top of page

Part 15 of 49 - Video Presentations of the "1st Conference on Integrating Early Detection of Heart and Lung Disease through Low-Dose CT": Day 1 Session 2: Panel Discussions

Averting Premature Death from Lung Disease by Early Detection



Thursday, September 19, 2024 | New York Academy of Medicine (NYAM)

1216 5th Ave, New York, NY 10029



During the second panel discussion on the first day of the conference, experts in lung cancer screening, interstitial lung diseases, and pulmonary medicine emphasized the importance of early detection and intervention for lung diseases, including COPD, emphysema, and bronchiectasis. They highlighted the utility of low-dose CT scans and the need for comprehensive reporting and follow-up. Challenges in reporting mild disease findings and the differences in approaches between the US and other countries were also addressed. The panelists also discussed the potential benefits of new therapies and the importance of involving pulmonologists in patient care to enhance lung disease screening and management and improve patient outcomes.




Watch The Panel Discussion Below:

Panel Discussion Video
Panel Discussion Video


See Slides and Images from "Session 2: Averting Premature Death from Lung Disease by Early Detection" Panel Discussions Below:


-



Click Here to Watch the Video


[Jim Mulshine] [0.16s] Okay.

[Jim Mulshine] [0.48s] We're gonna move right to the discussion.

[Jim Mulshine] [2.00s] Can our 3 additional panelists please come join us?

[Jim Mulshine] [5.04s] Thank you.

[Jim Mulshine] [8.56s] And as we adjust the stage, We have a series of questions that we're gonna go through with the panelists and hopefully leave a little bit of time for interaction from the audience as well.

[Jim Mulshine] [25.24s] Busy pretty busy place up here.

[Jim Mulshine] [31.35s] Can we ask, starting with Ella, can we introduce the 3 new panelists to have them introduce themselves?

[Rozemarijn Vliegenthart] [39.19s] Thank you.

[Ella Kazerooni] [39.67s] I'm Ella Kazerooni.

[Ella Kazerooni] [40.63s] I'm a cardiothoracic radiologist at University of Michigan, so I really appreciate all the structural heart heart disease this morning.

[Ella Kazerooni] [46.72s] Disclosure, my husband is an interventional cardiologist.

[Ella Kazerooni] [49.67s] Usually say that at radiology meetings.

[Ella Kazerooni] [52.55s] And I'm also the chair of the American Cancer Society's National Lung Cancer Roundtable, which has a goal of creating lung cancer survivors with a strategic component clearly focused on early detection.

[Rozemarijn Vliegenthart] [65.33s] Hi.

[Rozemarijn Vliegenthart] [65.57s] My name is Rozemarijn Vliegenthart.

[Rozemarijn Vliegenthart] [67.41s] I'm a cardiothoracic radiologist as well from, Groningen, the Netherlands, and I focus on early detection of disease.

[Rozemarijn Vliegenthart] [74.97s] I'm involved in Nelson study and, lead a population based study where we determine reference values in the general population called human life.

[Jim Mulshine] [85.64s] And Javier?

[Javier Zulueta] [88.68s] Javier Zulueta, pulmonologist.

[Javier Zulueta] [91.32s] And by the way, we're equal not only in women and men, but also in pulmonologists and others.

[Javier Zulueta] [100.22s] So I'm a chief of pulmonary and girdle care at Mount Sinai Morningside, right on the other side of the park, and, I've been involved with the lung cancer screening and with the ILKAC group since 1999.

[Javier Zulueta] [112.38s] First met Claudia.

[Jim Mulshine] [114.33s] Yes.

[Jim Mulshine] [115.21s] So, to just get started, we have a series of questions.

[Jim Mulshine] [118.25s] I'll I'll pose the first one, which is, what other lung diseases?

[Jim Mulshine] [122.41s] We've heard about emphysema, lung cancer, bronchiectasis, and what other lung diseases could we potentially evaluate in a screening setting that have mortality implications?

[Jim Mulshine] [138.47s] Javier?

[Javier Zulueta] [139.34s] Pulmonary hypertension.

[Javier Zulueta] [142.35s] We can see on the CT scan just by measuring the pulmonary artery.

[Javier Zulueta] [146.51s] We can find the signs of pulmonary hypertension and and and the prevalence is not that low.

[Javier Zulueta] [152.51s] I can't quote numbers right now, but, and and many of those who have a pulmonary artery greater than 3.1 centimeters, are at risk of having heart disease.

[Javier Zulueta] [162.33s] So

[Jim Mulshine] [163.29s] Yeah.

[Jim Mulshine] [163.78s] Okay.

[Jim Mulshine] [164.18s] Great.

[Jim Mulshine] [165.46s] So the next question, in addition to what we've already heard from the initial comments, what interventions are actionable today in terms of these kinds of findings that we're discussing?

[Jim Mulshine] [179.58s] Ella, wanna start off?

