Pulmonologists Play Critical Role in Lung Cancer Management

Timothy Saettele, MD

Timothy Saettele, MD

The role of the pulmonologist in the treatment of patients with lung cancer has continued to evolve over time, said Timothy Saettele, MD. Moreover, the tools at this specialist’s disposal to diagnose and stage the disease have come a long way over the past 10 to 15 years.

“It’s important to realize that the role of the pulmonologist has been increasing in the treatment of [patients with] lung cancer,” said Saettele, an interventional pulmonologist at Saint Luke’s Hospital. “We do everything from the diagnosis of the cancer to staging the mediastinum, and in the future, we will have opportunities for treatment as well.”

Not only do pulmonologists play a key role in diagnosis and staging, they are also instrumental in managing complications associated with lung cancer, such as pleural effusions and malignant central airway obstruction, and in the management of associated medical diseases, such as chronic obstructive pulmonary disease (COPD) and emphysema. Over the past decade, novel technologies and techniques, such as endobronchial ultrasound and navigation bronchoscopy, have allowed pulmonologists to see through the walls of the airway and diagnose lesions in the periphery of the lung, which were previously difficult to detect.

In addition to these new techniques, liquid biopsies have been introduced in this space, offering a safe, noninvasive way to not only detect early lung cancer, but to also potentially identify optimal therapies, according to Saettele.

OncLive: What is the role of the pulmonologist in the management of patients with lung cancer?

What are the benefits of using bronchoscopies in non—small cell lung cancer (NSCLC)?

How have bronchoscopic technologies in lung cancer evolved over recent years?

Are any ongoing clinical trials looking at the use of bronchoscopies in this space?

Is bronchoscopy more useful than other rebiopsy approaches?

What is the role of liquid biopsies in NSCLC?

What are the benefits of liquid biopsies?

What other advances have been made in the diagnosis and management of NSCLC?

Do any challenges need to be addressed before we can move the needle forward?

In an interview during the 2018 OncLive^® State of the Science Summit^TM on Non—Small Cell Lung Cancer, Saettele explained the critical role of the pulmonologist in the management of patients with lung cancer and highlighted novel and available methods to improve diagnosis and staging of nodules or masses.Saettele: It’s important to keep the pulmonologist in mind in dealing with patients [with] lung cancer. Often, some complications the patients have are respiratory in nature—if their COPD is flaring up, or they have pleural effusions or obstruction of airways. The pulmonologist is at the frontline to help with those problems and can really improve quality of life, and hopefully, extend survival as well.Bronchoscopy has different roles in NSCLC, and probably the most studied and the most prevalent [place for its use] is in diagnosis and staging. When you’re talking about diagnosis and staging of NSCLC, bronchoscopy presents several benefits compared with traditional biopsies. For instance, [previously], you needed 2 procedures to diagnose and stage a mediastinum. Now, with bronchoscopy, you can perform mediastinal staging and diagnosis of a lung nodule or mass with just 1 procedure. [This approach] also cuts down on complications, such as pneumothorax, that you would often see with [the use of a] CT-guided needle biopsy.They have evolved quite a bit, actually. Ten to 15 years ago, advanced bronchoscopic techniques such as endobronchial ultrasound and navigation bronchoscopy just didn’t exist. Since then, we have [acquired] the ability to see through the walls of the airway with ultrasound technology, to biopsy outside of the airways, and to diagnose lesions in the periphery of the lung that we [had not been] able to see [previously]. Also, [those capabilities] will continue to evolve over time.Yes. One [area of research] that I’m particularly interested in is [evaluating] the use of bronchoscopy to treat patients with early-stage lung cancer. Therefore, in addition to being able to diagnosis and stage a new lung cancer, we will be able to use radiofrequency ablation or cryoablation to actually treat a stage I lung cancer in the periphery all in 1 procedure in the future.There is definitely a role for bronchoscopy with rebiopsy. Some data show that the yield for a diagnostic specimen for, for instance, a lymph node biopsy for restaging, is not as high as it was prior to treatment. However, it is the least invasive option that we have available.[They’re] not really used in the diagnosis of lung cancer, but in the molecular testing of lung cancer to see what treatment is best out there. Often, our oncologists use both together: a tissue-based molecular test as well as a cell-free DNA or liquid- based test. Often, you’ll get different results, [but they can] complement each other. Our oncologists see that they can select a treatment [based off of results from] a liquid biopsy that they weren’t able to offer with just a tissue-based diagnostic test.We can expedite care for the patients. For instance, at the time of biopsy and the time of diagnosis from a bronchoscopy, we can send the assay—a blood-based assay—at that time, and have the results ready for the oncologist by the time the patient shows up and sees them.A lot of new technology will come out in the near future. We’ll be able to improve the diagnostic yield of peripheral navigation bronchoscopy. With the use of robotic navigation technologies and the use of cone beam CT [bronchoscopy], we’ll be able to [more successfully] reach nodules and masses that are further out and smaller. Hopefully, [we’ll be able to] obtain more tissue as well. That is all coming in the next 5 to 10 years and is really exciting.Certainly. This technology is brand new and it hasn’t been tested in very many patients yet. We need to sit down and develop trials that are thoughtfully based—where we can compare new technology with old standard technology, and ensure that we’re doing our patients a service.