
Breast cancer surgery; reasoning and cognitive impairment; lung biopsies: Upstate Medical University's HealthLink on Air for Sunday, Jan. 5, 2025
Surgeon Scott Albert, MD, tells about current surgical options for breast cancer. Syracuse University psychology professor Jeffrey Zemla, PhD, discusses reasoning styles with and without mild cognitive impairment. Ronaldo Ortiz-Pacheco, MD, explains lung biopsies.
Transcript
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a breast surgeon talks about current surgical options.
Scott Albert, MD: ... Obviously, there's certain circumstances where a mastectomy makes a lot of sense, but we are at the point where we can offer more than one surgery to patients. ...
Host Amber Smith: A psychology professor discusses reasoning and cognition.
Jeffrey Zemla, PhD: ... There are a lot of factors that influence the way a person reasons. So age might be one of them, experience might be another, as well as different cognitive functions like working memory, executive functioning and so forth. ...
Host Amber Smith: And a doctor shares what's important to know about lung biopsies.
Ronaldo Ortiz-Pacheco, MD: ... Doing a bronchoscopic biopsy allows us to also take a look at the lymph nodes within the chest and allows us to do a procedure called staging, which is basically looking at the lymph nodes and making sure that those lymph nodes are not involved with any cancer cells. ...
Host Amber Smith: All that, and a visit from The Healing Muse, right after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, can cognitive decline be predicted based on how someone reasons? Then we'll hear how biopsies of the lung are done and what the results may mean. But first, the current surgical options for breast cancer.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Undergoing mastectomy can be both physical and emotional, but in recent years, less invasive ways of treating breast cancer mean fewer breast-removing surgeries. With me to talk about some of the newer techniques is Dr. Scott Albert. He leads the breast cancer care team at the Upstate Cancer Center.
Welcome back to "HealthLink on Air," Dr. Albert.
Scott Albert, MD: Hi. Nice to be here, and thanks for having me.
Host Amber Smith: Now, are you seeing more younger women with breast cancer diagnoses?
Scott Albert, MD: Yeah, I think the short answer is we have noticed there's been a rise in breast cancer in younger women, and that's been sort of ongoing for the last couple years.
Host Amber Smith: Do we know why that is?
Scott Albert, MD: That's a good question. I don't think we have all the answers. I think there's a whole host of reasons. I think, probably, we have better screening. We probably are also noticing the effects of some of the issues in our society, like obesity and alcohol use.
Those are all factors that impact breast cancer, and I think that's contributing to this rise in a younger population.
Host Amber Smith: Now, before we get into surgery, let me start by asking you to address what has changed or improved about biopsies, because if something's wrong on a mammogram or breast imaging, isn't the next step often to sample the tissue with a biopsy?
Scott Albert, MD: Correct. Yes. We've gotten very good at biopsying abnormalities in the breast, and we can detect abnormalities that are very small, on the order of millimeters. And so really, the gold standard is to perform a core needle biopsy of an abnormality. This is for a couple reasons. One, it allows us to get adequate tissue for sampling and testing, but also it allows us to mark the site with a special clip in order to know where to go back and find this abnormality in the future. And that's a very important aspect of doing a core biopsy.
Host Amber Smith: I understand breast cancer treatment is extremely individualized these days, but that surgery may be part of that treatment. So let's talk about the different types. Are there fewer mastectomies where the entire breast is removed these days?
Scott Albert, MD: Yes. I would say breast cancer treatment has become very, like you said, individualized and tailored, and we really have a whole toolbox of options, and some of those options are actually flipping the order of treatments.
So we are shrinking tumors with effective chemotherapies. This allows us to then give patients the choice of breast preservation, so they can, rather than get a mastectomy, have the option of getting a lumpectomy. And we know based on huge clinical trials throughout the world over many years, that there's really no survival benefit to a mastectomy. And so obviously there's certain circumstances where a mastectomy makes a lot of sense, but we are at the point where we can offer more than one surgery to patients. And so I think the lumpectomy or lumpectomy and partial mastectomy, we use those words interchangeably, are more common than maybe 20 years ago.
Host Amber Smith: Has the recovery changed along with that?
Scott Albert, MD: Yes. The recovery for breast cancer surgery has, I think, changed dramatically.
From my experience, and actually during COVID, I think, we started sending more and more patients home after mastectomies and mastectomies with reconstruction. And we realized patients do just as well going home the same day in many cases, than staying in the hospital. And so the recovery has really been changed quite a bit, actually, I think in the last five years or so.
And from a lumpectomy, and patients do very well. It's an outpatient surgery. They take minimal pain medication afterwards, and so we've really started to minimize the effects of surgery on patients as we get better treatments overall.
Host Amber Smith: What improvements have been made in reducing scars?
Scott Albert, MD: We can position scars on the breast in areas that are more cosmetically appealing. So whether it's underneath the breast or at the edge of the areolar skin (around the nipple), or more in the axilla (armpit area), these are all areas that are pretty nice in terms of cosmesis (preserving appearance). But we also realize we can identify lesions using newer technologies, so this allows us to find these small areas through these smaller incisions.
