Intro 00:04
Welcome to Cancer Care Connections. On this week’s episode, Cheryl spoke with Dr. Christopher Paschold, oncologist and hematologist for Virginia Oncology Associates. Dr. Paschold shares his expertise on the latest in cancer treatment and screening for Non-Small Cell Lung Cancer. He emphasizes the risk factors involved in developing this cancer, the importance early detection plays in improving outcomes, and the importance of screening for those at high risk.
Cheryl 00:36
Dr. Christopher Paschold joins us today. He specializes in treating patients with head, neck, and lung cancer. He's a recipient of a variety of awards, including being invited into the Life Sciences Honors Program at North Carolina State University. He represents Virginia Oncology Associates as a member of the Sarah Cannon Lung Research Committee. He arrived at Virginia Oncology Associates in 2003. Dr. Paschold, thanks so much for joining us today.
Dr. Paschold 01:02
Oh, thanks for having me.
Cheryl 01:03
Great to talk with you, and I know this is something you see on a daily basis, and we're talking about non-small cell lung cancer. What do you see in your office related to this disease?
Dr. Paschold 01:15
Well, we see a variety of stages; early stage, late stage. The problem with lung cancers is a lot of times they're asymptomatic for long periods of time; don't give a lot of warning signs necessarily early, and we see more and more later than we like; Later stage disease and we'd like to see, but that's mostly what we see and see several a week, unfortunately.
Cheryl 01:38
Oh, that's too bad. But as far as risk factors, who are the people who should be paying attention? Loved ones of people who should be paying attention as well?
Dr. Paschold 01:48
Yeah, good question. I mean, the big one obviously is smoking, and there's a correlation between how many pack-years you've smoked as to increased risk. There are other risk factors: radon is one, and pollution we think is probably contributory. I still think there's probably a little risk for people who grew up in a house of smokers. That's not as well studied.
Cheryl 02:10
But I know, as we were talking before, this podcast episode is, even though the numbers you're seeing are declining over the years, it's still a large number of patients, you see.
Dr. Paschold 02:21
Yeah, there are about 250,000 new cases in the US a year and there are estimated about 500,000 current survivors that are alive in the US. It's the third leading cause of cancer in the US and the first in the world. It's quite common.
Cheryl 02:38
You mentioned that people come into your office later than you would like to see.
Dr. Paschold 02:43
Yes.
Cheryl 02:44
So talk a little bit more about that.
Dr. Paschold 02:46
Yeah, I think a lot of times lung cancers can be fairly asymptomatic, since there's not a lot, of you know, it's mostly air in the lungs, so there's not a lot of warning signs. And people will show up sometimes if it's spread and they develop pain. Sometimes there'll be some coughing or blood or worsening shortness of breath. Recently, in the past couple years, we've started instituting CT screening for lung cancer, which is a good tool. It's basically now covered by all insurances. Anybody who's over 50 and smoked for 20 years is a candidate, and like I said, it's covered. And we're hoping we'll start to see a migration and I think we already are starting to see a migration to earlier stages, which obviously the earlier you catch it, the more likely you're gonna cure it.
Cheryl 03:27
And so, going back to the screening, where would somebody go to get that type of screening? Do they start with you or do they go somewhere else to get that?
Dr. Paschold 03:35
Typically now it's through their PCP. They can probably self-refer to some places, but it's been added to most of the templates. Have you had your mammogram? Have you had your colonoscopy? Are you at risk for lung cancer? So usually the primary care doctor will do it. Occasionally I'll see patients who might have another medical problem and then I'll ask them about their smoking history and they'll meet the criteria and I'll send them, but typically it's through their primary care physician. But, like I said, it's been covered. It's now all insurance, including Medicare is paying. And it's actually, by test, it's a much bigger lifesaver since lung cancer is deadlier than other cancers. It's much...saves a lot more lives per scan than a mammogram or colonoscopy.
Cheryl 04:15
And so I want to go back to that. And you were saying that if you see people later, then the chance is greater that they don't have a good outcome.
Dr. Pachold
Correct.
Cheryl
So, talk a little bit more about that.
