortality has gone down significantly, especially in larger tertiary care centers. So, our way of thinking, traditionally, the whole intergroup trials, the whole paradigm of pneumonectomies being bad and bad outcomes overall, I think we can't judge and decide on current treatment standards based on surgical standards from decades ago. And I think that's really important to recognize.  Dr. Michael Zervos: All of this stuff has really changed over the past 10 years, and I think technology has helped us evolve over time. And as the science has evolved for you with the clinical trials, the technology has evolved for us to be able to compensate for that and to be able to deal with that. The data is real for this. Personally, what I'm seeing is that the data is better for this than it was for the old intergroup trials. We're able to do the surgery in a better, more efficient, and safer way. The majority of these surgeries for this are not going to be pneumonectomies, they are going to be mostly lobectomies. I think that makes sense. I think for the surgeons who might be listening, it doesn't really matter how you're actually doing these operations. I think if you don't have a very extensive minimally invasive or robotic experience, doing the surgery as open is fine, as long as you're doing the surgery safely and doing it to the standard that you might expect with complete lymph node clearance, mediastinal lymph node clearance, and intrapulmonary lymph node clearance. Really, I think that's where we have to sort of drive home the point, really less about the actual approach, even though our bias is to do it robotically because we feel it's less morbidity for the patient. The patients will recover faster from the treatment and then be able to go on to the next phase treatments. Dr. Vamsi Velcheti: In some of the pre-operative trials, the neoadjuvant trials, there have been some concerns raised about 20% of patients not being able to make it to surgery after induction chemo immunotherapy. Can you comment on that, and why do you think that is the case, Sandip?  Dr. Sandip Patel: Well, I think there are multiple reasons. If you look, about half due to progression of disease, which they might not have been great operative candidates to begin with, because they would have early progression afterwards. And some small minority in a given study, maybe 1% to 2%, it's an immune-related adverse event that's severe. So, it's something that we definitely need to think about. The flip side of that coin, only about 2 in 3 patients get adjuvant therapy, whether it be chemotherapy, immunotherapy, or targeted therapy. And so, our goal is to deliver a full multimodal package, where, of course, the local therapy is hugely important, but also many of these other molecular or immunologically guided agents have a substantial impact.  And I do think the point around neoadjuvant and perioperative is well taken. I think this is a discussion we have to have with our patients. I think, in particular, when you look at higher stage disease, like stage 3A, for example, the risk-benefit calculus of giving therapy upfront given the really phenomenal outcomes we have seen, really frankly starting with the NADIM study, CheckMate816, now moving on into studies like KEYNOTE-671, AEGEAN, it really opens your eyes in stage 3. Now, for someone who's stage 1/1b, is this a patient who's eager to get a tumor out? Is there as much of an impact when we give neoadjuvant therapy, especially if they're not going to respond and may progress from stage 1 and beyond? I think that's a reasonable concern. How to handle stage II is very heterogeneous. I think two points that kind of happen as you give neoadjuvant therapy, especially chemo-IO that I think is worth for folks to understand and this goes to Mike's earlier point, that is this concept if they do get a scan during your neoadjuvant chemo immunotherapy, there is a chance of that nodal flare, where the lymph nodes actually look worse and look like their disease is progressing. Their primary tumor may be smaller or maybe the same. But when we actually go to the OR, those lymph nodes are chock-full of immune cells. There's actually no cancer in those lymph nodes. And so that's a bit of a red herring to watch out for.   And so, I think as we're learning together how to deliver these therapies, because the curative-intent modality is, in my opinion, a local modality. It's what Mike does in the OR, my colleagues here do in the OR. My goal is to maximize the chance of that or really maximize the long-term cure rates. And we know, even as long as the surgery can go, if only 2 or 3 patients are going to get adjuvant therapy then 1 in 10, of which half of those or 1 in 20, are not getting the surgery and that's, of course, a big problem. It's a concern. I think better selecting towards those patients and thinking about how to make these choices is going to be hugely important as we go over. Because in a clinical trial, it's a very selective population. A real-world use of these treatments is different. I think one cautionary tale is that we don't have an approval for the use of neoadjuvant or perioperative therapy for conversion therapy, meaning, someone who's “borderline resectable.” At the time at which you meet the patient, they will be resectable at that moment. That's where our best evidence is, at the current time, for neoadjuvant or perioperative approaches.  