So I think a combination of being able to put these incisions inlocations that are cosmetically appealing but also having these localization techniques where we can identify these small masses -- those techniques have improved.
Traditionally we've used wires, so we put these small wires in and identified these small clips that have placed at the time of biopsy, but now there's other techniques like radio frequency tags and stuff. So this allows us to minimize the incisions.
Host Amber Smith: Well, let me ask you about targeted, or immunotherapy. Is that changing the timing or the way that surgery is done?
Scott Albert, MD: Yes, I think we are realizing that many times, we can shrink tumors, and we can get pathologic complete response rates, meaning we take out the site that was biopsied, and there's no residual tumor, by using these targeted therapies. So these are in combination with chemotherapies, but as we continue to find the right recipes, the right chemotherapy regimens for certain tumors, we are increasing our chances of pathologic complete responses.
That's the goal: finding the right recipes to remove the tumor with systemic treatment and minimize the chance of this spreading to other parts of the body.
Different tumors require different treatments, and so we are really starting to tailor and hone in on which treatments are best for which tumors. In fact, we are opening a trial where we're using targeted therapies in hormone receptor positive breast cancers in the neoadjuvant setting, so before surgery, whereas we've been doing that for a little while for other types of breast cancer, like a triple negative breast cancer, but we just opened a trial for using that targeted therapy in hormone receptor positive breast cancer.
So this is actually very important. Surgery could be obsolete in five to 10 years, maybe longer, maybe 20 years. We'll see how effective these treatments are, but it's amazing how well our therapies are working.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.
I'm talking with Dr. Scott Albert, who leads Upstate's breast cancer care team.
I've heard of something called axillary staging. Can you explain what that is and how it's used?
Scott Albert, MD: Yeah. So when I talk to patients about breast cancer, we talk about two aspects of the breast operation.
We talk about removing the tumor for therapy. Obviously we want to get rid of the tumor, make sure the margins are clean.
But the second part of the operation that I explain to patients is axillary staging, where we want to get information about the biology of the tumor by removing a lymph node or lymph nodes. And that can be done in a minimally invasive way, where we inject a dye in the breast that goes into the lymphatics, stops in a node, and we remove that node, called the sentinel node, or sometimes more than one, and that gives us staging information.
Now that, again, is pretty minimally invasive, but we don't always need that information at this point because we have other tools now, in terms of biology testing of the tumor, that we may not always need the axillary information. And that's important because the sentinel node procedure is better than what used to happen, where you would have a formal axillary dissection, where you'd remove a whole bunch of lymph nodes.
Now we're down to removing one, maybe two, three lymph nodes. And in the future we may be going to the point where we don't always need to stage the axilla because we have all this powerful molecular information from the tumor. So axillary staging is still an important component and sometimes can be actually therapeutic because we are removing abnormal nodes in certain cases, but usually it has diagnostic purposes only, meaning giving us staging information for that patient.
Host Amber Smith: Now, axillary is important. That's the lymph nodes that are closest to the breast, in the armpit?
Scott Albert, MD: That's correct. Yes. So the lymph nodes in the axilla, those are typically the first lymph nodes that drain the breast. And those are the lymph nodes that give us information about the potential for that tumor to spread elsewhere.
Host Amber Smith: Now, let me ask you about radiation. Is that typically part of a woman's treatment regimen?
Scott Albert, MD: Yes. The team that treats breast cancer patients is a surgeon, a medical oncologist and a radiation oncologist, amongst a larger group of team members. But radiation oncology is a subspecialty that really, I tell people a lot of times, it makes surgery better, meaning it reduces the risk of a recurrence in the breast or in the axilla by the addition of radiation.
And radiation can be given a whole variety of ways, various techniques to minimize the side effects, but really does provide added benefit to the breast cancer patient in terms of minimizing the chance of this becoming an issue in the future.
Host Amber Smith: Minimally invasive robotic surgeries are used in a lot of different surgical specialties.
Do they have a role in breast cancer surgery?
Scott Albert, MD: The short answer is, probably not yet. There are some clinical trials looking at using the robot for a mastectomy. My issue is that we don't want to compromise an oncologic operation for the benefit of a technology. So I think there's probably going to be a point where the technology will be beneficial, whereas I think at this point it might be too early to use on a routine basis. But I suspect there'll be a point in the future where as the technology improves, we can tailor our use of it to the oncologic operation.
Host Amber Smith: Well, let's talk a little about reconstruction. If it's needed, if there's a mastectomy, is that commonly done during the initial surgery?
Scott Albert, MD: The most common way to do breast reconstruction is in coordination with a plastic surgeon at the time of the initial operation, where the breast surgeon leaves a skin envelope for the plastic surgeon to do the reconstruction. And that reconstruction typically is done in stages.
And the first stage is a temporary expander or temporary implant.
And then the second stage, when the breast cancer treatment has been completed, is a smaller operation where the expander comes out and the more permanent implant is placed, so that's the most common way to do breast reconstruction. So it does take a bit of coordination.