Dr. Paschold 04:27
Yeah, typically if the patients a higher stage, like a stage 3 or 4, they're treatable and sometimes long-term survival is possible. But it's a lot harder and, you know, involves chemotherapy, radiation, sometimes just chemotherapy alone. So we obviously prefer to, if someone's going to have it, to get it early. But we still see a lot of later stages and our treatments have improved substantially in the past five years. But it's a tougher fight.
Cheryl 04:51
As far as advances in treatment, what have you noticed? What have you seen? What has worked?
Dr. Paschold 04:56
Well, yeah, one big one's been immunotherapy. These are drugs that sort of turn on the immune system and help kill the cancer, versus chemotherapy, which directly kills the cancer cells. We've seen a nice big jump in molecular studies where we're actually digging deeper into the tumor itself, finding pathways that allow us to use targeted therapies, oral drugs. Some are very treatable and minimal toxicity, so that's been a nice change where up to about 30% or so of patients we don't have to necessarily go straight to chemotherapy on.
Cheryl 04:51
And as far as quality of life...
Dr. Pachold
Much Better
Cheryl
...the result of that is...
Dr. Pacahold
...tremendous.
Cheryl
Yeah.
Dr. Paschold 04:56
Yeah, it's very good.
Cheryl 05:34
So as far as patients..and we talk about on this podcast quite a bit about patients sort of being their own advocates.
Dr. Paschold 05:42
Yes.
Cheryl 05:43
A lot of the experts we've talked to here on the show have really talked about the patients sticking up for themselves and making sure that they're following through. What can they do if they feel like they're at risk? How can they help themselves?
Dr. Paschold 05:58
I think that with, a big one to start is the screening exam. If they meet those criteria and even if people have quit smoking for less than 15 years, they're still covered. It's an annual test, fairly painless 10, 15 minutes in a CT scanner. If they have the risk factors, they definitely want to talk to a provider about starting that process. Obviously, the biggest thing they can do to advocate for themselves is to not smoke or quit smoking as far as reducing their risk, and having family members help out, and try and encourage if they have a smoking family member to stop and get screened are the big ones. And, if they have concerning respiratory problems, see their primary care physician as well.
Cheryl 06:38
Well, we know that people listening to this podcast. It could be the patient, it could be the family of that patient. What kind of resources would you offer to those family members to kind of help on this, because it's not an easy thing?
Dr. Paschold 06:53
Right, right. I know a lot of...I know Sentara and others have smoking cessation classes; primary care physicians, there's a few prescription medications that can help with that. There's nicotine replacement. So there are tools and there's plenty in the community, smoking cessation classes, but it really has to start primarily with the patient. If he or she's not really going to commit to it, then it's not going to happen, unfortunately.
Cheryl
Yeah, In many things right?
Dr. Pachold
That's right, yeah, right yeah.
Cheryl 07:22
What is the message for them?
Dr. Paschold 07:24
Well, you know, get screened. Advocate for yourself, like you said. There's a lot of resources: the American Cancer Society if you're diagnosed, your healthcare provider, there's a group called LUNGevity that also has a good website, and chats and support groups that you can do after the diagnosis. But be..advocate for yourself. Get screened. If you do have the diagnosis, be involved with your care. Know what the latest treatment options are. Seek out extra opinions if needed. Those are the big ones after the diagnosis.
Cheryl 07:55
I think it's interesting that you would mention seeking extra opinions because I think it feels like the diagnosis is the diagnosis, but sometimes getting other views can help.
Dr. Pachold
It can..
Cheryl
..and get to the next point.
Dr. Paschold 08:09
The clinical trials are out there. We offer some, other places offer different ones. We always encourage patients who want to get another opinion. You know it's always their duty, but most patients, with the way data moves now, we stay pretty up-to-date on what's available. And you know between medical societies and pharmaceutical companies, if a new treatment becomes available, then we know about it pretty much as quickly as anyone else.
Cheryl 08:36
We know that at Virginia Oncology Associates they're on the cutting edge.
Dr. Paschold 08:40
Right.
Cheryl 08:41
And so can you talk about some things that are kind of on the horizon for those with lung cancer?
