Chapters Transcript Video Lung cancer in never-smokers: What physicians should know The incidence of non-smoking related lung cancer is, is going up and it's going up very quickly. And we're seeing that a lot throughout the whole population. I think it's on the news now. You can hear about it on, on, on TV, read about it in the New York Times, and we're seeing a lot of that, and especially here in, in Orange County and what we, the patients we treat, like my Even as a lung cancer, thoracic surgeon specialist, I see probably a majority of non-smokers. Hi, I'm Lindsay Carrillo, director of business development at UCI Health. Hi, I'm Doctor Sunil Verma, Associate Chief Medical Officer for ambulatory UCI Health. I'm also an otolaryngologist here. Welcome to Physician Huddle by UCI Health. Today, we are joined by Doctor Hari Kashaba, assistant clinical professor of surgery and thoracic surgery. Welcome, Harry to the podcast. Thank you for having me. Tell us a little bit about your role at UCI. So here at UCI I am one of the thoracic surgeons. There are about 3 of us here that do, uh, specifically thoracic surgery, um, focusing on the lung, esophagus, the chest wall, thymus. Um, we do everything from cancer surgery to non-cancer surgery, specifically lung cancer, esophageal cancer, thymic cancer, metastatic lesions that come to the lungs. And we also do benign procedures as well. When I say benign, I mean non-malignant. So infections, inflammations, diagnosis, pain, pectus, these types of things are, are, are areas that we focus on. And so my role is, is one of the surgeons taking care of our patients that come with these ailments. Cool. We've been talking a lot about lung cancer screening rates. You're telling me that it's actually getting better, but still not where we want it to be. What are the barriers there? How can other physicians out in the community help close that gap? So, you are right, we are getting better here in California with lung cancer screening. Um, before, let's say back about 5 years ago, we were about 1% of potential eligible patients being screened in California, which is pretty dismal, if you think about it. So if you take lung cancer screening, where you have to be between 50 and 80 years old, you have to be, uh, have smoked in the past, about 15 pack years, uh 20 pack year smoking history in the last 15 years, or if, um, um, and you're a current smoker or you've quit. You would be eligible for screening for lung cancer. Specifically, we have to get these patients that have smoked in the past or currently smokers. However, we were just doing a bad job here in California, so now we're closer to 13% of these eligible patients. However, it's still, if you think about it, 13% of people that are eligible, still pretty dismal. When you talk about barriers, I think there's a couple of different barriers. You have physician barriers or provider barriers, and you have patient barriers. I think when physician barriers come about, and Doctor Verma can talk about this is, um, an outpatient visit is only a certain amount of time. And especially when you have primary care providers, they have to deal with everything from diabetes, heart disease, depression, and then to add this onto their plate, it can be hard to talk about all of this. And then you have to make sure that you know about the smoking history, you know their age, you know their quit date, their pack years, all these things. So it can make it a little bit difficult to actually get patients screened from a provider or physician standpoint, and then The screening is a CT scan, a low-dose CT scan. So, to follow up those results, and who's gonna follow that up? Where do you send them afterwards? So, if you have a person with a lung nodule, now, now what do you do? So, I think that can be difficult. And then from the patient's standpoint, there's a lot of feeling that they did it to themselves, especially when you talk about patients that have smoked in the past. They're worried that, hey, like I did this to myself, so maybe that's a problem, and they, they feel bad about that. So I think there's a little bit of that kind of stigma behind lung cancer and lung cancer screening, especially. So how is, what's made that jump from 1 to 13% or what initiatives do you have in mind to even get that number higher? So that's a good question. There are certain initiatives that we've kind of done as a statewide. Um, initiatives. One is, of course, getting the word out, knowing that lung cancer screening exists, getting it out there to patients. Um, also, we've made it kind of the stigma we're trying to get behind, uh, get away from that, from even from providers, from physicians saying like, hey, ask about lung cancer screening, just like you ask about your, the breast mammogram, the colonoscopy, ask about the low dose CT scan for your patients that have smoked in the past. 2 is also getting it. What I've done here, what we've done is getting it out there to our nurses and MAs even, because when they're checking in the patient, they could also ask about smoking history, not just asking, oh, did you smoke or do you currently smoke? Like, oh, how many cigarettes do you smoke, how many packs, and what do you think, or have you been screened for