There's obviously lots of other strategies, and using a patient's own tissue is another option, but in the last, maybe, 10 years, it's become more commonplace to use implants for a variety of reasons.
But there are other ways to reconstruct the breast. And also, interestingly, probably in the last couple years, it's been a little bit in favor, patients frequently ask about no reconstruction, and that's also an option for many patients. I think it's interesting how, I think, the mainstream media does have an influence on, and social media has an influence on, patients' decisions many times, and I think sort of a trend of going flat has been pretty common. Patients will ask for that pretty frequently these days, so kind of a pendulum that swings back and forth, in terms of the breast cancer operation itself.
Host Amber Smith: If a woman has the lumpectomy, where a smaller amount of tissue is taken out, is reconstruction ever needed? Or would it leave one breast smaller than the other, necessarily?
Scott Albert, MD: Not typically. I would say we try to minimize the amount of breast tissue that's removed, radiation techniques have improved, so there's less deformity to the breast. So not usually do we need to do anything, but maybe there is a point down the road where either the patient wants some symmetry to the untreated breast, so sometimes a plastic surgeon might get involved for a breast reduction or a breast lift, or in some cases you could put a small implant in on the treated side if needed.
But that, I would say, is not very common.
Host Amber Smith: Let me ask you about the implants that are used today. Are they liquid or solid or gel? What are they made of these days?
Scott Albert, MD: They're more or less a gel, a silicone gel. They work well. They don't have the issues in the '90s, where there was concern about silicone rupture. They don't rupture per se like they did maybe back then, and so they are safe and relatively easy to work with for a plastic surgeon.
Host Amber Smith: Now, I realize your specialty is surgery, but can you speak about the therapies that may be prescribed after a woman has surgery?
Scott Albert, MD: Yeah, I always tell people that breast cancer in many ways is a chronic disease. So, it's a disease that we treat, and then we follow. And, just like high blood pressure or diabetes, you give a therapy, and then you see how that therapy performed. And in breast cancer, many times after surgery and radiation, in certain breast cancers, we need some maintenance therapy.
So estrogen receptor positive breast cancer is the most common type of breast cancer, 60% to 70% of breast cancers. And many time those patients will be offered estrogen receptor blockade therapy or endocrine therapy. And so that's given for a long period of time, five years, sometimes 10 years, and that's a pill.
Other breast cancers may require some maintenance chemotherapy, and the use of neoadjuvant chemotherapy has then allowed us to offer different therapies after surgery, depending on how effective those neoadjuvant therapies were, those therapies before surgery.
So it's pretty common for patients that need some therapy after surgery and radiation.
Host Amber Smith: What about mammograms after surgery and after all of this? You said it's a chronic disease. Is that how you keep monitoring it?
Scott Albert, MD: Yeah, so exams, typically patients are seeing a few different physicians: the breast surgeon, the medical oncologist and the radiation oncologist if needed, and you're seeing a doctor a couple times a year. Mammography is still performed yearly, unless there'ssomething that we need to follow closer, so then it might be at most every six months. And clinical exams and having breast awareness is what we usually counsel patients about.
So this is a team approach, and we follow these patients for a long period of time afterwards.
Host Amber Smith: Well, Dr. Albert, I appreciate you making time for this interview. Thank you.
Scott Albert, MD: Thank you.
Host Amber Smith: My guest has been Dr. Scott Albert. He's the director of the breast cancer care team at the Upstate Cancer Center.
I'm Amber Smith for Upstate's "HealthLink on Air."
How reasoning styles may change with age -- next on Upstate's "HealthLink on Air." From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."
Can a person's cognitive decline be predicted based on their ability to reason?
I'll talk about that with Dr. Jeffrey Zemla. He's an assistant professor in the psychology department at Syracuse University. He specializes in aging, memory, reasoning and computational modeling, and he has a paper on this subject in the Journal of Aging, Neuropsychology and Cognition.
Welcome to "HealthLink on Air," Dr. Zemla.
Jeffrey Zemla, PhD: Hi. Thanks so much for having me.
Host Amber Smith: Your paper describes two different types of reasoning, fast, automatic and intuitive, compared with slow, deliberate and analytical. Is everyone one or the other from the day they're born and for the rest of their life?
Jeffrey Zemla, PhD: I don't think so. I think we're all capable of relying on intuition, just as we're all capable of deliberate and analytical thought. However, it seems to be that some people are more predisposed to relying on intuition than others.
Host Amber Smith: So what influences which way a person reasons?
Jeffrey Zemla, PhD: I think there are a lot of factors that influence the way a person reasons.
So age might be one of them, experience might be another, as well as different cognitive functions like working memory, executive functioning and so forth.
Host Amber Smith: Is one better than the other?
Jeffrey Zemla, PhD: Not necessarily. I think relying on intuition can be nice because it's very cognitively efficient and fast.
So in domains where time matters, relying on intuition can be beneficial, but sometimes it's helpful to deliberate more and to make sure that we're doing everything exactly as we should. So in those cases, I think analytical thought can be better.