Dr. Vamsi Velcheti:   I think the other major issue is like the optimal sequencing of immune checkpoint here. Obviously, at this point, we have multiple different trial readouts, and there are some options that patients can have just neoadjuvant without any adjuvant. Still, we have to figure out how to de-escalate post-surgery immunotherapy interventions. And I think there's a lot of work that needs to be done, and you're certainly involved in some of those exciting clinical trials. What do you do right now in your current clinical practice when you have patients who have a complete pathologic response to neoadjuvant immunotherapy? What is the discussion you have with your patients at that point? Do they need more immunotherapy, or are you ready to de-escalate?  Dr. Sandip Patel: I think MRD-based technologies, cell-free DNA technologies will hopefully help us guide this. Right now, we are flying blind along two axes. One is we don't actually know the contribution of the post-operative component for patients who get preoperative chemo-IO. And so this is actually going to be an ongoing discussion. And for a patient with a pCR, we know the outcomes are really quite good based on CheckMate816, which is a pure neoadjuvant or front-end only approach. Where I actually struggle is where patients who maybe have 50% tumor killing. If a patient has only 10% tumor killing ... the analogy I think in clinic is a traffic light, so the green light if you got a pCR, a yellow light if you have that anywhere from 20%-70% residual viable tumor, and then anything greater than that, you didn't get that much with chemo-IO and you're wondering if getting more chemo-IO, what would that actually do? It's a bit of a red light. And I'm curious, we don't have any data, but my guess would be the benefit of the post-op IO is because patients are in that kind of yellow light zone. So maybe a couple more cycles, we'll get them an even more durable response. But I am curious if we're going to start relying more on MRD-based technologies to define treatment duration. But I think it's a very complicated problem. I think folks want to balance toxicity, both medical and financial, with delivering a curative-intent therapy. And I am curious if this maybe, as we're looking at some of the data, some of the reasons around preferring a perioperative approach where you scale it back, as opposed to a neoadjuvant-only approach where there's not a clean way to add on therapy, if you think that makes sense. But it's probably the most complicated discussions we have in clinic and the discussion around a non-pCR. And frankly, even the tumor board discussions around localized non-small cell lung cancer have gone very complex, for the benefit of our patients, though we just don't have clean data to say this is the right path.   Dr. Vamsi Velcheti: I think that the need for a really true multidisciplinary approach and discussing these patients in the tumor board has never been more significant. Large academic centers, we have the luxury of having all the expertise on hand. How do we scale this approach to the broader community is a big challenge, I think, especially in early-stage patients. Of course, not everyone can travel to Dr. Zervos or you for care at a large tertiary cancer centers. So, I think there needs to be a lot of effort in terms of trying to educate community surgeons, community oncologists on managing these patients. I think it's going to be a challenge. Dr. Michael Zervos: If I could just add one thing here, and I completely agree with everything that has been said. I think the challenge is knowing beforehand. Could you predict which patients are going to have a complete response? And for that matter, say, “Okay. Well, this one has a complete response. Do we necessarily need to operate on this patient?” And that's really the big question that I add. I personally have seen some complete response, but what I'm mostly seeing is major pathologic response, not necessarily CR, but we are seeing more and more CR, I do have to say. The question is how are you going to predict that? Is looking for minimal residual disease after treatment going to be the way to do that? If you guys could speak to that, I think that is just tremendously interesting.  Dr. Vamsi Velcheti: I think as Sandip said, MRD is looking very promising, but I just want to caution that it's not ready for primetime clinical decision making yet. I am really excited about the MRD approach of selecting patients for de-escalation or escalation and surgery or no surgery. I think this is probably not quite there yet in terms of surgery or no surgery decision. Especially for patients who have early-stage cancer, we talk about curative-intent treatment here and surgery is a curative treatment, and not going to surgery is going to be a heavy lift. And I don't think we're anywhere close to that. Yet, I'm glad that we are having those discussions, but I think it may be too hard at this point based on the available technologies to kind of predict CR. We're not there.  