[Ella Kazerooni] [181.02s] Yeah.

[Ella Kazerooni] [181.26s] Would you mind popping up the couple slides that I have?

[Ella Kazerooni] [183.34s] Because I think it'll make that clear in this bigger COPD space that is somewhat amorphous.

[Ella Kazerooni] [189.51s] It's not well studied, and we really don't know.

[Ella Kazerooni] [192.79s] Yes.

[Ella Kazerooni] [193.19s] You could go to the next one.

[Jim Mulshine] [196.16s] Next slide, please.

[Jim Mulshine] [199.29s] You want the

[Ella Kazerooni] [200.89s] So, we really do not understand COPD in the way cardiovascular medicine understands ischemic heart disease and atherosclerotic coronary disease.

[Ella Kazerooni] [209.53s] We are several decades behind what has happened in the cardiovascular community to understand the disease state.

[Ella Kazerooni] [216.09s] And it's taken, I would say, the last couple of years and some major NIH funded studies to try and understand what COPD really is, what its disease phenotypes are clinically and importantly with an imaging component.

[Ella Kazerooni] [230.57s] And these two studies, COPD gene, started in 2007, and then we're now on the 4th round of serial high quality CT imaging, to collect information on patients.

[Ella Kazerooni] [241.47s] And SPIROMIX is another multicenter large study.

[Ella Kazerooni] [244.28s] So these two studies funded by NIH are using serial high resolution quality imaging to look at lung disease to help us understand it better in the way you understand, atherosclerotic coronary disease both clinically and to phenotype the disease, and phenotypes drive treatments and clinical trials and better patient outcomes.

[Ella Kazerooni] [264.64s] And this model was just published in the blue journal for which is the pulmonary medicine journal, just this month.

[Ella Kazerooni] [271.31s] It's still, online ahead of print, and it takes this wealth of data in COPD gene and tries to figure out what is this kind of COPD thing that we talk about so loosely.

[Ella Kazerooni] [283.14s] And we hear comments like emphysema is not COPD, but isn't it just preclinical COPD?

[Ella Kazerooni] [288.50s] Isn't it subclinical disease instead of it's not COPD?

[Ella Kazerooni] [292.50s] And so this model has taken a lot of data from these serial CT patients.

[Ella Kazerooni] [297.30s] This was almost 9,000 patients and use this, you know, maybe a little bit hard to understand graphic.

[Ella Kazerooni] [303.31s] These are pictures of different phenotypes of COPD based on clinical symptoms, based on imaging data, based on patient reported symptoms and outcomes to try and understand that it is really complex.

[Ella Kazerooni] [315.83s] When I was in med school, it was emphysema, asthma, and chronic bronchitis, and that was very simple and straightforward.

[Ella Kazerooni] [323.67s] And people thought they might have known what they were talking about, but it's so much more complex.

[Ella Kazerooni] [327.99s] And these subtypes, as you can see here, they're much more detailed and broken down in the way patients respond in their symptoms.

[Ella Kazerooni] [334.75s] Next slide.

[Ella Kazerooni] [339.07s] And what we've been able to show is that people's phenotype of disease changes over time.

[Ella Kazerooni] [344.36s] There are people who are emphysema predominant patients who stay that way.

[Ella Kazerooni] [348.18s] There are patients with small airway disease who morph in to emphysema and chronic bronchitis.

[Ella Kazerooni] [353.38s] It's a much more complex disease state with lots of inflammatory things happening in the lungs with pulmonary vascular changes we're seeing are happening.

[Ella Kazerooni] [361.75s] So it's much more complex.

[Ella Kazerooni] [363.68s] This graph this chart at left shows you the patients who are stable over 2 time points and all the patients at the bottom who have changed their phenotype of disease.

[Ella Kazerooni] [373.67s] And so treating somebody today and treating somebody in 2 years or 5 years may look very totally different if we don't understand this better.

[Ella Kazerooni] [380.47s] So people are moving across these phenotypes.

[Ella Kazerooni] [382.79s] Can you click one more, please?

[Ella Kazerooni] [384.79s] And this is just looking at the people who change.

[Ella Kazerooni] [387.11s] Look at all that crosstalk between one time point and a second time point.

[Ella Kazerooni] [391.73s] Just a couple years down the road, they're changing their phenotypic expression.

[Ella Kazerooni] [396.05s] Next.

[Ella Kazerooni] [399.40s] And then we're trying to drive this into how can we identify the genetic underpinnings, the proteins to drive drug discovery, and target different phenotypes, and this is just one example of taking this phenotyping and matching it to proteomic predictors.

[Ella Kazerooni] [416.63s] So we have so far to go in COPD to understand it.

[Ella Kazerooni] [420.48s] A little bit of emphysema is not no COPD.

[Ella Kazerooni] [423.27s] It's probably just subclinical disease or a little bit of small airway wall thickening or a little bit of mucus bugging.