lung cancer? These basic questions. You know, it's interesting when I treat patients and I, I treat a fair number of smokers and, and prior smokers. If you ask the question, are you, um, do you smoke, you'll often get a no. But if you ask the question, how many cigarettes do you smoke a day, they will discreetly answer that question. So oftentimes it's actually how you frame it to get that answer, especially for my population who's often quitting before laryngeal cancer surgery. I don't know if you've seen that as well with your patients because there is this guilt that we're doing it to ourselves, but there's also recognition that a lot of it's outside their control. I mean, this is an addictive process that they've, they're, they're addicted to it. And so, uh, I, I think also educating the people asking the questions can get the right answer from the patients and realize it's not a judgment that we're passing, but we're enabling them to get the right tools to help their health. I think that's the biggest, uh, biggest thing is what you're saying, not to judge the patient, but you're, you're asking them to, um, allow for them to get the best health or allow us to provide the best health for them possible. I think that's the biggest thing is get away from the judgment, but have you smoked or do you smoke? Have you smoked before? How about when you're in college, these types of things make it almost like it's not a, not a big deal, but it is because it changes how we can deliver care and especially in lung cancer screening. So tell me a little bit about these low dose CTs. I don't have a lot of experience with it. But I'll CCT reports and they'll say like there's some nodules on there, right? And then I think if you're not a lung doctor, it's kind of intimidating, right? Because it feels like a lot of patients have lung nodules from granulomatous disease or exposure environmentally or maybe I'm wrong, correct me, but what is the protocol for somebody once you find something, if you will, on the scan that's not super worrisome, who follows that patient? That's a good question, and if you take All people with CT scans, or you look at all CT scans, there's a lot of people that have lung nodules for various reasons, like you said, you have, of course, cancer could be one. You have granulomatous diseases, um, fungal diseases, infectious diseases, um, histoplasmosis, coccidio, these types of fungal diseases are, we see, they're pretty rampant. TB in our population here in Orange County, we have a lot of patients that have come from other countries where tuberculosis is, is a pretty endemic, and those patients have gotten treated so you they could still have lung nodules from those. So we have a lot of different reasons why patients might have lung nodules. So if we get a CT scan, a low dose CT scan specifically for someone that has smoked in the past that's eligible for lung cancer screening. We follow those, and that, that person that could be following them would usually be a primary care doc, um, one of the pulmonary doctors, or even us as thoracic surgeons can follow them. So, I think there's a couple of different avenues, and we have actually a lung nodule clinic here at UC Irvine where we try to get these patients in so we can follow them because the primary care, like I was saying, they could be bogged down by so many other. Things that they're worried about, colonoscopy, diabetes, these things. So, the lung nodule clinic can take that burden off the, the primary care, especially if they find an abnormal finding, and they can figure out they need to get a repeat scan, they get a need to get a biopsy, you need to get a lung resection. We can figure that out. And the face of lung cancer has changed. Uh, you know, when, when I was in med school, it was so much concentration on smokers. But it's not just smokers anymore, is it? That's correct. Uh, the incidence of non-smoking related lung cancer is, is going up, and it's going up very quickly. And we're seeing that a lot throughout the whole population. I think it's on the news now. You can hear about it on, on, on TV, read about it in the New York Times, and we're seeing a lot of that, and especially here in, in Orange County and what we, the patients we treat, like my Even as a lung cancer, thoracic surgeon specialist, I see probably a majority of non-smokers. These are people that are finding incidental nodules, um, like if they are in a trauma, if they have fallen while working, they get a CT scan and all of a sudden there's a lung nodule, like you were saying, and then followed up, eventually biopsied. And they're coming to my clinic for a lung cancer resection, and many of these patients, if, if not a majority are have never smoked or not smokers at all. So we're seeing a huge amount. We've actually been seeing it in certain populations more. If you look kind of worldwide, we're actually seeing it in a lot of the Asian population and amongst Asian women who have never smoked. And if you look at in the Taiwanese data, they just did a study where they looked at their whole population and they found a really high predominance of this EGFR mutation, lung cancer, especially amongst their women in the Taiwanese population. So we're seeing a lot of