Host Amber Smith: Is this something where a different type of reasoning can be taught or learned?
Jeffrey Zemla, PhD: I think in this particular domain, it's not something that we really teach, but something that we try to assess as an individual, whether they're more likely to use one or the other, but again, we'recapable of using both of these systems.
Host Amber Smith: Do you think people are able to be deliberative and analytical at work, but then intuitive when they're at home?
Jeffrey Zemla, PhD: Absolutely. Yeah. So I find this in my own job. I do a lot of data analysis where I have to be analytical, but that doesn't mean that's going to carry over to my everyday life. So, just as different people can be predisposed to analytical thought or intuition for different problems, I might be predisposed to use analytical versus intuitive thought as well.
Host Amber Smith: Well, let me ask you something that gets a little bit closer to your research. What happens to reasoning when a person is developing dementia?
Jeffrey Zemla, PhD: So we know that people who have dementia or people who are developing dementia have difficulty with reasoning and decision making in a few domains, including financial decision making, medical decision making. They also seem to be more susceptible to scams as well.
Host Amber Smith: So their ability to notice those or figure them out declines as the dementia sets in.
Jeffrey Zemla, PhD: That's right. Yes.
Host Amber Smith: Probably people have seen the commercial where the woman has trouble remembering the name of the man that she sees in the grocery store.
Is that normal decline?
Jeffrey Zemla, PhD: I think it could be. Certainly, declines in memory are the most prevalent symptom of dementia and, in particular, Alzheimer's disease. But I do want to caution that I think a lot of older adults notice that they have problems with their memory. Maybe they can't recall the name of an acquaintance or a coworker who they don't see very often, and they automatically jump to thinking that this is a sign of dementia, whereas someone who's younger and has that same sort of retrieval failure might not consider that this is something pathological in nature. I think the big difference in terms of memory is sort of the severity and frequency of these problems.
So if you forget the name of someone that you don't see very often, that's not really a severe problem -- right? -- compared to forgetting the name of your brother or your child. And again, the frequency matters, too. So if I have trouble with my memory every few days or once every few weeks, that's totally normal.
Whereas if I tend to forget things quite often, multiple times a day, and those problems are severe, that could be more worrisome.
Host Amber Smith: Now, you mentioned older people becoming targets of scams, and that's not people with dementia, that's people who are aging, not necessarily in decline.
Are they more susceptible because they're not able to be analytical with their reasoning?
Jeffrey Zemla, PhD: I think that's an open question, but a direction that I'm very interested in looking at. So I think there's an interpretation or a plausible story about why that might be the case.
So you can consider maybe that you get an email, and you have to decide whether this email is legitimate or not. So there are clues in the email as to whether it's legitimate. You can look to see whether the domain name is misspelled. You can look to see whether the language used is consistent with who purportedly sent the email and so on and so forth.
But you have to recognize those things. And so if you just see, "Oh, this email is from my mom, I'm going to trust it, rely on my intuition," without sort of critically assessing that, you might be more susceptible to falling for these scams. But I'll say this is an open area of research, so the connection between susceptibility to scams and reliance on intuition is still an open topic.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with assistant professor Dr. Jeffrey Zemla from Syracuse University's department of psychology, and we're talking about a paper he published in the Journal of Aging, Neuropsychology and Cognition.
Now, what is the cognitive reflection test? What can you tell us about it?
Jeffrey Zemla, PhD: So the cognitive reflection test is a three-question test that's designed to test whether someone is predisposed to analytical or intuitive thought. I think the best way to explain it is through an example. So here's one of the questions on the test, and I'll preface that: Typically this test is administered visually. You get to read it, so it might be a little more challenging if you're listening at home.
Here's the question. In a lake, there's a patch of lily pads. Every day the patch doubles in size. If it takes 48 days for the patch to cover the entire lake, how long would it take for the patch to cover half the lake?
What do you think?
Host Amber Smith: Oh, my goodness. It's not twice that, it's not half that. It couldn't be that easy. I don't know.
Jeffrey Zemla, PhD: So I think your mind is in the right place, right? So most people will say 24 days because they think it takes 48 days to cover the entire lake. Half the lake must be half as many days, 24.
In fact, we often don't really have to think about it that long for the answer "24" to pop in our mind. So we call that the intuitive answer. Unfortunately, this answer is incorrect. The correct or analytical answer is "47 days." So if we look at this problem again, it takes 48 days to cover the entire lake, but we also said that every day the patch doubles in size, meaning the preceding day, on the 47th day, the lake has half of the lily pads to cover the lake.
But to arrive at this answer, we sort of need to suppress our intuitive response of 24 days. We need to consider that that answer might be wrong and think about it a little more critically. So it's definitely not an easy problem to get, even for healthy individuals.
Host Amber Smith: So how many people took this test in your study?
Jeffrey Zemla, PhD: So in our study we had about 90 participants. Half of them were cognitively healthy older adults, 65 years old plus, and half of them were older adults with mild cognitive impairment, MCI.
