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What Is the Role of an Interventional Pulmonologist?

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Published on October 12, 2021

The Role of Interventional Pulmonology in Lung Care

In this video, Patient Power co-founder and care partner Esther Schorr sits down with Yaron Gesthalter, MD, from UCSF Health to discuss the role of interventional pulmonologists and their team. From cancerous to non-cancerous lung issues, Dr. Gesthalter covers it all.


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Transcript | What Is the Role of an Interventional Pulmonologist?

Esther Schorr:          
Greetings, this is Esther Schorr from Patient Power. In this program we're going to learn together about a medical team that works with patients that are having issues with their lungs. This team are called interventional pulmonologists, that's kind of mouthful. And this group plays a key role in getting to the right diagnosis and the right treatment plan. In fact, these experts will recommend a patient see an oncologist if they determine that the lung issues in fact potentially cancerous and it isn't always. So rather than talk about lung cancer treatments today, we're going to learn together about the first medical steps that are taken so a patient can get the right diagnosis and right team on board if it turns out that lung cancer is involved.

I'd like you now to meet Dr. Yaron Gesthalter, the co-director of Interventional Pulmonology Medicine at the University of California, San Francisco. Aside from the daily work that he does in diagnosing a wide variety of both cancerous and non-cancerous lung and sleep issues, Dr. Gesthalter has done research to investigate how to reduce lung cancer risk through a variety of preventative and screening methods. Well, very much welcome to you, Dr. Gesthalter. It's good to have you here.

Dr. Gesthalter:          
Thank you, Esther. It's great to be here.

Esther Schorr:          
Thank you, taking time with us. So, let's start here, what is the overall role of an interventional pulmonologist?

What Is an Interventional Pulmonologist?

Dr. Gesthalter:                      
Let me start by answering what an interventional pulmonologist is, because I think that might clarify that piece. What an interventional pulmonologist is, is a doctor who after training in internal medicine and pulmonary medicine did an additional year of training in a fellowship that really focuses on minimally invasive procedures that relate to thoracic medicine. And thoracic medicine spans the different diseases that relate to the airways, to the lung tissue itself, and to the lining of the chest wall called the pleura.

A lot of times there are different diseases that affect each different type of compartment. And what we specialize in are procedures that can alleviate some of those diseases. We typically use different types of cameras and do procedures that are based on endoscopy, where we can put a scope, a camera, endo inside some sort of lumen, and we can do all sorts of different diagnostic or therapeutic interventions by deploying different types of tools.

Because of the unique skill set that we have a lot of these tools are highly applicable to the management of cancer. So, what's unique about an IP doctor, an interventional pulmonologist, is that a lot of the tools that we have are applicable to both diagnostic and treatment of patients with lung cancer. So, because of that, oftentimes we'll be the first point of contact for a patient who either has a suspected lesion, or if someone who already has a known diagnosis of cancer but has some sort of other problem with their cancer that might be infiltrating their airway or causing shortness of breath in some way. We'll also be able to help the oncologist, or the other treating doctors, help with some of those problems, typically through some sort of minimally invasive procedure.

Esther Schorr:          
Okay. So, if you're at the front end of diagnosing lung cancer or other lung diseases that might not be cancerous, what's the difference between what you do and say a radiologist or a pathologist, because those are terms that we're more familiar with?

Dr. Gesthalter:

Of course. So ultimately for good cancer care you need a team, and each service or provider brings something different or unique to the table. Oftentimes there is some degree of overlap, but really it needs a team of different members such as you're saying. The pathologist, the radiologist, and the pulmonologist and the surgeon or what have you. So, in the initial evaluation phase, it's typically going to be on the table of the radiologist to basically define, hey, there's a suspicious lesion here. We're seeing something that's concerning. There's also some clinical input that will either be provided by the primary care provider or the pulmonologist who often receive those concerning images and need to act upon them.

And discussion with the radiologist will decide typically what the best type of approach for diagnostic procedure is because ultimately, we need some form of tissue to really confirm what the suspicious lesion is. Matter of fact, we like to say that tissue is the issue in our field, right? So, you can't really just guess based off of a series of images, there's really images that give you some form of shadow. It doesn't really tell you what the issue is on hand. So, there will usually be some form of biopsy in someone who is suspected as having a suspicious lesion or has high risk for having a cancer.