Dr. Michael Zervos: Can I ask you guys what your thought process is for evaluating the patient? So, when you're actually thinking about, “Hey, this patient actually had a good response. I'm going to ask the surgeons to come and take a look at this.” What imaging studies are you actually using? Are you just using strictly CT or are you looking for the PET? Should we also be thinking about restaging a lot of these patients? Because obviously, one of the things that I hate as a surgeon is getting into the operating room only to find out that I have multiple nodal stations that are positive. Which really, in my opinion, that's sort of a red flag. And for me, if I have that, I'm thinking more along the lines of not completing that surgery because I'm concerned about not being able to provide an R0 resection or even having surgical staple lines within proximity of cancer, which is not going to be good. It's going to be fraught with complications.  So, a lot of the things that we as surgeons struggle with have to do with this. Personally, I like to evaluate the patients with an IV intravenous CT scan to get a better idea of the nodal involvement, proximity to major blood vessels, and potentially even a PET scan. And though I think in this day and age, a lot of the patients will get the PET beforehand, not necessarily get it approved afterwards. So that's a challenge. And then the one thing I do have to say that I definitely have found helpful is, if there's any question, doing the restaging or the re-EBUS at that point to be particularly helpful.  Dr. Sandip Patel: Yeah, I would concur that having that pathologic nodal assessment is probably one of the most important things we can do for our patients. For a patient with multinodal positive disease, the honest truth is that at our tumor board, that patient is probably going to get definitive chemoradiation followed by their immunotherapy, or potentially soon, if they have an EGFR mutation, osimertinib. For those patients who are clean in the mediastinum and then potentially have nodal flare, oftentimes what our surgeons will do as the first stage of the operation, they'll actually have the EBUS repeated during that same anesthesia session and then go straight into surgery. And so far the vast majority of those patients have proceeded to go to surgery because all we found are immune cells in those lymph nodes.  So, I think it's a great point that it's really the pathologic staging that's driving this and having a close relationship with our pathologists is key. But I think one point that I think we all could agree on is the way that we're going to find more of these patients to help and cure with these therapies is through improved utilization of low-dose CT screening in the appropriate population in primary care. And so, getting buy-in from our primary care doctors so that they can do the appropriate low-dose CT screening along with smoking cessation, and find these patients so that we can offer them these therapies, I think is something that we really, as a community, need to advocate on. Because a lot of what we do with next-generation therapies, at least on the medical oncology side, is kind of preaching to the choir. But getting the buy-in so we can find more of these cases at stage 1, 2 or 3, as opposed to stage 4, I think, is one of the ways we can really make a positive impact for patients. Dr. Vamsi Velcheti: I just want to go back to Mike's point about the nodal, especially for those with nodal multistation disease. In my opinion, those anatomic unresectability is a moving target, especially with evolving, improving systemic therapy options. The utilization for chemo radiation has actually gone down. I think that's a different clinical subgroup that we need to kind of think differently in terms of how we do the next iteration or generation of clinical trials, are they really benefiting from chemo-IO induction? And maybe we can get a subset of those patients in surgery. I personally think surgery is probably a more optimal, higher yield to potentially cure these patients versus chemo radiation. But I think how we identify those patients is a big challenge. And maybe we should do a sequential approach induction chemo-IO with the intent to kind of restage them for surgery. And if they don't, they go to chemo consolidation radiation, I guess. So, I think we need to rethink our approach to those anatomically unresectable stage 3s. But I think it's fascinating that we're having these discussions. You know, we've come to accept chemo radiation as a gold standard, but now we're kind of challenging those assumptions, and I think that means we're really doing well in terms of systemic therapy options for our patients to drive increased cures for these patients. Dr. Michael Zervos: I think from my perspective as a surgeon, if I'm looking at a CT scan and trying to evaluate whether a patient is resectable or not, one of the things that I'm looking for is the extent of the tumor, proximity to mediastinal invasion, lymph nodes size. But if that particular patient is resectable upfront, then usually, that patient that receives induction chemo checkpoint inhibition is going to be resectable afterwards. The ones that are harder are the ones that are borderline resectable upfront or not resectable. And then you're trying to figure out on the back end whether you can actually do the surgery.  