Mild cognitive impairment -- I consider it sort of a precursor to dementia in that it's worse than typical, normal cognitive aging, but it's not quite as severe as Alzheimer's or dementia. So these are individuals who can typically function in their everyday life. They can go grocery shopping, they can do their everyday activities, but they do show some signs of cognitive decline.
Host Amber Smith: So what were your findings, then?
Jeffrey Zemla, PhD: What we found is that healthy older adults were able to solve about twice as many of these problems as those with mild cognitive impairment. So this is evidence that healthy older adults are more reliant on analytical thinking, or more predisposed to use analytical thinking, than those with mild cognitive impairment.
Host Amber Smith: Now, does that surprise you, or does it make sense that people with mild cognitive impairment would rely more on their intuition?
Jeffrey Zemla, PhD: I think it makes sense. So we know that people with mild cognitive impairment have fewer cognitive resources available to them. What I mean by that is that they show declines often in working memory or executive functioning or language or attention and things like that.
Now, if you consider that you have fewer cognitive resources available to you, you have to be a little bit more careful or judicious in how you use those resources.
So if you think about the lily pad question I gave you, this is a question that really doesn't have great importance, right? There's no consequences to you getting it wrong. There's no real incentive for you getting it right. So if you're an individual with mild cognitive impairment, for you to get the correct analytical answer, you have to engage in a really effortful thought.
So I think there is a possibility that those with mild cognitive impairment are not reflecting on the automatic or intuitive response that comes to mind because arriving at the correct answer is a lot more difficult for them compared to a healthy older adult.
Host Amber Smith: Do you think that people who are becoming cognitively impaired know that they're becoming cognitively impaired?
Jeffrey Zemla, PhD: I think many of them do. So in particular in the domain of memory, memory tends to be something that's very salient. We notice when our memory is worse than it used to be, so many individuals notice this and consider that they might have cognitive decline.
In fact, in our study, what we found was that subjective cognitive decline was a strong predictor of whether the individual had mild cognitive impairment or not.
Host Amber Smith: What about if they're losing their analytical skills? Will they realize that that's slipping away?
Jeffrey Zemla, PhD: I think it's less likely that they'll notice declines in analytical skills, and for a few different reasons, right?
Unlike memory, with analytical reasoning, sometimes there's no correct response, right? There's not necessarily a correct way to make investments for retirement and so forth. And often we have very poor feedback for those decisions that we make as well. The participants in my experiment, for example, they did this task, they were never given the correct answer, and so they might not have ever realized that they got it wrong.
So I think recognizing that your reasoning is declining is a lot more difficult than recognizing that your memory is declining.
Host Amber Smith: Now, what additional research on this subject are you proposing?
Jeffrey Zemla, PhD: Well, I think it would be worthwhile to see whether this has any downstream effects on things like susceptibility to scams that we talked about earlier.
Perhaps there are some interventions that we can do to get individuals to recognize that analytical thought is required and perhaps that would result in them being less susceptible to scams. I also think that tests of reasoning and decision making might be an interesting way to measure the cognitive profile of an individual to see whether they have something like mild cognitive impairment to begin with.
So generally, the cognitive screeners used for dementia and mild cognitive impairment focus on things like memory, attention, language and so forth.
And rarely do they have any tests of complex reasoning and decision making, even though we're learning more and more that these might be areas in which those with MCI have trouble with.
Host Amber Smith: Well, thank you so much for making time to tell us about your work.
Jeffrey Zemla, PhD: Thank you so much.
Host Amber Smith: My guest has been Dr. Jeffrey Zemla, an assistant professor of psychology at Syracuse University. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- you likely need a lung biopsy if a doctor believes you may have lung cancer.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith." This is HealthLink on Air."
If a doctor suspects that you may have lung cancer, you will probably undergo a lung biopsy, so today I'm talking about how that procedure is done and what results may mean with Dr. Ronaldo Ortiz-Pacheco. He's an assistant professor of medicine at Upstate.
Welcome to "HealthLink on Air," Dr. Ortiz-Pacheco.
Ronaldo Ortiz-Pacheco, MD: Thanks for having me.
Host Amber Smith: Let's talk first about how lung cancer biopsies are done. This would be scheduled after a medical scan shows something unusual in the lung. Is that right?
Ronaldo Ortiz-Pacheco, MD: Yes, that's correct. Right now, the United States Preventive Services Task Force recommends lung cancer screening for all patients 55 to 80 years old who have smoked 20 pack-years, or who have quit within the last 15 years.
Pack-year means the amount a person smokes per day multiplied by the amount of years that they've been smoking. So a person who smokes one pack per day for 10 years has a 10 pack-year history. So the more pack-years, the higher the riskof lung cancer.
And those patients are the ones who are encompassed in the lung cancer screening. There's different ways to categorize spots on the lungs; lung nodules is the medical term, and depending on the size, depending on the location, depending on how that nodule looks determines if a nodule will be a candidate for biopsy.
Host Amber Smith: And are the biopsies done in the hospital?
Ronaldo Ortiz-Pacheco, MD: Yes. Right now, currently, at Upstate, we do our biopsies in the hospital via either interventional radiology, thoracic surgery or pulmonology.