[Ella Kazerooni] [428.96s] It's all disease that may not be symptomatic that we don't even really understand.

[Ella Kazerooni] [433.82s] And the next I'm almost done.

[Ella Kazerooni] [435.98s] Sorry.

[Ella Kazerooni] [439.74s] I did wanna show this.

[Ella Kazerooni] [441.50s] Back real quick for this.

[Ella Kazerooni] [442.62s] But we talked about patient report, patient level reports and impact of, like, seeing their coronary calcium and talking about it.

[Ella Kazerooni] [449.64s] You can do the same thing in lung cancer screening and take all of the things you can see on the screening CT and put them into a patient center report.

[Ella Kazerooni] [458.21s] And this was just a study we done did with this report, with a group in Minnesota as well to look at if you show them information that's real based on their own CT and you tell them, tell people what it means to them, what would happen if they quit smoking physiologically, functionally, future state health, it does increase the likelihood that they're gonna quit smoking and have more quit attempts.

[Ella Kazerooni] [480.94s] So I think this is very powerful information that was said before about calcium.

[Ella Kazerooni] [484.38s] And I think one more.

[Ella Kazerooni] [487.17s] Yes.

[Ella Kazerooni] [487.97s] So this is, also just out in print, which is leveraging CT.

[Ella Kazerooni] [494.21s] And I think while you've seen all this conversation today in the cardiovascular community and where you are in moving this frontier, the respiratory community is behind in pushing this.

[Ella Kazerooni] [504.90s] And this is really the first major paper also in the blue journal, multi country, really putting it on paper and saying that the lung community needs to leverage us as well.

[Ella Kazerooni] [514.58s] And so I just want to make that important point.

[Ella Kazerooni] [516.35s] There's so much in there, but we have to get our communities on board to recognize.

[Ella Kazerooni] [520.56s] Yeah.

[Rozemarijn Vliegenthart] [520.88s] Okay.

[Rozemarijn Vliegenthart] [521.00s] I'll stop there.

[Jim Mulshine] [521.84s] So, to make your comments even more complicated, the leading cause of death in individuals with COPD long term is cardiovascular disease.

[Jim Mulshine] [532.01s] So this is this is a bowl of spaghetti.

[Jim Mulshine] [535.62s] And, so the next question that we had was what interventions okay.

[Rozemarijn Vliegenthart] [541.86s] So thank you.

[Rozemarijn Vliegenthart] [542.50s] This is great.

[Rozemarijn Vliegenthart] [543.70s] Question, should we do expiratory CT as part of lung scan screening?

[Ella Kazerooni] [547.75s] Yeah.

[Ella Kazerooni] [547.99s] So this is a really important question.

[Ella Kazerooni] [549.43s] All that COPD gene study data is, inspiratory and expiratory CT, high resolution, really good quality, trying to get the best information.

[Ella Kazerooni] [558.87s] Can we do it low dose?

[Ella Kazerooni] [560.07s] We've been modeling low dose CTs and standard dose CTs to be able to try and extract the same.

[Ella Kazerooni] [565.15s] But also, would you so as you're talking about expanding the rest of the chest and a coronary calcium CT, would you add an expiratory CT to get the more powerful information from the lungs that you don't currently get?

[Ella Kazerooni] [578.01s] And so as we think about it, we think more holistically both in the cardiac and the lung standpoint.

[Ella Kazerooni] [582.33s] Yeah.

[Jim Mulshine] [582.49s] I agree.

[Claudia Henschke] [583.05s] So you still have a 2 step process.

[Claudia Henschke] [585.05s] So when you see that first one, so don't equate it immediately with screening.

[Claudia Henschke] [589.76s] The first?

[Jim Mulshine] [591.45s] Yeah.

[Jim Mulshine] [591.61s] But this this is the this is the the transition that we're talking about.

[Jim Mulshine] [595.85s] Screening is a screening test, and then it's a gateway to diagnostic tests that work up various findings from screening.

[Jim Mulshine] [604.26s] And so this is the bucketing we have to do for the primary care community and for the for the people at large to try to map what the information from screening is and how do we apply it.

[Jim Mulshine] [616.60s] So in that spirit, can we move on to

[Ella Kazerooni] [623.48s] Oh, it's a missed opportunity when they come for screening.

[Ella Kazerooni] [626.36s] Looking at expiratory sequence at the same setting is 5 seconds.

[Jim Mulshine] [630.04s] No.

[Jim Mulshine] [630.28s] No.

[Jim Mulshine] [630.52s] That's that's not true.

[Jim Mulshine] [632.12s] Ella,

[Javier Zulueta] [633.08s] I would I would, I would do a spirometry before an expiratory CT.

[Javier Zulueta] [636.60s] Bingo.

[Ella Kazerooni] [637.16s] But the problem is, you know

[Albert Rizzo] [638.44s] made a full amount.