Dr. Paschold 08:46
Sure, there's more and more genetic testing being done on tumors and I think that's going to translate to better therapies. We have a new clinical trial that's looking at standard treatment versus a little bit more novel drug-related...It's a chemotherapy but it's bound to a target that actually gets into the lung cancer cells better, that we just started here. I think hopefully we'll start seeing a migration toward earlier cases if the screening picks up. It's already estimated, if it gets implemented well, it'll save tens of thousands of lives per year just by doing that.
We still treat, and sometimes get involved in treatment with earlier lung cancer patients, with surgery or after surgery. But, hopefully, we'll start to see that change on the horizon as well. And there has been a nice drop in smoking. About three or four years ago was the first time that cancer-related deaths in the US went down and they continue to decline. And most of that was because of the decline in the death of, you know, people passing away from lung cancer. So that's a very positive thing and it's linked to better treatments, it's linked to less smoking, and I think we'll start to see more with screening.
Cheryl 09:15
I would say that having conversations like this helps as we talk about the repercussions, the consequences of not getting the screening and continuing to smoke.
Dr. Paschold 09:50
Yeah, those are the best things you can do to try and help yourself for sure.
Cheryl 10:06
Can you walk me through a patient's journey after that patient has been diagnosed?
Dr. Paschold 10:09
Sure. A little bit depends on sort of where things are at. If it's caught early, it usually, let's say, for example, with the screening CT scan they find a smallish lung nodule...Typically will be followed by some sort of biopsy. Either they can be biopsied with CT guidance or through bronchoscopy, where they go down in the patient's lung and look around and take biopsies. Then it becomes a little more stage-dependent. Stage 1 is if you just have a small tumor. That's typically referred to surgery and removed. And now they're doing less invasive lung surgeries than they used to. They're using robotic-based surgery, so it's a quicker recovery. Still a tougher surgery, but people are getting through it quicker.
Stage 2 disease, so if you have a tumor with an involved lymph node, typically will be either a little chemotherapy then surgery, or surgery then chemotherapy. Stage 3 is more lymph nodes and that's typically sometimes chemotherapy and surgery, or chemotherapy, radiation, and some follow-up with immunotherapy which we give after that, which is newer. Stage 4, unfortunately, if it's spread, typically it's just chemotherapy or targeted therapies and immunotherapy based. So it's really where you sort of catch it in the diagnosis and it has a little bit to do... there are different subtypes of non-small-cell lung cancer. That kind of tweaks the treatment options a bit.
Cheryl 11:27
You mentioned earlier that you tend to see patients who are toward the later end.
Dr. Pachold
Correct.
Cheryl.
Where do you normally see them?
Dr. Paschold 11:36
It typically is Stage 2, 3, and 4. We still see a lot of Stage 4 disease. And I think some of that is just patients maybe putting off getting seen or maybe not having the resources to get seen in a timely fashion, which is always something we hate to see, but I still think that's part of it. And even with successful surgeries, some people's cancer comes back two, three, four, or five years down the road and we end up having to treat it some other way.
Cheryl 12:27
We've been talking about lung cancer and the not so great outcomes when you diagnose someone in a late stage, but I know you have a story of hope.
Dr. Paschold 12:38
Yeah, there's a lot out there now, especially with immunotherapy. When I was being trained, the survival for Stage 4 lung cancer was less than a year, in general. That's greatly increased with immunotherapy, and I have several patients who are five, six years into the diagnosis and appear to be free of disease. There's actually in the lung cancer community talk about maybe curing Stage 4 lung cancer, which was unheard of, at least in a small subset of patients. But now we're seeing, and I see routinely, people who are well into their diagnosis and basically on scans and lifestyle are leading pretty normal lives by just coming to the office once a month for a one-hour infusion and going about their life. So it's been a great change.
Cheryl 12:54
That's incredible. Can you talk more about the medicine of that, the immunotherapy itself?