Host Amber Smith: And when the biopsy's actually done, is the person sedated, or can they feel the biopsy happening?
Ronaldo Ortiz-Pacheco, MD: So it depends on what type of biopsy is being done. Usually, if an interventional radiologist is doing a biopsy, it usually involves a needle going through the skin, into the lung, into the lesion. Those patients are usually sedated. They'll have some sort of local anesthetic to the area where the needle is going to be introduced.
For patients undergoing surgery or bronchoscopy, we usually have them under general anesthesia, with an anesthesiologist present during the case.
Host Amber Smith: And when you find a node or a nodule, are those cells that make up that node or nodule, are they inside the lung, or could they be on the exterior surface of the lung?
Ronaldo Ortiz-Pacheco, MD: So it depends on the type of cancer. It depends on what we're suspecting of what's going on. A lot of the cancers can have their origin in the actual meat of the lung, as I call it. The medical term, scientific term, is the parenchyma. But you can definitely have lung cancer arise within the airways, within the tubing inside the lung.
The way I like to describe the lungs to patients is think of a tree, and your main windpipe, your trachea, is the trunk of the tree, and it's hollow on the inside, and that divides into two big branches, your left and your right side, and then they start dividing into basically little microscopic berries, if you will. And cancer can arise from any portion of the tracheal-bronchial tree, as they call it, or the actual meat, parenchyma, of the lung.
Host Amber Smith: And we should be clear, I mean, we talked about lung cancer screening for people that have been smokers, but you can get lung cancer even if you're not a smoker. Is that right?
Ronaldo Ortiz-Pacheco, MD: That's correct. The biggest risk factor for any cancer is age. Unfortunately, we have a lot of patients who don't meet the screening criteria. And they get a CT scan, either a trauma workup, or they're having some sort of symptoms, and those patients are found to have either a large mass or an incidental pulmonary nodule, which needs to be followed, depending on its characteristics, size, for an extended period of time, whether it be three months, six months or a year, depending on patient risk factors.
Host Amber Smith: Now, what can you tell us about the endoluminal system that Upstate has?
Ronaldo Ortiz-Pacheco, MD: So the endoluminal system: We have currently the Ion by Intuitive. It is the same company that makes the da Vinci surgical robot. The Ion endoluminal system is basically a robotic bronchoscopy.
It's kind of like an endoscopy, if you would go for a gastroenterologist to check your esophagus or going for a colonoscopy, checking the colon; we check the airways. It basically takes out the human element of having to navigate ourselves and replaces that with a robot. So we actually drive the robot with a control panel up into a suspected nodule.
We make a virtual map of the lungs using a preexisting CT scan. We're able to segment the target that we want, meaning we get to make a virtual image of that nodule. And the bronchoscope itself, the machine itself, kind of makes a path which we follow, based on the imaging that we have. It's a 3D image, superimposed onto a live view, and we can drive up to the area in question and then biopsy the nodule, with needles, forceps, cytology brushing (brushing to collect sample cells), just to maximize the amount of cells that we can get to identify what exactly is going on with that nodule.
Host Amber Smith: So what you're able to obtain through this newer system, that's still considered a biopsy?
Ronaldo Ortiz-Pacheco, MD: Yes, it's considered a biopsy. Depending on the location, depending on some of the imaging technologies that are available to us, sometimes it is preferable to undergo a bronchoscopic biopsy, rather than one by interventional radiology or surgery.
Doing a bronchoscopic biopsy allows us to also take a look at the lymph nodes within the chest and allows us to do a procedure called staging, which is basically looking at the lymph nodes and making sure that those lymph nodes are not involved with any cancer cells.
That's not to say that this is the end-all, be-all way to biopsy lung cancer.
Everything has its trade-offs, right? With bronchoscopic biopsy, not using a robotic bronchoscope, historically, the yields have been anywhere between 30% to 70%, depending on the size and location of the nodule. With the robotic platform, particularly the ones that we have here at Upstate, we're able to bring up that yield to high 70s, maybe even low 90s, depending on, again, size, location and other imaging that we use intraoperatively to identify where the nodule is.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Ronaldo Ortiz-Pacheco. He's an assistant professor of medicine at Upstate, where he specializes in lung cancer biopsy.
Now, this seems like a very precise procedure. How can it be done accurately if the patient is breathing? Because wouldn't that cause the lungs to move?
Ronaldo Ortiz-Pacheco, MD: So that's always a limitation. We try to minimize the amount of movement that the patient has during the procedure, particularly the robotic bronchoscopy.
We use full anesthesia. We use a paralytic. That happens mostly during general anesthesia as well. So the only movement that we're seeing is the breathing that the breathing machine is doing for the patient. We try to be as accurate as possible by getting a CT scan the day of the procedure to allow for any small variations that might have been present during any prior CT scans, which can affect the accuracy of which we can go and get the nodule at.