Esther Schorr:          
But that's where your team comes in?

Dr. Gesthalter:
Yeah. And that's why I say that there is also some overlap between the different services. So, for instance, radiologists can also do needle biopsies where they can advance a needle through the chest wall in the context of lung cancer, under a CT guidance, which is where some of the radiology platforms come in hand, come in useful. And they can advance a needle into the suspicious lesion and aspirate small pieces of tissue and send that off to the pathologist who ultimately will interpret what the tissue looks like to the clinician who's providing care for the cancer, if it turns out to be cancer.

Esther Schorr:          
So you're a bridge, it sounds like. You work with those folks depending on what the tests are that are needed, what has to happen with that tissue or which tissue needs to be gotten to try to figure out the-


Dr. Gesthalter:          
Exactly. So, one approach that we spoke about would be through what we call a transthoracic needle biopsy, where they do a needle through the chest wall, but sometimes there are issues with that approach. So, for instance, we do see that putting a needle through the lung can sometimes actually cause the lung to deflate, which can be a problem. And it happens, luckily, it's not very common and usually when it does happen, we can just monitor and observe. But it is a consideration. And then sometimes the lesion is so deep in the chest wall that it's hard to get at it with the needle. That's where endoscopy comes into play.

So a lot of the tools that we have are very good at getting the more deep, the more central lesions. And also, if there are a few areas that we need to sample, and let's say there's a lesion on the right and also maybe a lesion on the left that we would be better at sampling sort of multiple spots. That feeds into something that we'll probably talk about called staging, where we'd want to see if there's definitely... What's the total tumor burden of disease inside the chest wall? But at the end of the day, the initial phase in someone who suspected as having a cancer the initial priority is to get tissue to the pathologist so that they can interpret the tissue for the clinician to act upon.

Esther Schorr:          
Okay. Yeah. So, it's really a team effort is what it sounds like for sure. So, okay. Let's just back up a little bit and talk about what are some of the non-cancerous types of lung conditions and what separates them from lung cancer?

What Are Some Examples of Non-Cancerous Lung Conditions?

Dr. Gesthalter:          
Sure. There's a lot of overlap between what we use in the cancer context to the non-cancer context. The ability to use a bronchoscope to deploy tools into the airway is a very powerful tool. I'll say that sometimes when patients have advanced cancer that can infiltrate into the airway and cause narrowing of those airways, we can deploy tools to either clean up that tumor or dilate the airway back to its normal [inaudible] or even place a small little tube called a stent to keep that airway open and to keep the breathing open. That's in a tumor context.

There are times when we'll also have other reasons to have airway narrowing that is not cancer-related. That is not stemming from a tumor that's pinching the airways. Despite it not being a cancer, it can still lead to shortness of breath. And we do have to sometimes dilate those airways and bring them back to a normal lumen size. Fortunately, it's also very uncommon. More recently, what we're seeing is that patients with COPD, which is typically thought of as a smoking-related disease that can lead to a significant amount of shortness of breath.

Classically, that's a disease that's treated by lung transplant as the sole curative option or symptom palliation with different types of inhalers or other medications. There are also surgeries that have been done to remove diseased parts of the lung to sort of shift the physiology to the healthier part of the lungs. But that's pretty morbid surgery, which is not really been something that's picked up because of the morbidity of surgery. In recent years, they've developed these one-way valves that we can deploy endoscopically into those diseased parts of the lung to deflate those more diseased parts of the lung and allow the healthier parts of the lung to take over. It's a very simple procedure, fortunately, but it's really shown itself to have a sustained benefit for patients who meet the criteria for this procedure. And we're seeing that after one year, people are still reporting that their breathing has improved and that their ability to walk has improved.

Esther Schorr:          
Okay. So, what are some of the types of tests that your team would do that would determine whether something is cancer or another type of lung condition? You mentioned a few, you mentioned needle biopsies and you mentioned a bronchoscope. Are there other ones that we should just know about?

