One of the most important cancer-fighting strategies is catching and removing tumors early before they have a chance to grow and metastasize.
Dr. Alexi Matousek, a cardiothoracic surgeon at Sacred Heart Medical Center, is trying to do that with lung cancer. Lung cancer doesn’t have a widely-used early screening tool, as there are for prostate and breast cancers.
Instead, Matousek is using a robot called ION and leveraging two of his other roles at Sacred Heart, director of robotics and research mentor for medical students.
In this case, the medical student is Christian Held, a second-year from the University of Washington.
This interview has been lightly edited for length and clarity.
Christian Held: What we've seen is a shift towards earlier diagnosis and taking patients who historically would have been in a situation where they might have had imaging of their lungs that showed something potentially concerning, and they got put into a position of, okay, we'll kind of look at it. We don't know if we can really go in and get a sample of this concerning lesion unless it gets bigger. These nodules that we're looking at are sometimes below a centimeter in size.
And prior to about two and a half years ago, they really weren't going into biopsy anything below a centimeter and a half. And these represent potential lung cancers that, if caught early, can really shift patient outcomes. These really tiny potential lung cancers would fall into the earliest stage, the stage 1A is what it's called.
And so one of the previous students from last year, he did a project which showed that since the implication of ION, the robotic platform, they've been able to resect way more T1A lung cancers.
And prior to the implementation of ION, it was about a third of what they're doing now. So my project specifically is kind of looking a bit deeper into the technology and what is really driving this shift towards an earlier stage.
We're looking at how effective, meaning how well, the ION robot is able to sample these small nodules, how safe it is, and then kind of how, in a broader sense, it is affecting the time it takes patients to get treatment and overall outcomes.
DN: How does the robot take the sample?
CH: Traditionally there were a few different methods.
The standard method of biopsying something in somebody's lung was use a big needle, go in through the side of the chest, and then make sure you're there with CT scans. While accurate, it carried a big risk and one in three patients who had this kind of procedure would end up with a pneumothorax or a collapsed lung.
There were improvements then with the development of bronchoscopy technology where you're able to go in through the patient's intubation tube and then actually kind of navigate your way through the airways and find your way to where the CT scan says that the nodule is.
DN: So the doctor and the technician is looking at a scope or something like that to see where it's going down and through.
CH: Exactly. And really the big update or the big improvement with the ION robot is that it's able to take the CT scan of the patient's lungs and then completely map it out in three-dimensional space. Dr. Matousek had a good analogy of it's kind of like Google Maps. It creates a whole map of the lungs and then you'll actually see as you're in there, you have the video camera that shows where the bronchoscope is and then kind of a Google Maps street view of a line going through a simulated mapped out lung and then really shows you the best way to get in there.
With this improved navigation of what's called shape-sensing robotic-assisted bronchoscopy, where it's able to know exactly where it is in space using fiber optics, we don't need to have that camera in the bronchoscope as we're actually taking the biopsy itself. And so not needing both the camera and the biopsy tools, they were able to make the size of the bronchoscope catheter about half the size. A smaller catheter is able to get into smaller airways, more peripheral airways, where a lot of these really tiny nodules might be hiding and then it's able to really get in there and sample the nodule with really, really precise accuracy.
DN: What is your research doing in relation to that then?
CH: Over the last school year or so before summer started, we were working on putting together a database of all of the patients who have had ION over the past two and a half years. One of the pulmonologists here, Dr. Patel, had been recording a lot of this data. So we wanted to put it into a database that would allow for really comprehensive data collection and analysis. And so having that built, I'm kind of going through all of these patients' charts, seeing which tools were used when they had the ION.
There's imaging modalities that are used in conjunction with the robot, such as an ultrasound probe at the tip of the bronchoscope, as well as 3D fluoroscopy, which kind of gives an updated version as the patient is on the table, gives an updated version of that Google Maps creation that we had talked about. And so looking through, did they have these different methods of biopsying? And then exactly what did the pathology report show? And then we're looking to see, were there any adverse events? And then kind of compiling that, we'll be comparing it to known data and looking at their long-term outcomes as we go forward.
Alexi Matousek: So Christian's work, he's described it eloquently, but the context is that the community of providers that treats lung cancer here in Spokane is not familiar with this technology. They're not used to us being able to biopsy things that are tiny. Fir referring oncologists from Tri-Cities or the region, or our radiation colleagues that come to Tumor Board, or our medical oncologists here in town, this is new.