Fortunately, we're not really taking many patients to the operating room under those circumstances to find that they're not resectable. Having said that, I did have one of those cases recently where I got in there and there were multiple lymph node stations that were positive. And I have to say that the CT really underestimated the extent of disease that I saw in the operating room. So, there are some challenges surrounding all of these things. Dr. Sandip Patel: Absolutely. And I think for those patients, if upfront identification by EBUS showed multi nodal involvement, we've had excellent outcomes by working with radiation oncologists using modern radiotherapy techniques, with concurrent chemo radiation, followed by their immunotherapy, more targeted therapy, at least it looks like soon. I think finding the right path for the patient is so key, and I think getting that mediastinal pathologic assessment, as opposed to just guessing based on what the PET CT looks like, is so important. If you look at some of the series, 8% to 10% of patients will get a false-positive PET on their mediastinal lymph nodes due to coccidioidomycosis or sarcoidosis or various other things. And the flip side is there's a false-negative rate as well. I think Mike summarized that as well, so I think imaging is helpful, but for me, imaging is really just pointing the target at where we need to get pathologic sampling, most commonly by EBUS. And getting our interventional pulmonary colleagues to help us do that, I think is so important because we have really nice therapeutic options, whether it's curative-intent surgery, curative-intent chemo radiation, where we as medical oncologists can really contribute to that curative-intent local therapy, in my opinion.  Dr. Vamsi Velcheti: Thank you so much Sandip and Mike, it's been an amazing and insightful discussion, with a really dynamic interplay between systemic therapy and surgical innovations. These are really exciting times for our patients and for us. Thank you so much for sharing your expertise and insights with us today on the ASCO Daily News Podcast.   I want to also thank our listeners today for your time. If you value the insights that you hear today, please take a moment to rate, review, and subscribe to the podcast wherever you get your podcasts. Thank you so much. [FH1]   Dr. Sandip Patel: Thank you. Dr. Michael Zervos: Thank you.   Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Follow today's speakers: Dr. Vamsidhar Velcheti @VamsiVelcheti Dr. Sandip Patel @PatelOncology Dr. Michael Zervos   Follow ASCO on social media: @ASCO on X (formerly Twitter) ASCO on Facebook ASCO on LinkedIn   Disclosures:  Dr. Vamsidhar Velcheti: Honoraria: ITeos Therapeutics Consulting or Advisory Role: Bristol-Myers Squibb, Merck, Foundation Medicine, AstraZeneca/MedImmune, Novartis, Lilly, EMD Serono, GSK, Amgen, Elevation Oncology, Taiho Oncology, Merus Research Funding (Inst.): Genentech, Trovagene, Eisai, OncoPlex Diagnostics, Alkermes, NantOmics, Genoptix, Altor BioScience, Merck, Bristol-Myers Squibb, Atreca, Heat Biologics, Leap Therapeutics, RSIP Vision, GlaxoSmithKline   Dr. Sandip Patel: Consulting or Advisory Role: Lilly, Novartis, Bristol-Myers Squibb, AstraZeneca/MedImmune, Nektar, Compugen, Illumina, Amgen, Certis, Eli Lilly, Roche/Genentech, Merck, Pfizer, Tempus, Iovance Biotherapeutics. Speakers' Bureau: Merck, Boehringer Ingelheim Research Funding (Inst.):Rubius, Bristol-Myers Squibb, Pfizer, Roche/Genentech, Amgen AstraZenece/MedImmune, Fate, Merck, Iovance, Takeda   Dr. Michael Zervos: No relationships to disclose

David Tom Cooke, MD, Founding Chief of the Division of General Thoracic Surgery at UC Davis, joins the first episode of 2023 to discuss his colleague's specific role in lung cancer screening and intervention, advances to minimally invasive, robotic and bronchoscopic techniques, and evolving strategies in individualized patient care. Episode Highlights 0:14 Intro 1:52 Introducing David T. Cooke, MD 3:23 The role of thoracic surgeons in improving lung cancer screening rates 6:22 Shared decision making in thoracic surgery 8:16 Lobar, wedge resection or segmentectomy? Plus, robotic techniques? 12:22 PET/CT scans in the staging process 13:52 The surgeon approach to stage IV lung cancer 16:02 Patient follow-up—improved mortality and longer life expectancy 18:50 Prioritizing surgery and neoadjuvant therapy regimens 20:48 Thoracic surgeon role in palliative care 22:57 What's on the horizon in the field: robotic surgery 24:17 Outro Check out other lung cancer episodes of Lungcast: Innovations in Interventional Pulmonology with Dr. Carla Lamb  Lung Cancer Screening: Trials, Tribulations & Triumphs with Dr. James Mulshine Future of Lung Cancer Precision Medicine with Andrea Mazzochi Get More From Lungcast Lungcast on HCPLive: https://www.hcplive.com/podcasts/lungcast Lungcast on American Lung Association: https://www.lung.org/professional-education/lungcast Spotify: https://spoti.fi/3YEDxKw Apple Podcasts: http://bit.ly/3jCVevq YouTube: https://www.youtube.com/@Lungcast/videos