women, a lot of Asian women, never smokers, especially. Are there any environmental factors that play into this as well? I mean, you mentioned like some genetic things, but What else? That's a good question. I, I don't think we know enough. Here actually at UC Irvine, we have a lot of research going on in that, in that world of, of pollution, environmental exposures. I actually have a study looking at family history, so I'm screening patients of or screening family members of patients that have driver mutation lung cancer. So I think we're learning more and more about it. One other thing that I'm actually interested in, I think we can do that here at UC Irvine is looking at these forest fires. Um, we have this lung cancer consortium amongst all the UCs. And this would be interesting to look at our populations that are exposed to these different forest fires that we're having throughout the state and seeing if there's an increased incidence of lung cancer. Of course, even not lung cancer or other pulmonary diseases, but especially from a cancer standpoint, it'd be really interesting. But I don't think we have enough data to look specifically at true environmental exposures. Yeah, California is not known for good air quality per se, so yeah, there's a lot there. Yeah, it's, it's funny, we've gotten, I feel like we've gotten better from when we think about like car pollution. I remember growing up and it was, it was awful, but now we don't see the car pollution, but now we see other types of pollution, right? We're seeing these forest fires, we're seeing other environmental things that are coming about, and I wonder if the, there must be some predisposition there, and I'm, I'm hoping we can do that research to find that out. Moving on to treatment a little bit. Uh, how have things changed with treatment and, and what modalities are you using to treat patients? Um, I imagine the surgeries of the old are no longer the current thing. So what, what technology are you using and how is that helping outcomes? That's a, that's a phenomenal question because there's the technology have changed in so many different ways, especially the way we treat lung cancer or cancer in general, but lung cancer. I'm gonna talk about a couple of different things there. One is, as a surgeon, things that I really utilize now that has, that has changed. And 2 would be kind of in lung cancer, cancer treatment, things that have changed that now affect me. So, as a surgeon, as you, as we all know, minimally invasive surgery now is the kind of almost standard of care, if not the standard of care for a lot of our, our resections, especially in lung cancer. I do a lot of robotic surgery, so robotic surgery is kind of the, uh, it's forefront of removing these lung nodules. We can do lobectomies where we take out a whole lobe of the lung or even what we call sublobar resections or segmentectomies where we take out a smaller portion of the lung, but still do a really good cancer operation where we take out the Cancer, good margins also take out lymph nodes really well because when lung cancer spreads, it spreads to the lymph nodes first and foremost, so we want to know if they're involved. So we're able to do that minimally invasive. What does that mean? That means patients have less pain postoperatively. That means patients can get out of the hospital quicker. Hopefully, most of our patients are out of the hospital in a day or two, even after a lobectomy or a big lung cancer resection. And if patients need, let's say systemic therapy afterwards, chemotherapy, immunotherapy, targeted therapy, they can get on that treatment quicker. So there's a lot of different um good benefits from doing minimally invasive surgery that we do. So I think that's one of the biggest things that has come about from a surgical standpoint. From a technology, from a treatment standpoint, when you think about systemic therapies, stuff like targeted therapies, immunotherapies have really changed the landscape of how we treat cancer. Now we do a lot of genetic testing. I was talking about EGFR mutations, but we have so many different mutations now. In lung cancer, and even as a surgeon that affects what I do because patients are are living longer. They're taking these therapies, we're getting them on them after surgery, before surgery, so that really changes our management and how we, how we do this. And patients that were before deemed unresectable, we're now kind of seeing them becoming to a more resectable state, which, which can be great for patients if we're able to get them to surgery. Love it Uh, you and I have talked a little bit about your own backstory. You have an interesting path to medicine that I don't think a lot of people have followed. Do you mind sharing a little bit about that? Sure, yeah, I'm happy to, to talk about that. So, um, I kind of talk about my previous life. I was actually an engineer. I was an electrical engineer. Um, I worked actually for the Department of Water and Power doing telecommunications. Um, I was in actually, I still remember this. I was in charge of the back end. Uh, radio frequency infrastructure for like the walkie-talkies that, like, you know, the people on the power lines that they use when they're up there, and it was, we