And we have different maneuvers that we can do during the operation to ensure that we don't have focal areas of lung collapse, the nodule doesn't move just by different anatomic processes that happen during surgery, and basically try to be as accurate as possible.
Host Amber Smith: Does a biopsy run the risk of disturbing the cancer cells so that they spread?
Ronaldo Ortiz-Pacheco, MD: There's only, I would probably say only case reports, of supposed cancer being spread by biopsies. It's not something that's very common, particularly with lung cancers. That's not to say that there aren't some cancers that run the risk of, quote unquote, "seeding the tract," meaning seeding the area where you stick a needle into and actually causing the cancer to kind of spread within that tract, but in terms of lung cancer, that's very rare that it happens. I haven't heard of any cases, at least in my career, of that happening.
Host Amber Smith: When you're doing the biopsy, and you're visualizing the cells, can you tell whether it looks cancerous? Can you tell just by looking?
Ronaldo Ortiz-Pacheco, MD: So when we do the biopsies, we usually have cytology, a cytology tech, who has an on-call pathologist to discuss the case.
We basically give them a sample, where they put it on a slide, and they take a look at the cells under the slide, and they can identify if cells are abnormal. If they're normal, if it's an adequate specimen, meaning there's cells and not just blood, they can also tell, if it's very obvious, if there's evidence of cancer on the actual slides. But the actual results take about maybe three to five business days, usually, to get all of the special stains done, all of the special surface markers on the tumor cells. So it's definitely a process that takes about three to five days. But usually we can have a pretty good idea of where we're at during the biopsy.
And that kind of dictates where we will take a biopsy from, or if we keep going in the same direction, or if we need to move a little bit and see if we can get a different area, which will yield a different result.
Host Amber Smith: How do you instruct your patients to prepare for a lung biopsy?
Ronaldo Ortiz-Pacheco, MD: So I think the most important rule is don't eat anything after midnight or at least eight hours before a procedure. It's standard with any procedure that goes under any anesthesia.
If they're on blood thinners, usually we like to tell them to hold them for about two to three days before doing that. If they're on a medication called Plavix, which a cardiologist or a general practitioner might have placed them on for heart disease, we usually tell them to hold that for five days. Aspirin is usually safe for these procedures. A low-dose, baby aspirin is usually OK for them.
Host Amber Smith: What is recovery like?
Ronaldo Ortiz-Pacheco, MD: For robotic bronchoscopy, barring any complications, which are pretty low, the patient usually goes home the same day. Recovery is usually about one to two hours in the recovery area, in the procedural suite, and usually an X-ray afterwards. And then we just instruct them that if they have any chest pain, difficulty breathing, within the next eight to 12 hours to come back to the hospital.
Usually patients complain of a scratchy throat or maybe a little bit of a sore throat from where the breathing tube is inserted by the anesthesiologist. And some patients can have maybe a little bit of blood come up when they cough, but it's usually just a few specks of blood, and it's usually self-limited, anywhere between a couple of hours to maybe a day and a half after the procedure itself. But usually, patient recovery time is same day.
Host Amber Smith: Now, you said it may take three to five days to get the results. Will the results be clear enough that it is either cancer or it's not?
Ronaldo Ortiz-Pacheco, MD: Our pathologists are very well-trained, and they can usually be very spot-on with what type of cancer cells are present on the samples that we give them.
And that's all based on special dyes that they put on the cells. It's special markers that identify what type of cancer cells are available on that sample.
We always run the risk of not getting a diagnosis, which is actually one of the risks that I always tell my patients, right? We always talk about complications during the procedure, and I always say that one of the risks is, "Hey, we might not get a diagnosis, and we might have to do another procedure," whether it be a repeat bronchoscopy or ask a radiologist to see if they can biopsy from the outside or talk to a surgeon and see if the patient is a candidate for a more invasive biopsy.
Surgery is probably the most accurate way of getting any diagnosis for cancer. The problem is that involves a bigger surgery. It involves general anesthesia, usually involves the recovery period about one to two days, again, barring any complications. And also, it involves patient being healthy enough to have a portion of their lung taken out, right? That's what usually these surgeries entail.
Host Amber Smith: If it is cancer, how quickly do lung cancers grow and how urgently do you need treatment to begin?
Ronaldo Ortiz-Pacheco, MD: I think the person who answers that will win a Nobel Prize. If we kind of step back and explain a little bit about lung cancer, there's two big types of lung cancer that we worry about, which is the non-small cell and the small cell.
Usually, small cells can be pretty aggressive. Within a couple of weeks they can progress to pretty big sizes that do compromise the airway, unless there's some sort of intervention, which is usually chemotherapy.
And then the non-small cell is divided into two types, which is the adenocarcinoma and the squamous cell carcinoma, "adeno" meaning that the cells look more like glandular tissue, and "squamous cell" is more of cells arising from the surface of tissues.
In terms of how fast they grow, there are some adenocarcinomas that grow over a period of 10 years. Patients can live with them, and they'll usually pass away from something else. And there are other adenocarcinomas that are pretty aggressive. Within three months' time, they can double in size.