Intro: Dr. Thomas Varghese Jr. is the Associate Chief Medical Quality Officer and Chief Value Officer at the Huntsman Cancer Institute, and Chief of General Thoracic Surgery at the University of Utah. Dr. Varghese is a national leader in minimally invasive applications for general thoracic surgery, recognized by Castle Connolly as one of America's “Top Docs”, and is ranked in the top 10% of the nation by Press Ganey for patient satisfaction scores. His research interests bridge the world of Educational Research and Health Services Research, specifically in the arena of optimizing performance at the patient, surgeon and system levels. He created the Strong for Surgery program, which is now a formal Quality Improvement program of the American College of Surgeons, and active at 331 clinical sites across the nation and 3 state surgical collaboratives.Dr. Varghese holds national leadership positions in the Society of Thoracic Surgeons, Thoracic Surgery Directors Association, American College of Surgeons, and the Society of University Surgeons. Dr. Varghese is active on social media and is the Deputy Editor of Digital Media and Digital Scholarship for the Annals of Thoracic Surgery.Questions We Asked: Where did your passion for leadership come from? Who were your mentors and what made that relationship special? Have you found your mentors formally or informally? How can you create a good formalized mentorship program? How do mentors effectively help their mentees find their career path? How do you create a good mentor/mentee relationship? How can those in the majority be allies to minority groups in medicine and science? How do you be comfortable saying “I don't know”? Quotes & Ideas: “Never stop looking for best practices” You can and should have different mentors for the various areas of your life (academic, career, social, spiritual, etc.) “Mentorship is someone with a particular knowledge or skills that shares them with someone else who does not have it on their own.” “A mentor does not always have to be older than you.” Identify OKR (objectives and key results) and set a time deadline for it “An ally is someone who builds a culture of inclusion” and “A leader is someone who betters the culture of those they lead”. Leaders need to be allies. “Are we better today than we were yesterday, and are we going to be better tomorrow than we were today and how do we achieve that.” “Diversity doesn't end because you hire the next diverse faculty. You have to make sure they thrive in their position.” “You don't know, doesn't necessarily mean you don't act.” “MD means make decisions.” “We are living in the greatest time in history.” “Seek your tribe members” Books Suggestions: The 4 Disciplines of Execution by Sean Covey Peter Drucker Start With Why by Simon Sinek Adam Grant 

Medical Doctor (specializing in General Thoracic Surgery) currently practicing at The Cleveland Clinic in Cleveland, OH, Dr. Jim Wudel, joins us this week to answer Kate's 3,574 questions and also explain why he thinks everyone should be more patient with servers. Also? Write a letter to your doctor. They'll love it!  Also, today is my mom's birthday, so happy birthday, Ma! I love you! Get in touch with us directly at servicefromhellpodcast at gmail.com! Cleveland Clinic Resources Dr. Wudel Info

On today's episode, meet Dr. David Tom Cooke. Dr. Cooke is the Section Head of General Thoracic Surgery at UC Davis Health System, Task-Force Chair Comprehensive Lung Cancer Screening Program, Vice Chair for Faculty Development & Wellness, and Associate Director Cardiothoracic Robotics Program. He is a graduate of UC Berkeley and Harvard Medical School, he did his residency at Massachusetts General Hospital and Fellowships at Stanford University and University of Michigan. He trained with the some of the best, and now he's one of the best!.

To claim credit for this episode, visit: www.ce.mayo.edu/regmedonline Guest: Dennis Wigle, M.D., Ph.D. (@DrWigle) Host: Darryl S. Chutka, M.D. (@ChutkaMD) Regenerative Medicine has some amazing capabilities and in the near future, it's likely to significantly change how we practice medicine. It faces some challenges in educating both the medical community as well as the general public regarding its current realistic capabilities. There are many unsubstantiated claims made by practitioners to the public regarding the benefits of regenerative medicine therapy. We'll discuss how the true potential of regenerative medicine is conveyed to both clinicians and the public with Dr. Dennis Wigle, a thoracic surgeon and chair of the Division of General Thoracic Surgery at the Mayo Clinic. We'll discuss some of the common misperceptions of regenerative medicine and how a consultation service can educate both the public and medical community regarding the benefits of regenerative medicine. Specific topics discussed: How to provide education to the public and the medical community When and why the regenerative consultation service was formed How the regenerative medicine consultation service works Common misperceptions community regarding the realistic benefits of regenerative medicine  Additional resources: For more information about Mayo Clinic's Regenerative Medicine Consult Service, visit: https://www.mayo.edu/research/centers-programs/center-regenerative-medicine/patient-care/regenerative-medicine-consult-service  Additional educational opportunities from Mayo Clinic: https://www.mayo.edu/research/centers-programs/center-regenerative-medicine/education https://college.mayo.edu/academics/biomedical-research-training/phd-program/tracks/regenerative-sciences/ Connect with the Mayo Clinic's School of Continuous Professional Development online at https://ce.mayo.edu/ or on Twitter @MayoMedEd.