had to be able to communicate from that person to the base to people all the way in Nevada, Oregon, cause we get power and water all over. So that's what I was actually in charge of as a young engineer and I was fine. I, I, I had no problems. I had no, I wasn't looking to go medicine, go into medicine, but my mother actually had a double lung transplant for idiopathic pulmonary fibrosis. And after that, I said, you know what, this is kind of what I want to do with my life. So I quit my job, went back to school while she was recovering. I helped her recover, went to night school, extension school. And took like biochemistry and organic chemistry stuff I had never taken as an electrical engineer. Yeah, and then I sat for the MCATs and thankfully did OK and went to medical school in Cleveland at Case Western, and I've always kind of wanted to do thoracic surgery, and uh that was my thing, and I did a lot of research and lung transplant and cancer and My career now is more focused on cancer, but that's kind of why and why I do thoracic surgery and why the lungs are kind of interesting to me and um it it's good. I I enjoy this a lot. I enjoy treating my patients, treating um the family members also being part of it, cause I, I remember when I was in that boat and I knew nothing, and as a family member, we have to, uh, you you're scared, you don't know what you can do and So I'm always, uh, I always try to treat the patient and help hopefully the family as well. And the friends, there's a lot of people that are involved in a in a patient care. That's a really unique story. I mean, I, I, I can't imagine uh. Switching paths, right, like that. I know it's not late in life, but yeah, to just be on the entire engineering trajectory, not having done science before, and then making that sort of acute right-hand turn. Uh, did your mom support it? I mean, I imagine at the end she did, but, but was it, was there a lot of eyes being raised on you? Like what the heck, dude? I, I think I understand why. No, this is, it's actually so, uh, so interesting because I, I was in, like I worked for the, the, the Department of Water and Power, like a city job, a government job, and the the Indian immigrant community, like my parents were immigrants and they came here. Like having a government job is like you're set for life, right? That's it. You've made it. You've made it, you work, get your pension, just like put your head down type things. And that's, I, I was like a 22 year old kid and like that's what it was. So I think even my mom was like, what are you doing? What's going on? And especially as we all know, like training, like medical school training is a long time. Like you're talking about an opportunity cost of at least a couple million dollars, like from a true just my er my salary, right? Because I took over a decade of training after medical school. So, it's like all of that, when you think about all that, you're like, people are like, wait, are you sure you want to do this? Like, like me and my mom was like, wait, really? What? And then of course, I think they, they, they saw that I, after, especially when you, you get in, you'd go through medical school, go to get into residency and fellowship. I enjoy what I do, and I think personally I'm more passionate. I am now about then compared to like telecommunications in the past, but no, it's, it was still have a passion for walkie-talkies, is that, right? I still have a passion for the walkie-talkies. So how does that inform how you work with families and patients? I mean, you had that front row seat and that experience of watching your mom go through that. Like, does it come up when you're teaching, you know, new medical students or residents here at UCI Health? Like, how does that impact your practice today? That's a great question. So one from, uh, I'll answer that in a couple of different ways because you have one is the, the actual clinical practice. I think it really does. Help and frame how I treat my patients, because I do think when you're treating the patient, you have everything else around it too as well. Especially when you're talking about cancer care, right? You have patients that are, are working, may not be working. The family members are working. They have to now come to surgical appointments, take time off, of course, for surgery. But then the family members have to do the same thing, cause they're probably doing it for a longer time, right? Because they have to take them to chemo appointments, radiation appointments. Be here, be there afterwards. Maybe after surgery, they need a little bit more help at home, the patients do. So, I, I, I try to inform the the patients, but also their family members about, hey, this is how it's gonna be. This is what's going, what's gonna happen over The course of treatment, whether that's from surgery onwards. So I'd really take that into mind or into consideration when I'm taking care of these patients. And of course it can be hard on, on patients as well and their family members. So I think we have to kind of think about all of, all of the people involved in the, in the care of these patients, not just us as the physicians, but all, all of the family and friends as well. From the medical students, I actually