Christian's work is really describing the quality and the safety of this new technology for our local community, not just relying on outside papers that have been published from around the country, but our true results from here and it has the effect of really showing people what's possible now.
It's a complete change in how we work up lung cancers. Even our radiologists, I have to tell every week, they'll review a scan and see a tiny nodule, and they'll say, well, by Fleischner criteria, their radiology societies will say, well, let's just watch this in three months because it's not that big and it's the first time we've seen it. Because the older methods of biopsying were more dangerous for patients and also maybe not that accurate.
But when you have a new technology that comes in that's safer and much more accurate, then it can change your threshold of intervention because you're always balancing harms versus benefits. If the benefit of biopsying something is maybe not that great and the harms are high, well, then you do a biopsy and you wait a little bit and you wait for it to get bigger. And then, oh, now it's bigger and now it's really dangerous and now we'll go after it.
But when your intervention is now safer and much easier to tolerate for patients, patients are going home from ION bronchoscopy in two hours, and they have no medicines and they're not in any pain. They might cough a little mucus with some little red tinge in it. But most of them, when I call them and say, I didn't even know anything happened at all. And so it's dropped the intervention threshold because it's so much safer.
Now you say, well, maybe we can biopsy this thing. So I'm in a conversation with the radiologist going, I know it's the first time we've seen it, but this guy has got a smoking history and it looks a little suspicious. It's super tiny, but we can hit it and we can hit it safely. So why don't I have a conversation with the patient about whether they want to try or not?
The other day we went after a lady who'd had a lung cancer on her right lung. We had her in surveillance and I'd done surgery for her on the right lung. We had her in surveillance where we get in CTs every few months and we showed this really tiny seven-millimeter lesion in the little nodule in the left upper lobe on the other side and we said, hmm, that's really tiny. Like Christian was mentioning, we never would biopsy that before ION. We would have just said, let's just watch in three more months and let's watch in six more months and let's see if it really shows us anything. But it had grown a little bit from like three millimeters to seven. And I said to her, you know, you made a cancer on the other side. Your body's been exposed to enough smoke to make a cancer once. Maybe it's making another one. And I said, I think we can hit that seven millimeter thing with the ION. So let's go try. So we did. We drove right to it. We used the 3D fluoroscope.
So Christian described it eloquently. When we drive all the way down the airway, it's like a bunch of branching tunnels. You're looking at tunnels and you drive down there and you can drive all the way to the surface of the lung because the catheter is so small. You drive all the way out there to where the virtual map says the nodule is. Then you spin the CT scan to prove that you actually are pointed at the real nodule in the moment. Then you throw a needle out. And then we have another technology called a cryoprobe, which is a little tiny fiber optic catheter that puts out carbon dioxide liquid that's cold. It freezes a little ice ball at the tip and when you pull on that, it takes a chunk of the lung out. So not only are you getting just individual cells like in a needle, but the pathologist is looking at a piece of lung that they can actually assess. Like, no, that's really cancer. Like, I can really see it.
And so our yield, as Christian is noticing in his database, when we use the cryoprobe, the diagnostic yield or our accuracy goes way up because we're getting better quality tissue out and we got a cancer in that seven-millimeter lesion. And then I had to decide, how am I going to get this out? Because it's deep in the lung and it's super small and there's no way I'm going to see it or feel it.
So we brought her back, and then we used the ION again and we drove down right back to the lesion that we found the first time and put a little bit of dye in there. Christian was in the case with me. Put a little bit of dye that was blue and then glows green on our infrared or night vision scope. And then we flipped her on her side. The ION took us about 20 minutes to do. And then we said, all right, we just inject it. And we said, all right, we're done. We take the ION away. We flip her on her side. We wash her body and prep her and drape her and put the surgical robot in, put the camera in her chest. And then there was this little blue dot right in the lung. And I was like, well, that's easy. Pick it up. And we fired the stapler underneath and felt the nodule in and got out in the early T1A and T0, earliest stage lung cancer.
The important part, as Christian is mentioning, is survival for the earliest stage T1A and T0 lung cancer is 92%, 88 to 92% in five years. The survival for stage 2 is 78, stage 3, 55, stage 4, 22. Survival from lung cancer really matters by how early you find it and the tragedy is because you can't feel your lung, there's no nerves in your lung. Lung cancer can grow in your lung for a long time and get big and spread around before you ever know. You don't get a cough. You don't get a pain. You don't get blood, nothing. And so you have no warning. So you have to rely on these images.