[Ella Kazerooni] [639.32s] You have to then Perfect.

[Jim Mulshine] [640.36s] Where is the idea of the good?

[Mark Metersky] [642.53s] But you could link it.

[Mark Metersky] [643.50s] Right?

[Mark Metersky] [643.65s] If you see something characteristic on the low dose CT, you you could

[Ella Kazerooni] [647.50s] The problem is you don't get the information.

[Ella Kazerooni] [650.29s] So when you do exploratory CT That's

[Jim Mulshine] [652.93s] why they have no guidelines.

[Ella Kazerooni] [654.22s] See on the inspiration.

[Ella Kazerooni] [655.25s] So you don't know what you don't see unless you do that.

[Ella Kazerooni] [657.65s] And that's that whole small airway disease cohort, that COPD gene has been identifying.

[Ella Kazerooni] [662.74s] You don't see it on an inspiration.

[Jim Mulshine] [664.42s] Okay.

[Jim Mulshine] [664.66s] So I'll bring you back to, Ella, to your comments about tobacco cessation.

[Jim Mulshine] [669.14s] Okay?

[Jim Mulshine] [670.02s] Because that's something that could be done now without US Preventive Services Task Force dithering any further.

[Jim Mulshine] [677.75s] So what other things are in that bucket of actionable interventions at this point in time?

[Jim Mulshine] [683.60s] And that's the next challenge to the panel.

[Jim Mulshine] [688.52s] Who wants to go first?

[Mark Metersky] [690.36s] I I think it's gonna vary depending upon what the finding is.

[Mark Metersky] [693.32s] For bronchiectasis, it's referral to a specialist.

[Mark Metersky] [699.78s] For obstructive lung disease, maybe an expiratory CT, maybe spirometry.

[Mark Metersky] [705.30s] Ultimately, it's gonna need action, but but for bronchiectasis and probably ILD, even the the primary care doctor isn't gonna know what to do.

[Jim Mulshine] [715.56s] Well, in the paper that doctor Rizzo quoted from New England Journal, on, the Canadian study on COPD, the intervention that they used that they felt was most efficacious was the doctor telling the patient to lose 5 to £10, which I think you could do right now.

[Jim Mulshine] [735.93s] But, okay.

[Jim Mulshine] [737.76s] But but see but but, you know, just getting vaccinations, you know, that are scheduled.

[Jim Mulshine] [744.85s] I mean, there's a variety of things, and so we have a block.

[Jim Mulshine] [748.53s] If there's a drug, the drug companies tell us we'll think about that.

[Jim Mulshine] [752.38s] But there's all these these these parameters of disease, you know, social determinants of disease that we heard about from doctor Harrington that we are kinda paralyzed in terms of underscoring not in the population.

[Jim Mulshine] [766.84s] The paper that you showed is a general population.

[Jim Mulshine] [770.44s] This is in the screening population in which there's a vastly higher risk profile than the general public.

[Jim Mulshine] [775.88s] And so our abilities to kind of get more proactive in terms of interventions is something that is a big opportunity.

[Ella Kazerooni] [785.39s] Physicians are drowning in activity.

[Ella Kazerooni] [788.83s] Their nurse practitioners and PAs are seeing the simple patients.

[Ella Kazerooni] [792.36s] They're seeing the most complex patients with the most comorbidities, and it's they're under tremendous stress.

[Ella Kazerooni] [798.15s] And so when we put things on our radiology reports, which I encourage radiologists to report coronary calcium, to report any emphysema, to report all these things, what we get back from primary care is, well, what's the next step?

[Ella Kazerooni] [810.09s] Can you articulate for them in a very simple pragmatic algorithmic approach what they can do?

[Ella Kazerooni] [815.76s] They can build that into their EHR and their health maintenance activities and make prompts to do it, but they need to know what to do because providing telling people to, you know, radiologists put in your reports.

[Ella Kazerooni] [826.40s] Okay.

[Ella Kazerooni] [826.64s] That's great.

[Ella Kazerooni] [827.20s] But somebody's gotta do something with it.

[Ella Kazerooni] [828.96s] And is that referral to a specialist in ILD?

[Ella Kazerooni] [832.00s] That's like with that pick list in our radiology report.

[Ella Kazerooni] [834.96s] Unsuspected ILD refer to pulmonary medicine to get PFTs.

[Ella Kazerooni] [838.48s] Same thing with bronchiectasis.

[Ella Kazerooni] [840.15s] But if you don't know that for all these other findings, like, okay.

[Ella Kazerooni] [843.27s] There's some mild airway wall thickening or there's some mild emphysema.

[Ella Kazerooni] [847.12s] Is there an action item?

[Ella Kazerooni] [849.90s] When does there become an action item?

[Ella Kazerooni] [851.66s] And and they're really needing assistance because some of it is in the primary care domain, and some of it's in the specialty.

[Albert Rizzo] [857.82s] I think you're right.