Dr. Gesthalter:
So I'll talk about the patient with the suspicious lesion. Usually it's someone who, for some reason, got a chest X-ray or chest CT and was found to have a suspicious lesion. It is worth mentioning now that we are seeing more and more screening detected lung cancers with the implementation of lung cancer screening which is taking patients who are at risk for developing cancer and putting them through a CT scanner once a year to try to detect these clinically silent tumors and address them early on in their development. But I will say that the first modality that a patient with a suspicious lesion will have is going to be some form of imaging, typically chest CT scan.

There is an additional type of scan that we like to get called a PET/CT scan, which is very similar to a CT scan, which can give you the anatomical information of a patient's body. But the PET scan tries to provide also a little bit of biological information. So, what they do is they'll inject a radiation-labeled sugar that will be absorbed in the body. It's very low radiation dose, but it's just enough radiation to emit a small dose of radiation that we can detect on our scanners.

Esther Schorr:          
That kind of light up?

Dr. Gesthalter:          
Exactly right. Light up and it actually, when you see it, it looks like an orange sort of blaze. It looks kind of pretty when you look at it, and there are certain areas that will absorb sugar at a much greater pace than other organs. Those are organs that are more biologically active. And with that, it'll absorb that radiated label. So, for instance, our brain is a very active organ, and you'll see it light up like orange, right? So, there are certain organs that we know that should light up like that. And there are certain areas in the body that should not light up like that. If we see an area that should not light up, that's where we get suspicious. And if we see one area that's where we'll go. But if we see a few areas, we might need to think about which one of those areas is the area that we need to biopsy to get both the diagnostic information, and also to make sure that we're staging the patient correctly.

As we spoke about before, tissue is the issue and the imaging cannot replace getting an actual pathological confirmation of disease. And the reason we need pathological confirmation or tissue is A, to confirm that this is indeed a cancer, but also to clarify what type of cancer we're dealing with. And this is something that's actually very exciting because over the last few years, we've really honed down on how to classify these tumors. It used to be that you just look under a microscope and say, okay, small cell, non-small cell. But now with our ability to evaluate each type of tumor's genome, we're able to decide which type of mutations they might have. And as a matter of fact, we're able to identify specific treatments that are very specific to those types of mutations. Not just mutations there are also different immune profiles, which can also tell the treating oncologist that they might need to actually give some form of immunomodulator therapy.

Esther Schorr:          
So you mentioned genomic testing or genomic sequencing. So where in this whole process does that happen? Is that something your group does or is that another group that is involved in giving you that data?

Dr. Gesthalter:
So the reason I mentioned in this specific question about IP is because that not only tells us sort of what we need to biopsy or the reason we need to biopsy, but it also tells us that we need to get a good biopsy. Which is why we'll also, oftentimes really focus on where we think that the highest diagnostic yield in the body will be for a biopsy. Ultimately, we pass this along to the pathologist to do the first pass, to look at the tissue and then decide specifically what type of additional biomarker evaluation the tissue should undergo. So, this is a discussion that will happen primarily at those tumor boards as an interdisciplinary discussion once we have tissue in hand.

Esther Schorr:          
That's what a tumor board is. Because I've never known what that was. So that's… We have it, what have we got?

Dr. Gesthalter:
Yeah, exactly right. And that's typically where I'll bring up the patient for the first time, introduce the patient to the oncologist, the surgeon, or the radiation oncologist. And I'll work with the pathologist to present what information we have, excuse me, also with the radiologist, what information we have. We'll review the imaging. The pathologist will tell us what they think the tissue then, either my team or another team was able to procure and say, “Yes, this looks like this kind of tumor, we should probably check this type of biomarker panel.” And then they'll get the ball rolling on that. So that way we try to bring the patient as a sort of neatly organized package to the oncologist so that they can start treatment as soon as possible.

Esther Schorr:          
Okay. So now we're at that point in describing all of this that we, let's assume we've branched, you've talked about if determined it's not cancer in some other kind of lung condition, that's a certain type of group of treatment paths. Now let's just say, if the diagnosis is lung cancer, that it's cancerous, we hear the word and you mentioned it earlier, staging. So, what is staging and what does that mean?