It's recommended that all smokers, age 55 to 80, who have more than 15 pack years, get an annual CT scan to look for developing cancers.
We also screen for other cancers. We screen for breast cancer. We screen for colon cancer. We screen for cervical cancer. And those screenings are kind of invasive. Women are letting their breasts get squished in vices, and people are letting people drive scopes up their bottoms, and cervix screening is not fun in the GYN office. But a lot of people are doing that. There's 68%, 78% of people that should be getting those screening tests are getting them done.
Only 6 % of people that should get a lung cancer screen in the nation are getting it. Here in Washington State, we're also 6% and we're higher on the west side than we are over here, so we're even lower. All you have to do is go into the doctor's office and sit on a CT scanner for 30 seconds. There's nobody poking and prodding and poking things up your orifices and none of that obnoxious stuff. You're just sitting on a CT scanner for 30 seconds.
Why don't people get that done? If they did get it done, it would save more lives than all those other cancers put together. Lung cancer accounts for 200,000 deaths in the United States every year, more than breast cancer, colon cancer, and cervical cancer put together. So if we could get people in early, they would have excellent survival.
Why don't people get scans? There's a lot of belief out there that lung cancer is a death sentence or that they deserved it because they're smokers. I tell all my smokers, humans are just addiction factories. We're all addicted to something. You're not any worse of a human because you smoke than someone else who doesn't smoke and drinks or cheats on their wife or whatever it is. We're all in the same human condition. You're not any worse off of a person because you smoke or are addicted to a very addictive chemical. Nicotine is as addictive as heroin is, gram for gram. So it's a very addictive substance, and patients are not any worse off or morally inferior because they're smokers and if they can get screened and we can find lung cancer very early, have excellent survival.
So the work Christian's doing is to convince our local community that the paradigm has changed. We can find super tiny nodules, super early, and treat them with excellent outcomes. Our surgery patient that we operated on went home the next day. One day in the hospital, done. Early stage lung cancer, out and cured. Nothing else needed to be done.
I tell people, you look back at this in a year going, oh yeah, I did have lung cancer surgery, didn't I? I have just these 340 tiny little holes in my chest. I have a numb chest, we numb every nerve up. No air leak, chest tubes out the next day, and they're home. No one's cutting people's chests open. People think they're going to be cut from stem to stern. They think people are going to rip their bodies open to get lung cancer out. Not with a robot. Tiny little incisions, like half an inch long, four or five of them. Walking around the next day, people have their arms over their head the next day.
This lady we sent home yesterday, she was looking this morning, she's in bed with both arms over her head, and I said, no one does that after lung cancer surgery. So she's walking around, she's going to go home.
One of Christian's colleagues is doing a study on the safety of sending someone home the same day, after an operation like this.
So what we really want our community to learn is that the paradigm has really changed, and if people can find lung cancer early, we can absolutely save their lives, no question and send them home very early with something that they, not really that big of an intervention.
DN: So I guess then the big question in the American medical system is does insurance pay for this?
AM: They do. It's required by law, the screening test for lung cancer. So it's absolutely paid for and it's just critical that people understand that they can be taken care of if they, but they won't, they can't trust their bodies to tell them. That's what's important. You can feel a breast lump, you can get some blood in your stool, and clue in that you have a problem.
Lung cancer will not give you any warnings, unless they're in imaging. Imaging is the only way to find it. In fact, we find 80%, because people don't get screened, we find 80% of the lung cancer we treat on imaging that was done for other reasons. Someone comes to the ER for a stomach ache, and gets a little scan of their belly, and it catches the bottom of the lung, and oops, there's a nodule in the lung. That's how we find 80% of our lung cancer.
If we actually screened people, we would find much more earlier in chest scans, but that's why we're advocating for that, and this ION technology that Christian is studying has just transformed what we're able to do.
So he mentioned that the year prior to ION, I did about 17 operations for this early stage, it's the earliest stage lung cancer, and the year after ION went in, we did 45. So it almost tripled what we did and so he's gonna look at the overall stage of presentation, because when people come in late with lung cancer, it's really deadly. When people come in early, it's not even, it's a haircut.