[Albert Rizzo] [858.54s] I think you're talking about implementation science.

[Albert Rizzo] [860.86s] Really, the system change, lot of practices are not efficient at what they do with regard to guideline care.

[Albert Rizzo] [866.89s] They may have the manpower to do it.

[Albert Rizzo] [868.17s] They just don't know how to do it.

[Albert Rizzo] [869.53s] And insurance companies are starting to pay for that to occur.

[Albert Rizzo] [873.38s] Lung Association has some projects where we'd go into the practices for asthma guideline.

[Albert Rizzo] [878.98s] And I think that takes some burden off the primary care doctor.

[Albert Rizzo] [882.26s] But I also think somewhere in between, we need a not a pulmonary specialist, but maybe a mid level who is like a respiratory therapist who's trained in some pulmonary medicine to go over some of these reports with patients and then figure out what's the next step for the primary care doctor to do if he's not gonna send it to a pulmonologist.

[Javier Zulueta] [900.08s] I think, Al, and and I I think from seeing your your fantastic presentations, all 3 of you, you you all 3 show that there's great promise for therapies for early disease.

[Javier Zulueta] [912.59s] In ILD, we know that, you know, the the current therapies just stop the progression.

[Javier Zulueta] [918.22s] So intuitively, you would think the sooner you start, the better.

[Javier Zulueta] [921.42s] Right?

[Javier Zulueta] [922.13s] You have to do the trials and all that, but there's a potential treatment there.

[Javier Zulueta] [925.34s] We just saw potential treatment for bronchiectasis.

[Javier Zulueta] [929.21s] So and and we're talking about prevalence as bronchiectasis is 20 some percent.

[Javier Zulueta] [933.05s] Emphysema, we know that's 30% in our cohort in the University of Nevada and and then ILCAP at large, it's about 28%, I remember.

[Javier Zulueta] [942.23s] And we just heard, you know, potential therapies or trials that are coming out with the longevity modulating, medications like metformin and things like that.

[Javier Zulueta] [951.58s] So we might have treatments for early disease, so we might have to start and I think, by the way, this is gonna change our our we're gonna solve our big problem that if you read anything about lung cancer screening today, the main problem is that implementation rates are below 10%.

[Javier Zulueta] [965.89s] We're terrible.

[Javier Zulueta] [967.01s] Well, pharma is gonna take care of that.

[Javier Zulueta] [968.93s] I mean, with all these treatments, I'm sure that we're and and we're talking about 20 to 30% prevalence of these diseases that can be treated early.

[Javier Zulueta] [977.27s] I think, lung cancer screening is gonna take off.

[Javier Zulueta] [980.88s] And we have we have to start referring to specialists for those treatments.

[Maria Padilla] [985.79s] I think the other aspect of this is that patients are becoming very familiar with their reports.

[Maria Padilla] [993.23s] And it's not uncommon for us to receive a patient who read about this little bit of pulmonary fibrosis and then and they are the motivating factor that it's coming in.

[Maria Padilla] [1006.48s] They want their PFTs done.

[Maria Padilla] [1008.24s] They heard about their family member who had pulmonary fibrosis, and they want a, a low dose CT scan to see if they're affected.

[Maria Padilla] [1018.06s] So I think that that's an, an area where we can do much more in educating our patients as to like you were doing with a report that tells them what it means, okay, and and what they can be done for.

[David Yankelevitz] [1033.96s] You know, one of the, things that I've noticed, and I've been looking at a little bit more carefully is that, and most recently with bronchiectasis, is that not all bronchiectasis progresses.

[David Yankelevitz] [1045.25s] Maria, you was alluding to this.

[David Yankelevitz] [1048.05s] We we looked at bronchiectasis mild, moderate, and severe.

[David Yankelevitz] [1052.85s] And even the moderates and the severes, about 15 to 20% seem to stabilize.

[David Yankelevitz] [1059.46s] They just don't and the miles also, some 20% of them don't seem to progress.

[David Yankelevitz] [1066.03s] So, you know, it raises the the o word, you know, the over diagnosis word.

[David Yankelevitz] [1071.92s] But we're seeing this in the ILDs.

[David Yankelevitz] [1073.92s] You know, everybody ILD from the time of diagnosis to death is, you know, couple of years.

[David Yankelevitz] [1079.12s] Well, we're seeing some ILDs that seem to be stable.

[David Yankelevitz] [1081.84s] I haven't quantified the ILDs as much.

[David Yankelevitz] [1084.00s] We were gonna do that at some point.

[David Yankelevitz] [1086.18s] So I think we're seeing this early disease.

[David Yankelevitz] [1088.27s] It's a very interesting, interactions, and and emphysema the same thing.

[David Yankelevitz] [1094.35s] Not all emphysema progresses.

[David Yankelevitz] [1096.35s] We're gonna look back, you know, we have 30 years of CT scans on some population that have been coming to us.