How Is Lung Cancer Staged?

Dr. Gesthalter:          
So staging is a very important process when we do the initial intake for a patient. And ultimately what we're trying to decide is what's the actual physical burden of cancer in the body. And there are few reasons why this is important, the most important reason, or probably the initially important reason or sort of the most immediate consequence of staging is what type of treatment will be offered to the patients. So, we like to think about lung cancer as a surgical disease. What does that mean? That if we can operate and remove a cancer and block without any leftover tissue, then we could potentially cure the cancer and "be done with it."

Those options are really only reserved for patients who have localized or earlier stage disease. Unfortunately, there are times where the primary tumor has already shed their cancer cells to distant parts in the body. That's what we call metastatic disease. Okay. That's no longer something that's amenable to local treatments such as surgery. Or even sometimes with radiation oncology, we can radiate the tumor almost definitive. So that's when medical oncologists will come into action and offer some sort of systemic treatment, either chemotherapy, or sometimes they can provide treatment that's more directed based on whatever biomarker profile they were able to get from the tissue.

So what we try to do is decide exactly what the disease spread has been in the body. And the initial pass will be with the CT scans or the PET scans that we spoke about. That will tell us, you know, everything looks normal, or everything doesn't look normal. If there's any doubt or concern on any of the images that we see, we'll want to confirm with some form of tissue diagnostic procedure. The reason is that there are sometimes what we call fake outs, that you see something light up on a PET scan, but it could have been just an inflammation or it could've been just an infection.

We see that lot in areas that have a high prevalence of fungal infection, or sometimes we see people who were exposed to coal as a child or fires that we sometimes see something called anthracosis, which is where the lymph nodes can still light up on the PET scan. But it's a completely benign process that you don't have to worry about. So, we wouldn't want to prevent someone getting a definitive surgery if there's some other cause for abnormal lymph nodes. And we also wouldn't want to subject someone to surgery if there are cells that are spread throughout the body, that the surgery wouldn't really be the thing to offer here.

Esther Schorr:          
So you really, along this whole continuum from the time when somebody needs to be diagnosed, there's the testing and then it sounds like there's a lot of additional discussion once you have the tissue to understand, is it localized? Can it be treated as a local disease or if it's metastasized, what's the spread of it and what's the best way to treat that? And if I got it right, the staging has to do with if it's localized, it's in earlier stage and if it's metastasized, then you sort of going up the staging scale. Is that right?

Dr. Gesthalter:          
Exactly. Right.

Esther Schorr:
If someone is treated for lung cancer, whatever stage it is, whatever treatment, I assume there's a chance that it could come back. And if that's the case, what happens as far as testing? Does the whole process start over again?

Dr. Gesthalter:
To a certain degree, yes, but not 100%. If someone's disease has recurred there might be some discussion about sort of enhancing surgical... There might be some discussion about additional surgeries if it's really focal or localized, or perhaps even local treatment with radiation. But if someone's cancer has come back and has demonstrated that it's come back in a distal part, then the issue won't be so much to offer local therapy but what type of systemic treatment such as chemotherapy or targeted therapy should be offered.

The paradigm right now is shifting towards one of treating cancer like a chronic disease, where if we have several lines of therapeutic options, chemo, or different type of agents, if the patient did well for a while on one, but then unfortunately progressed, then there's another agent that we can try. But oftentimes it will require a repeat biopsy to evaluate for any new markers that may have come up. Because what we do see unfortunately, is that even these targeted therapies they are very well tolerated and work very well for awhile, but oftentimes they will develop a resistance to these treatments at some point. And that's when the IP doc will help coordinate again, a re-biopsy to see if there's any additional treatment that can or should be offered.

Esther Schorr:          
Okay. But I mean, the negative part of that is, yeah, this could come back. The positive part of it, which it sounds like wasn't really the case, not that many years ago is that there's a relook at what's going on and there are now more and more options for creating a chronic situation where you can treat more than once to have somebody continue living.