So in terms of how fast cancers can grow, I usually tell my patients it's not an emergency for me to go and get a biopsy or set up a biopsy when I'm thinking somebody has lung cancer. But it is an urgency, right? I really wouldn't want to wait maybe more than a month before identifying a nodule and going after the biopsy.
Three months' time? It's kind of stretching it because usually, on average, there is an increase in the size of nodules, it's called a doubling time, and we use that three-month mark as kind of like the average. So I usually don't like to wait more than three months.
Host Amber Smith: What other information can you get from the biopsy?
Ronaldo Ortiz-Pacheco, MD: Not all nodules are cancer. Not all masses are cancer. We can figure out that hey, you know, this is an infection, right? Is it related to a bacteria that's similar to tuberculosis? Is it fungus? Is it a benign nodule due to inflammation, right?
So, not all nodules, not all masses, are cancer, but cancer is a life-changing diagnosis. It can be a potentially devastating diagnosis, right? And that's usually what we think about, when we go after these nodules.
Host Amber Smith: Does the biopsy give you any ability to do a genetic analysis on the sample?
Ronaldo Ortiz-Pacheco, MD: Yes. If we get enough tissue on it, whether it be with enough needle passes or with forceps, right, to get a good hunk of tissue, we can run that genetic analysis, which usually the pathologists do.
Host Amber Smith: If there is a mass, and it's noncancerous, does it need to come out?
Ronaldo Ortiz-Pacheco, MD: I always like to engage the thoracic surgeons in that case.
It depends on how fast it's growing, if it's compromising any organs within the chest. Usually, if there's a mass, and it's growing, I would rather a surgeon take a look at it and possibly consider removing the mass and then having a final pathologic analysis of what that mass really is. But it all depends on symptoms that the mass is causing, if it's compromising any other structures within the chest. The one we worry about is the heart and the vessels that run inside the chest. We don't want that to get compressed.
Host Amber Smith: So after you have the biopsy, then does that help inform what next steps may happen, what the treatment might be?
Ronaldo Ortiz-Pacheco, MD: Yes. So it all depends on how the patient is, how healthy they are, if they're strong enough for surgery. Usually, if we identify Stage 1 lung cancer, meaning it's a cancer that's localized to one portion of the lung, usually the best way to treat it is with surgery, but not all patients can tolerate surgery, so there's other ways of treating it.
We can talk to a radiation oncologist and have that area irradiated again, depending on the size of the tumor involvement. For patients with more advanced diseases, there are different strategies to help treat the cancer. It will usually involve some sort of chemotherapy or chemotherapy with some combination of surgery or radiation. For patients with Stage 4 cancer, which means cancer that's spread outside of the chest or outside of the localized region, usually the treatment for that is chemotherapy, and as you mentioned before, with the ability to get genetic testing, having special targeted therapies for that type of specific cancer.
Host Amber Smith: Well, Dr. Ortiz-Pacheco, I want to thank you for making time for what's been a really good overview of lung cancer biopsy. Thank you so much.
Ronaldo Ortiz-Pacheco, MD: Of course. This is what we're here for, and we're a busy service, and anything for the people of Syracuse and the surrounding area.
Host Amber Smith: My guest has been assistant professor of medicine Dr. Ronaldo Ortiz-Pacheco. I'm Amber Smith for Upstate's "HealthLink on Air."
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Two of our poets sent us very different views of a wake. Both views allow us to see how this ritual can be celebratory as well as devastating. First up comes from our Tennessee poet and professor, Daniel Gleason from Bryan College. Here is his "Toast at a Wake":
To your eyes, to their light and to their color.
To your ability to see every shade of color.
To pastels, neons, warms, cools, watercolors.
To dyed eggs and to the High Museum of Art.
To your kitchen, to the kitchen work
you did in countless kitchens in others' homes.
To keeping dirty dishes on one side of the sink.
To boiling eggs for precisely 13 minutes.
To mashed potatoes and gravy, to butter .
To your mother's squash casserole recipe.
To color schemes in culinary arts.
To the day you returned to the kitchen
after all the years, after all the treatments --
trazadone, doxepin, electroshock, witch hazel.
To knowing that you might not have returned, but did.
To seeing light and color return to your eyes.
To resurrection. To you I raise this toast.
See us.
Our second reading comes from Jennifer Campbell, an English professor from Buffalo, New York. Here's her poem "Deciding to Attend the Wake" -- for A.B.
It's not about whether I'd like
to be there, but do I have the right
to step into the tsunami of grief.
Signposts holding me back:
Young. Suicide. Jumped .
The prodigal son rent the earth
in two one sunny morning,
traffic halted by the divide.
Now a whole town in line
to tug you above the waves,
something I am not strong enough
to do having barely survived
the initial blast. I have one living son.
Even now, his light pries open my eyes
every day; his breathing calms mine
every night. How can I tell you
the cleaving is irreparable,
aftershocks expected?
Little comfort in knowing the feet
will still move forward, even when
there's no certainty of ground.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," inflammatory bowel diseases.
If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org
Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.
This is your host, Amber Smith, thanking you for listening.