Today on the podcast our guest is Dr. David Cooke, MD, FACS, who is Vice Chair for Faculty Development and Wellness, Task-Force Chair of the Comprehensive Lung Cancer Screening Program, Head, of the Section of General Thoracic Surgery, Associate Director, Cardiothoracic Robotics Program, and Associate Professor at University of California (UC) Davis. Dr. Cooke received his Bachelor of the Arts degree from UC Berkeley and, from there, he went on to get his MD from Harvard Medical School. Following that, he did his residency for Surgery at Massachusetts General Hospital. After that, he completed a fellowship in Cardiothoracic Surgery at Stanford University School of Medicine and then another fellowship in Cardiothoracic Surgery from University of Michigan School of Medicine. In this podcast, you’ll hear Dr. Cooke’s thoughts on the industry of medicine, the importance of mentors, some skills necessary to succeed in the field of medicine, what it’s like to be on the cutting edge of General thoracic Surgery, and what’s on the horizon for his field. White Coat Story is a podcast series for school students to gain first-person insights into the practice of medicine, and what it takes to get there.

Michael Morowitz, MD, is an associate professor of Surgery and an attending physician in the Division of Pediatric and General Thoracic Surgery. Dr. Morowitz’s research focuses on Necrotizing Enterocolitis (NEC), a mysterious disorder of intestinal inflammation in premature newborn infants. His lab studies the microbiome, the vast collection of microorganisms that cover our bodies, inside and out.

Jerry Cahill and Dr. Joshua Sonett, Professor of Surgical Oncology, Chief of the Division of General Thoracic Surgery at Columbia University Irving Medical Center, and Director of The Price Family Center for Comprehensive Chest Care, Lung and Esophageal Center– and Jerry’s transplant surgeon! – discuss the future of lung transplants. In this video podcast, Dr. Sonett shares his view that the future is bright. His goals through his work are to optimize lung availability, change public perception of organ donation, eliminate the need for anti-rejection medication, and helping patients see transplant as a positive step. This video podcast was made possible through an educational program from the Columbia University Irving Medical Center to the Boomer Esiason Foundation.

In his latest video podcast, Jerry sat down with Dr. Joshua Sonett, Professor of Surgical Oncology, Chief of the Division of General Thoracic Surgery at Columbia University Irving Medical Center, and Director of The Price Family Center for Comprehensive Chest Care, Lung and Esophageal Center– and Jerry’s transplant surgeon! – to learn more about the transplant process and the work being done at CUIMC. Some of Dr. Sonett’s most important advice for cystic fibrosis patients – make sure your CF care team works closely with a transplant team. Meet that transplant team early – way before you need a transplant. They can work with you and your care team to avoid the surgery as long as possible and to make sure that you are listed as soon as it becomes necessary. Tune in to learn more! This video podcast was made possible through an unrestricted medical program from the Columbia University Irving Medical Center to the Boomer Esiason Foundation.