think it's, it's really, we have to Really kind of inform and guide our medical students. Right now, as we all know, healthcare is changing tremendously. There's so many different forces, and it can be difficult as a medical student, as a resident to kind of stay focused on like why. Why did you go to medical school? Why are you doing this? It's a lot of sacrifice, right? I was just saying like an opportunity cost just for me alone, changing careers, right? But everyone's going through that. Every medical student is now taking up debt from undergrad medical school residency, right? Where you're making money, but you're not making a lot of money to pay off the debt. All these, all these issues, right? And then you have other forces where you're kind of, you, you kind of forget why you went to medical school sometimes or why you went to a certain specialty. So I always kind of tell the medical students that even once a week, I'm like, just remember why you went to this, just take a moment. Us in academia here at UC Irvine, it is easier. Doctor Verma can attest, we have students, we have residents, so they always ask us, oh, why'd you go to medical school or why'd you do Odo Garza? Why'd you do thoracic surgery? So I kind of get to talk about that, but The people that we train, not all of them are going to be in an academic situation. They might go out and just go to a private practice group or go to back home where they're from or something. So I always tell them, just keep reminding yourself why you did this. There's going to be other forces. Healthcare is going to keep changing, but at least you can keep doing what you're doing and why you, why you came into this field. Yeah, I think it's hard at times, right, to To remember to sort of always setting yourself in empathy for the patients and what they're going through, and it's a really easy thing to talk about, but not only are there different forces of just being trained and getting into competitive residencies and obtaining that job, but then that once you get that job, then that's when you really start, you know, for me it was in my I was in my early 30s, for you it was a little bit later on, right? And so, how do you go through those trials and tribulations of, of running a practice of managing your patients and still staying grounded and focused and when things aren't going right for patients, and I think that's difficult for us at times. Um, when I, uh, I think as I've gotten a little bit more senior in my career, I, I definitely have more empathy for my patients. I understand a lot of the reactions that often happen are out of fear, inconvenience, misconceptions. Um, challenges of, I, I, I think you said it really well. You have the patient who's taking their time off from their life and all the people that are supporting them, and so it can, it's, it's easy for us, you know, in that 1520, 30, 45 minute encounter with them to, as physicians to have a perspective, but turning that, the mirror on it and saying, what are they experiencing, how long do they wait to get here? How many questions do they have today, and how many questions are they gonna have the second I walk out of the room? Um, as time goes on, I'm, I'm certainly more empathetic towards that, uh, and I think more so as our family members go through medical conditions, friends. And it becomes even more personal, you know, even the fear of like me going through my own first colonoscopy, what are they gonna find? Oh my goodness, did I do it to myself? Should I have done this earlier? Once you start going through those big steps in life, I think you become certainly more empathetic towards your patients, so. It's too bad that it's, it's wonderful that your, your mother has this outcome, but it's too bad that you had to go through that to even just to, to fate to, to, to get to this point. Yeah, no, I think it's, it's the, the forces that we have to deal with, like you, you said it with going through training, but then of course, starting a practice, that's a whole different ball game, right? You have like the forces are just tremendous and going through a day of clinic, right? Even that, starting that out, how do you set time aside to set expectations with the patient? I think as surgeons, especially in thoracic surgery, that's something that I try to do for all the patients and family members. I tell them, hey, you're gonna have a chest tube. They're gonna like these basic expectations, you're gonna, you, you might feel some pain, but we're gonna try to uh try to get that, mitigate that as much as possible through minimally invasive surgery, non-narcotic medications, all these things that we do, right? So they know, and they know, hey, you have, I have residents, they, they're gonna be there, but they, I'm like, I'm with that the patient steering the ship. And of course the patients, the, the captain, I'm right next to them, the first mate. And then we have all our residents or fellows or trainees, nurses, everyone's part of this. So I think setting expectations for the patient and their family, hopefully they have a family member with them or a friend, and everyone knows, and I think that helps. So, you know, you've been around the, around the block, you've been at different