[David Yankelevitz] [1102.16s] So we're gonna be looking more carefully at this.

[David Yankelevitz] [1104.72s] But this to me is a a really super area to figure out why the disease is progressing some and not in others.

[Maria Padilla] [1112.79s] You have you have to also take into account the biomarkers that are associated with any of the diseases just like their genetic predisposition, to the underlying disease.

[Maria Padilla] [1123.98s] So an ILA and a patient, that has MUC5b, mutation, you know, you pay more attention to that, patient.

[Maria Padilla] [1133.80s] And the same thing for other diseases.

[Maria Padilla] [1137.40s] There are going to be these biomarkers that my dream is that I'm going to have a fibrotic panel.

[Maria Padilla] [1145.43s] I picked this one out.

[Maria Padilla] [1146.48s] I picked this one out just like I do connective tissue disease, and I checked the ANA and I checked all the other biomarkers that are there that I'm gonna have one for the progressive IPF or with the progressive pulmonary fibrosis together with the imaging, together with the physiology, together with the history of the patient that is so critical.

[Mark Metersky] [1170.67s] Just one response, David.

[Mark Metersky] [1172.99s] We wanna be careful that we're not suggesting that lack of progression is overdiagnosis because many of these patients, even if they're not progressing or symptomatic, unlike someone with a 5 millimeter nodule that doesn't progress.

[Mark Metersky] [1186.86s] So but it'd be it'd be nice to correlate that.

[Mark Metersky] [1190.06s] It's a really important question.

[Ella Kazerooni] [1192.06s] Also, I think one of the things we suffer in for in radiology is when abnormality is mild, it's hard to visually see if something's changed.

[Ella Kazerooni] [1200.37s] And so you can have somebody saying, you know, there's mild upper lobe central lavalier emphysema for 15 years.

[Ella Kazerooni] [1206.85s] But if you actually quantify that emphysema, it has changed a tiny bit every time over those 15 years.

[Ella Kazerooni] [1213.08s] And that longitudinal progression of early disease is often completely unrecognized.

[Ella Kazerooni] [1218.76s] We've had, an emphysema quantification lung volume tool running for about 12 years now.

[Ella Kazerooni] [1224.13s] And if I just look back at the last one or 2 ago, you know, 1%, 1.2%, doesn't change a lot.

[Ella Kazerooni] [1230.05s] But when you look over 8 years 10 years and you start to put that in your report, now it's more powerful because now you're saying it's not only there, but over the last 10 years, it's gone from 2% of their lung tissue to 7% of lung tissue.

[Ella Kazerooni] [1243.49s] You've defined a morphology and a prognosis because of progression.

[Ella Kazerooni] [1247.25s] But if you just go to the the last immediate chest CT or maybe just one before, that ILA might not have changed.

[Ella Kazerooni] [1253.66s] That emphysema might not have changed.

[Ella Kazerooni] [1255.11s] But that longitudinal progression, I think, is really important only to this.

[David Yankelevitz] [1259.02s] So to all our engineers in the audience, we need better measurement tools.

[David Yankelevitz] [1263.42s] AI.

[David Yankelevitz] [1263.98s] Just a just a thought for you guys.

[David Yankelevitz] [1267.47s] One of the things that, and, Ella, you kind of hinted at this, maybe not hinted, we're more overt.

[David Yankelevitz] [1273.79s] But, you know, there are, guidelines out there, for example.

[David Yankelevitz] [1278.67s] And when you look at the US Preventive Services Task Force when it comes to COPD and screening for COPD, they say don't do it.

[David Yankelevitz] [1286.02s] Not only is it not recommended, they actually say that it's harmful to do it.

[David Yankelevitz] [1291.45s] An interesting point.

[David Yankelevitz] [1292.97s] Right?

[David Yankelevitz] [1293.37s] Harmful.

[David Yankelevitz] [1294.25s] So now we have screening, and in all essence, we still are screening for emphysema.

[David Yankelevitz] [1300.17s] You can say we're screening for lung cancer, but every single report I comment on emphysema.

[David Yankelevitz] [1304.84s] So in all essence, I'm screening for emphysema as well, even though the US Preventive Services don't do it.

[David Yankelevitz] [1311.88s] I think, you know, this leads us to this idea of, you know, you have the patient on the table.

[David Yankelevitz] [1317.32s] He's already there.

[David Yankelevitz] [1318.46s] Ella was pushing, maybe we should get expiratory scans.

[David Yankelevitz] [1321.18s] Rosemarin was saying the same thing.

[David Yankelevitz] [1323.42s] Mort is pushing.

[David Yankelevitz] [1324.86s] He's on the table already.

[David Yankelevitz] [1326.30s] He's got the cardiac scan.

[David Yankelevitz] [1328.06s] Open up the field of view for sure.

[David Yankelevitz] [1330.06s] And that's still not being done.