Dr. Paschold 12:58
Sure, yeah. We always sort of knew the immune system played a role in cancer surveillance. And part of cancer is probably alluding that immunotherapy, there's several out there, that basically work by (for lack of a better term), the cancer cloaks itself to the immune system and these drugs uncloak the cancer, if you will, and allow your body's immune system to go after it. And they've really changed the landscape, not only for lung cancer but a lot of cancers, and made a huge impact on improving quality of life, improving survival, and there's more on the horizon...combinations, newer drugs. So it's just getting started. But in the past four or five years it's been a huge improvement for lung cancer patients, so a lot more to be optimistic and hopeful about.
Cheryl 13:39
That's exciting.
Dr. Paschold 13:40
It is very exciting.
Cheryl 13:41
And as far as clinical trials or things happening here at Virginia Oncology Associates, are there anything related to immunotherapy for lung cancer here?
Dr. Paschold 13:50
We have one that we just opened that uses standard immunotherapy with chemo, versus a little different chemo with a different immunotherapy drug. That just started, and then we're looking at a few more for different cancers at different stages or phases of the diagnosis.
Cheryl 14:07
Who is eligible for these clinical trials, for these new treatments?
Dr. Paschold 14:12
Well, the immunotherapy's been approved, FDA approved, and around for several years now, so that's pretty much all comers. There's certain criteria that you have to have to get it at certain points of the diagnosis, but that's really accessible to anyone. The clinical trials, they do usually have certain criteria because they have to have fairly strict entry points to make sure that the patients that are being looked at are similar to a degree. But we talk to most of our patients if they have a clinical trial option, about being involved. And then we have our research coordinators really do a deep dive into their medical records and see if they are a candidate. And if so, then maybe go on to the study.
Cheryl 14:49
This conversation is about non-small-cell lung cancer, but there are other types of lung cancer. Can you talk a little bit more about that as well?
Dr. Paschold 14:56
Yeah, there's small-cell lung cancer which makes up about 15% of the lung cancer we see; treated a little differently. It's a little bit more aggressive and tends to show up a little later. That one has a pretty high propensity to smoking...smokers. So that's one, and occasionally you'll see cancers that spread to the lung that start elsewhere. So those are ones that you have to sort of figure out where they came from and then treat it appropriately.
Cheryl 15:21
When you think about lung cancer, you typically think about the smoker who is diagnosed with it, but we have talked about a small percentage who have never smoked at all and still get it. What is the message to them, and how do they even get tested when they don't really have any risk factors related to it?
Dr. Paschold 15:39
Yeah, that is a little harder. We don't know if it's environmental or other causes related to it, but it's...10 to 15% are light or non-smokers. And the problem there is sometimes even the doctor's caring for them, that's not top of their mind because of it. And they wouldn't qualify for screening tests because they don't have the smoking history. It's just, if you start to get symptomatic, be your advocate and get checked, and don't say, if they say it's not anything to worry about and it keeps going on, keep pursuing it if you get anything respiratory-wise. But it is a tough, tougher population, just because they don't have access to the screening tools. But people automatically assume that people are smokers so they get stigmatized to some extent. But there are a fair number of patients that never smoked and still unfortunately, get lung cancer.
Cheryl 16:26
..And the symptoms are, as small as they are, just coughing?
Dr. Paschold 16:30
Cough can do it. Change in your stamina, if you get short of breath in an activity you used to be able to do easily and now it's harder. Certainly, any coughing up of blood is a red flag; not always cancer, but something that needs to be evaluated, quickly. But those are yeah, those are big ones.
Cheryl 16:48
Doctors are thinking else you'd like to add?
Dr. Paschold 16:50
I think you've hit it all. I think just be your advocate and help yourself stop smoking, if you are, and get help early if you need it.
Cheryl 16:58
Dr Paschold, thank you so much.
Dr. Paschold 17:00
Thanks for having me.
Exit 17:06
That’s all for this episode of Cancer Care Connections. Stay tuned for our next episode where Cheryl will sit down with Dr. Graham Watson, oncologist and hematologist for Virginia Oncology Associates. Dr. Waston will discuss the novel therapies in cancer treatment, immunotherapy, and targeted therapy, and how they differ from the more well-known cancer treatment, chemotherapy.
Don't forget to subscribe to our podcast via Apple Podcasts, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections. buzzsprout. com. Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at VirginiaCancer. com or find us on Facebook or Instagram at Virginia Oncology Associates.