Dr. Gesthalter:
Yeah. And that's really the exciting piece about our field in the most recent years is that we've really developed a lot of options that we used to really only have a handful of systemic chemotherapy agents just a few years ago. But now with the advent of molecular sciences and sequencing we're able to really get to delineate or to get a higher resolution of what type of mutations patients have in their tumors and to target those mutations with a specific treatment.

And it's really hard to follow these regimens because there are coming up at such an incredible pace. So, patients really do have the advantage nowadays that weren't afforded just not even a decade ago with so many new treatments and so many different options. And if one doesn't work well, we'll be following very closely to see if that happens and if it doesn't work, then there's another option.

Esther Schorr:          
That's the encouraging part of the direction of medicine and the work that you do. So, what are the key risk factors for lung cancer? And is there anything that patients, people just generally can do to lower their risk factors?

What Are the Key Risk Factors for Lung Cancer?

Dr. Gesthalter:          
So we talk about two types of risk factors. One is a modifiable where you can do something about it, and one is a non-modifiable risk. Certain things we know that cancers tend to increase with age, sorry. We know that the prevalence of cancers tends to increase with age. That's not something we can do anything about. There's also nothing we can do about any form of genetic predisposition. It may be that some people have a little bit of a higher risk in their genetics and their DNA. And again, that's not something that we can even quantify nowadays. And that's not something that we can do anything about.

But there are modifiable risk factors that we can definitely do something about. In broad terms, we like to say that a good healthy lifestyle will reduce your risk – exercise, good food, nutritious food – but by far the most common risk factor for lung cancer is smoking. Tobacco cigarettes is by far the most recognized and well-studied and validated risk factor for the development of lung cancer. And I'd strongly encourage anyone who's smoking to strongly consider stop smoking by any means necessary. And nowadays there are very good treatments that typically require actually a few different treatments to be successful in cessation efforts.

Esther Schorr:          
Okay. But with regard to diagnosis of lung cancer, obviously you said the one big thing you can control is don't smoke and have a healthy lifestyle, the things you noted. But I think we both want to recognize that there are people that without smoking and still doing all those healthy things, there are these other factors that can come into play that somebody is diagnosed with lung cancer. And now then we have all these options for treatment. I mean, that's what I'm taking from the conversation.

Dr. Gesthalter:          
Yes, yes. There are many people that we can reduce the risks for development of lung cancer. And unfortunately, there are people that no matter what we do, we just can't identify them just yet. There are patients who were never smokers that will unfortunately develop lung cancer. And we are not able to identify them as being at risk beyond sort of the general questions of family history and things that are not very specific or sensitive for detection of that. There are ways to identify people who do not have a suspicious lesion yet, or who are at risk of developing cancer and to identify their cancers at earlier stages, which is similar to breast cancer or colorectal screening, is lung cancer screening. And that's something that's been implemented in the last decade where patients who have a certain age or certain smoking status who might qualify for once-a-year CT scans to identify these lesions and act upon them if we see something.

Esther Schorr:          
So that's the preventative that gets into preventative medicine, which really that part of it we didn't have a decade ago really or know to do that. That's encouraging. So, before we close, is there anything else you would like to add to help patients understand more about what you do and what they can... I think you've covered what they can do to stay out of having to see you.

Dr. Gesthalter:          

I would strongly encourage patients to talk to their providers, ask them any of these questions. There's a lot of taboo about lung cancer. Some people even feel shame because of the smoking relationship, but I like to tell patients when they do convey that to me, that the smoking piece is a fixed game. It's a very highly addictive process, and it's not entirely fair. There are ways to improve our chances of preventing cancer, of detecting it earlier and treating it earlier. But that just requires medical follow-up.

And I would say that even though nobody wants to get cancer, and it's always better to not have cancer than to have cancer, but if you do lung cancer, today is not the same disease it was a few years ago. The options are tremendous. We're much better at treating and palliating symptoms, a large share of what an interventional pulmonologist does is symptom management. So, there is a lot of room for hope and optimism that we can hopefully provide.

Esther Schorr:          
Thank you so much, Dr. Gesthalter for sharing your expertise with us. We have to remember that with all cancers there's a team of experts that work together to get patients to better health. I also want you all to remember that knowledge can be the very best medicine of all.

 

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