health systems, both as as a, as a patient or as a family member to a patient, you've trained across the country. What's special here about UCI Health? I think, uh, UC Irvine, the people are what really make it. When I say the people, I think it's from kind of the top down. Everyone I've worked with is um there for the patient. They want to get the the best experience outcome for the patient as possible. And uh uh whenever I call on when we've had patients together, whenever I've talked to you, like I just pick up a phone and call you, you're, you're gonna answer my call, right? That's doesn't happen in a lot of, in, in a lot of hospital systems, even amongst physicians, where I can just pick up the phone and call someone and get, get in, be like, hey, am I doing the right thing? Or can you see my patient? I have to, I'm really worried about this lung nodule, if you have a patient or vice versa, hey, I had this. Complication potentially. Can you help me out with this complication? Like with Doctor Verma, if I, if, if there's a, a, a lymph node on the vocal on the recurrent laryngeal nerve, and I need his help from a vocal cord sample, I'll give him a call, and I think that's something that it's huge from, like I said, the top down. If I, if I call our CMO Joe Carmichael, I'll say, hey, like Joe, like I'm worried about this. Is this OK? He, he, he'll pick up my phone call down to my intern, right? So, I, I, I, I think that's the biggest thing here at UC Irvine is the people. Um, I think we're, we're all cordial, we're all there for the patient, we're all happy to pick up the phone. I think that's, that's a, that's a big deal. It says a lot. Well, I, I, I just really, I think it's been really special watching the growth of thoracic surgery here. You know, when I started, it was cardiothoracic. And not too many people. Now, cardiac is completely separate from thoracic, and as you said, we have multiple physicians within our surgeons within our thoracic surgery, uh, division. Uh, all the different skill sets, you know, all adding different things to the patient with their own perspective. So it's just really nice to see the diversity of patients we now can take care of, and then the teams that you have on your medical colleagues, or radiation colleagues, nursing, therapy, what all of that, uh, to, to really help each other out. So it's been really special seeing that growth, and it's been really rapid, you know, especially over the, frankly, the last 5 to 10 years. It's been awesome being part of that growth, um, since I've, this is my first job out of fellowship and It's been, my first case was a basic bronchoscopy, and this was what, not like 5 years ago, we didn't have enough bronchoscopes, right? So I had to delay the case, get a bronchoscope, but These are growing pains. These are like the good growing pains. Right now, it's like you said, we're kind of getting to, we're like a well-oiled machine. We have 3 of us from an attending standpoint, but we have a nurse practitioner that helps us out, both inpatient, outpatient. Our resident team compliment, they're learning how to, they're learning a lot. They're great. Um, the nursing staff on the floor, we have a, one of the nurses did one of her kind of, uh, promotional step up projects on how to, how to get like good breathing techniques postoperatively for all electthoracic surgery patients. So, it's kind of been really, really exciting to see that we have research, we got pretty advanced clinical care. With minimally invasive, maximally invasive. I think something actually we don't talk about is we are a referral institution here and so we take on really complex cases that other places just don't want to do or can't do or don't have the expertise. And a lot of those are like you're taking on like big cases, we're taking out big tumors, open, kind of a little bit what we would consider old school surgery, but It's some of it might not be old school. It's just a different way because they're on a chemotherapy or immunotherapy or like that they probably would never have been seeing a surgeon in the past, but we're doing that. So, I think um we're doing some pretty advanced stuff and it's been, it's been pretty exciting to see that growth and That's another thing about UCI that is pretty cool compared to other places is we are growing. We've been growing since I've got here, and not just in thoracic surgery, but we have a new hospital in Irvine. We got all like, it's pretty, you guys are like the forefront of that, but it's pretty amazing to see that and be part of that. No, it's fun. I'm glad we're keeping you busy. Yeah, yeah, no, that's good. When I, when I see you at 5:30 or 6 p.m. in the surgeon's lounge and you're barely sitting down, I think, OK, yeah, we're definitely growing. Yeah, yeah, 5:30 is usually we, we still have another case after that. That's lunch. Fantastic, Doctor Keshiva. We really appreciate you coming. Thanks for being with us. Thank you for having me. This has been the Physician huddle by UCI Health. Thank you for joining us. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shahen, Angelica Yagubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, view the show notes or visit clinical connection. UCIhealth.org. Created by