[David Yankelevitz] [1332.58s] Still in major academic institutions, they're doing coronary calcium scoring, and they're not even opening up the field in the area that was scanned.

[Ella Kazerooni] [1340.82s] Even though it's in the SCCT guideline to use a wide field of view, they still don't do it.

[Ella Kazerooni] [1344.97s] It boggles my mind.

[Ella Kazerooni] [1346.38s] And even though there's been series after series of papers published about the number of lung nodules and lung cancers that are missed because people are just combed down to the heart.

[David Yankelevitz] [1356.46s] And and so more is pushing us.

[David Yankelevitz] [1358.14s] More is pushing us.

[Ella Kazerooni] [1359.18s] Fear.

[Ella Kazerooni] [1359.57s] I just I just presented at the American Society of Nuclear Cardiology this very issue because it's both a patient care issue.

[Ella Kazerooni] [1367.09s] It's a institutional risk issue.

[Ella Kazerooni] [1369.88s] I I'm also a kind of an administrative oversight of all diagnostics for our health system.

[Ella Kazerooni] [1374.45s] And And when you look at the different issues around it, you can't ignore the fact that people can have lung cancer outside that little field of view that's going to impact their life and their families.

[Ella Kazerooni] [1384.92s] There has been, there have been lawsuits that have been filed and settled around this very issue.

[Ella Kazerooni] [1391.66s] To not do it in my mind is medical malpractice.

[David Yankelevitz] [1397.59s] Really?

[David Yankelevitz] [1397.98s] Well and and we have to also think then, while he's on the table, do we just go up that couple of centimeters more and cover the rest of the lung?

[David Yankelevitz] [1406.40s] And we'll hear all about the pushback for this, all the harms we might be causing.

[David Yankelevitz] [1410.64s] But to me, this is an obvious thing that we should be doing.

[David Yankelevitz] [1414.00s] Okay.

[Jim Mulshine] [1414.48s] Sorry.

[Jim Mulshine] [1414.80s] But

[Rozemarijn Vliegenthart] [1415.28s] vice versa, calcium scoring or at least the amount of coronary calcium on any chest CT is also not done in the majority of people and not in clinical scans.

[Rozemarijn Vliegenthart] [1424.91s] So I think if there's one message, do it starting tomorrow.

[Rozemarijn Vliegenthart] [1429.00s] This is something we can all do.

[Rozemarijn Vliegenthart] [1430.68s] Right?

[David Yankelevitz] [1431.00s] I heard something about in your country, they don't even allow you to report the calcium score.

[David Yankelevitz] [1435.56s] Is there some truth to that, Ruben?

[David Yankelevitz] [1437.80s] No.

[Rozemarijn Vliegenthart] [1438.04s] That is for a very specific screening study.

[Javier Zulueta] [1440.36s] Oh, okay.

[David Yankelevitz] [1442.28s] Just checking.

[David Yankelevitz] [1442.84s] Okay.

[David Yankelevitz] [1443.08s] I think we're you have an ex you have 2 or 3 experts right there?

[Albert Rizzo] [1452.03s] I'll I'll start.

[Albert Rizzo] [1452.51s] I think the first thing, if they've not had pulmonary frontal studies, get that done.

[Albert Rizzo] [1456.27s] I mean, we know well well, that test is gonna tell them if they have defined COPD.

[Albert Rizzo] [1463.01s] Okay?

[Albert Rizzo] [1463.41s] And it's gonna at least trigger potentially an evaluation by a pulmonologist.

[Albert Rizzo] [1471.81s] Well, I think that's where we need.

[Albert Rizzo] [1475.53s] That's a great study because I think if, emphysema is seen on that CAT scan, maybe the radiology department should have one of those simple portable spirometers.

[Albert Rizzo] [1483.05s] You're blowing this before you leave and get a value.

[Albert Rizzo] [1486.26s] Wow.

[Albert Rizzo] [1486.58s] That could be a study.

[Jim Mulshine] [1488.25s] Sorry.

[Javier Zulueta] [1488.49s] To tell you the data that we found at in Novara, in the University of Novara in Spain, we had a a 30% of individuals had emphysema, and 28% of individuals independently had COPD.

[Javier Zulueta] [1500.82s] But there were 15% of the emphysema patients that had no obstruction in their spirometry.

[Javier Zulueta] [1505.78s] So in general and, you know, I have, some opinions because no no evidence whatsoever about is it early disease or is it a different disease.

[Javier Zulueta] [1515.05s] I I I kinda think that emphysema is is a whole different disease than the chronic bronchitis, but that's not for this discussion.

[Javier Zulueta] [1522.89s] But there is evidence that, so there is emphysema without airway obstruction, but they have limitations.

[Javier Zulueta] [1529.53s] You do physiologic studies on them, You do 6 minute walk tests.

[Javier Zulueta] [1532.57s] You do and they desaturate.