Tuberculosis has been humanity’s oldest and greatest killer. Starting at the turn of the nineteenth century, the White Plague was decimating entire generations in the crowded and unclean cities of Europe, North America, and across the globe. But as medical science learned more about the disease, doctors and reformers developed new ways to combat it, most notably specialized tuberculosis hospitals that sought to heal their patients with fresh air, rest, and a nutritious diet. This episode discusses the sanatorium movement and the gradual conquest of tuberculosis, long before effective antibiotic therapy existed. Along the way we’re going to talk about the King’s Evil, the dangers of rebreathed air, the healing powers of mountains, and the social determinants of health. Plus, a brand new #AdamAnswers about maternal placentophagy. All this and more on Episode 39 of Bedside Rounds, monthly podcast on the weird, wonderful, and intensely human stories that have shaped modern medicine, brought to you in partnership with the American College of Physicians. To claim CME and MOC credit, please go to www.acponline.org/BedsideRounds.   Sources: Adams, J. F. Alleyne. "The Segregation of Consumptives." The Boston Medical and Surgical Journal 157, no. 2 (1907): 35-40. Barberis I et al, The history of tuberculosis: from the first historical records to the isolation of Koch's bacillus, J Prev Med Hyg. 2017 Mar; 58(1): E9–E12. Bertolaccini et al, Surgical treatment of pulmonary tuberculosis: the phoenix of thoracic surgery? J Thorac Dis. 2013 Apr; 5(2): 198–199. CDC: World TB Day 2018, retrieved from: https://www.cdc.gov/tb/worldtbday/history.htm Cox GL. Sanatorium treatment contrasted with home treatment. After-histories of 4,067 cases. Br J Tuberc 1923; 17:27–30. Coyle CW et al, Placentophagy: Therapeutic Miracle or Myth? Arch Womens Ment Health. 2015 Oct; 18(5): 673–680. Daniel TM, Hermann Brehmer and the origins of tuberculosis sanatoria, Int J Tuberc Lung Dis. 2011 Feb; 15(2):161-2. Daniel TM, Jean-Antoine Villemin and the infectious nature of tuberculosis, Int J Tuberc Lung Dis 19(3):267–268 Daniel TM, “The history of tuberculosis,” Respiratory Medicine (2006) 100, 1862–1870. Daniel VS and Daniel TM,, Old Testament Biblical References to Tuberculosis, linical Infectious Diseases, Volume 29, Issue 6, 1 December 1999, Pages 1557–1558. Davies RPO, Tocque K, Bellis MA, Rimmington T, Davies PDO. Historical declines in tuberculosis in England and Wales: improving social conditions or natural selection. Int J Tuberc Lung Dis 1999;3:1051–4. Dormandy T, The White: A History of Tuberculosis, 1999. Farr et al, “Human Placentophagy: A review,” AJOG, April 2018. Frith J, History of Tuberculosis. Part 1 – Phthisis, consumption and the White Plague. J Mil Vet Health, 22,2. Gaensler EA. The surgery for pulmonary tuberculosis. Am Rev Respir Dis 1982;125:73–84. Grigg RN. (1958), The arcana of tuberculosis. Am Rev Tuberc Resp Dis; 78:151-172. Hayman J, “Mycobacterium Ulcerans: An infection from Jurassic Time?” The Lancet, Nov 3, 1984. Holloway-Kew KL et al, Lessons from history of socioeconomic improvements: A new approach to treating multi-drug-resistant tuberculosis, Journal of Biosocial Science 46(5):1-21, October 2013. Jacobaeus HC. The Cauterization of Adhesions in Artificial Pneumothorax Treatment of Pulmonary Tuberculosis under Thoracoscopic Control. Proc R Soc Med 1923;16:45-62 Morse D, Brothwell DR, Ucko PJ. Tuberculosis in ancient Egypt. Am Rev Respir Dis. 1964;90:524–541. Murray JF. Bill Dock and the location of pulmonary tuberculosis: how bed rest might have helped consumption. Am J Respir Crit Care Med 2003;168:1029–1033. Murray JF. Mycobacterium tuberculosis and the cause of consumption: from discovery to fact. Am J Respir Crit Care Med 2004;169: 1086–1088. Murray JF, Sanatoriums and climate, The Lancet Infectious Disease, Vol 16, Issue 7, P786, July 01, 2016. Murray JF. The white plague: down and out, or up and coming? J. Burns Amberson Lecture. Am Rev Respir Dis 1989;140:1788–1795. Murray JF et al, “Treatment of Tuberculosis. A Historical Perspective,” Annals of the American Thoracic Society. Vol. 12, No. 12 , Dec 01, 2015. Pomerantz M. Surgery for the management of mycobacterium tuberculosis and nontuberculous mycobacterial infections of the lung. In: Shields TW, Lo Cicero J, Ponn RB, et al. eds. General Thoracic Surgery, 6th ed. Lippincott Williams & Wilkins: Philadelphia, PA; 2005:1251-61. Tuberculosis Chemotherapy Centre, A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis in South India, Bull World Health Organ. 1959; 21(1): 51–144. Warren P, The evolution of the sanatorium: the first half-century, 1854-1904, Can Bull Med Hist. 2006;23(2):457-76.