[Javier Zulueta] [1534.33s] They they walk less.

[Javier Zulueta] [1535.37s] They're symptomatic.

[Javier Zulueta] [1537.05s] So the risk of lung cancer.

[Javier Zulueta] [1538.80s] And then the risk of lung cancer is 3 fold greater.

[Ella Kazerooni] [1542.24s] So I think one of the

[Claudia Henschke] [1543.68s] supposed to in women.

[Ella Kazerooni] [1547.57s] So it's really interesting when when radiologists are asked about reporting emphysema, and many of them say, well, what's the value when reporting mild emphysema?

[Ella Kazerooni] [1556.53s] You know, 1 1, 2, 3 percent of the lung is there.

[Ella Kazerooni] [1559.17s] There's no treatment for it.

[Ella Kazerooni] [1560.69s] Spirometry is usually normal.

[Ella Kazerooni] [1564.21s] Why should I even report it?

[Ella Kazerooni] [1565.49s] In the ACERES lung cancer screening registry, we've got about 7,000,000 lung cancer screens in there with lots of serial data.

[Ella Kazerooni] [1572.13s] And and when we looked at the first, you know, 1,600,000 screens, 62% of people have at least 62%

[David Yankelevitz] [1581.05s] of

[Ella Kazerooni] [1581.21s] the people with a significant internal finding had coronary calcium.

[Ella Kazerooni] [1584.81s] That was the number 1.

[Ella Kazerooni] [1586.20s] But the second most common is lung disease.

[Ella Kazerooni] [1588.20s] It was about 5% had some form of interstitial lung disease, but only 2.2% of people reported as having emphysema.

[Ella Kazerooni] [1595.88s] Because radiologists only think it's significant if it's moderate or severe, like like extensive tissue damage.

[Ella Kazerooni] [1601.57s] You know, 20% or more of the lung print come on.

[Ella Kazerooni] [1604.38s] And if a couple percent is actually preclinical disease, changing the mindset about radiologists, changing the mindset about pulmonologists as well, and primary care physicians to know it it may not meet the threshold for COPD by diagnosis now, but it is a risk factor for lung cancer, and it is something that maybe we should be watching more closely.

[Javier Zulueta] [1624.57s] And because of that, the last thing you said, if, in lung cancer screening program, compliance is an issue as well.

[Javier Zulueta] [1630.88s] We know that that, you know, less than 50% of the people come back for a second.

[Javier Zulueta] [1635.16s] If there's one patient you really have to call today with the data that we have, the biomarker the strongest biomarker for lung cancer risk is emphysema.

[Javier Zulueta] [1642.68s] So that's the patient you really

[Jim Mulshine] [1644.58s] Yes.

[Jim Mulshine] [1645.38s] Okay.

[Jim Mulshine] [1645.69s] So we Why are you thinking?

[Jim Mulshine] [1647.13s] We're out of time.

[Jim Mulshine] [1647.86s] Sam, you got the final final final final question.

[Jim Mulshine] [1652.17s] Okay.

[Jim Mulshine] [1652.89s] Thank you.

[Ella Kazerooni] [1653.54s] Really small small comment, which is, the approach in settled findings is so very different in the US than in other countries.

[Ella Kazerooni] [1660.11s] So we are we report everything.

[Ella Kazerooni] [1661.63s] That's kind of what we're kinda talked to do.

[Ella Kazerooni] [1664.35s] In the UK implementation of lung cancer screening, they only report certain and central findings back to the primary care physician, and they don't report the rest.

[Ella Kazerooni] [1673.19s] So mild coronary calcium doesn't get reported back to the PCP.

[Ella Kazerooni] [1677.52s] Mild emphysema does not get reported back to the PCP because there's no action item for the PCP to take is the way they frame it in their house in their national house system.

[Jim Mulshine] [1687.53s] Okay.

[Jim Mulshine] [1687.85s] So stay tuned.

[Jim Mulshine] [1688.89s] Show up tomorrow.

[Jim Mulshine] [1690.01s] We'll take up that very subject.

[Jim Mulshine] [1692.09s] Thank you all for a very, very, you know, passionate interaction on a an important topic that shows the importance of why we're all here.

[Jim Mulshine] [1702.54s] Thank you very much.







Comments


Contact Us Today

We'd love to hear from you. Please fill this form to request more information.

I'm interested in:
How did you hear about us?

Thank you for your interest.

A HeartLung representative will contact you as soon as possible!

  • Twitter
  • LinkedIn
  • Facebook
  • Instagram
  • Youtube

2450 Holcombe Blvd
TMC Innovations
Houston, TX 77021

©2025 HeartLung Corporation. All Rights Reserved. US Patent Nos US9119590*, US10695022, US11610686. and Patents Pending. AutoBMD™, AutoCAC™, AutoChamber™ and other trademarks shown on this website are protected under intellectual property rights of HeartLung Corporation in the United States.

bottom of page