Lung Health: Smoking, Cancer and COVID-19

We breathe about 22,000 times each day, rarely giving it a second thought — until it becomes difficult to do so.

Each November, health experts urge us to be vigilant about the health of our lungs with the observations of Lung Cancer Awareness Month, Chronic Obstructive Pulmonary Disease (COPD) Awareness Month and the Great American Smokeout. With the COVID-19 pandemic showing no signs of slowing down, there’s never been a more important time to take care of our lungs.

Baptist Health’s Resource Live program took on the subject of lung health with guest experts Mark Dylewski, M.D., chief of general thoracic surgery at Miami Cancer Institute, and the medical director for robotic thoracic surgery at Baptist Health; and Javier Pérez-Fernández, M.D., pulmonologist and critical care director at Baptist Hospital of Miami. Highlights of the program, hosted by Jonathan Fialkow, M.D., chief of cardiology at Miami Cardiac & Vascular Institute and chief population health officer for Baptist Health, are included in the Q&A below.

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Dr. Fialkow: “Let’s start by talking about the scope of lung disease. So, Mark, what can you tell us about lung cancer in 2020?”

Dr. Dylewski: “Lung cancer is the third most common cancer in the U.S. and around the world, but it accounts for the majority of deaths both in men and women both in the United States and around the world. So it’s a critical issue. We haven’t, as of yet, made huge strides in improving the long-term survival and the overall survival in patients with lung cancer. But we’re making strides in that effort. The treatment algorithm involves a complexity of treatments such as chemotherapy, radiation, and surgery, and it’s often a multidisciplinary approach to managing these folks.”

Dr. Fialkow: “Javier, let’s talk a little about COPD. What is it? How widespread is it?”

Dr. Pérez-Fernández: “COPD, chronic obstructive pulmonary disease, is a disease that’s caused by insult to the airway. Essentially, the most common insult is smoking. It produces essentially a narrowing of the airway, and it presents that typically after 20 years or so of being a smoker. It’s the most common chronic pulmonary disease for adults. It is the fourth leading cause of death in the U.S. Over 24 million people in the U.S. are affected with COPD, and it’s probably one of the most rapidly rising diseases worldwide.”

Dr. Fialkow: “So, COPD is emphysema and chronic bronchitis.” Dr. Pérez-Fernández: “Most of the patients have both diseases in one person. Typical emphysema essentially is a destruction of the lung inside. The little walls inside the lungs are getting destructed day after day, and it produces big balloons inside the chest. Chronic bronchitis is mostly the thickening of the airway and the production of mucus blocks and a lot of secretions, but those really are co-existent in most of the patients. Unfortunately, they’re very difficult to distinguish from one another.

“For years, we understood that there was no cure for it. What I really want to highlight here is that they’re both preventable. COPD is also treatable. So we do have significant number of tools nowadays to treat the disease and make people’s life close to normal.”

Dr. Fialkow: “Mark, can we speak to the symptoms that might make someone seek help to make sure they don’t have lung cancer?”

Dr. Dylewski: “One of the unfortunate things is that the COPD and the emphysema cloud the diagnostic picture of patients who present with lung cancer. Very few lung cancer patients have symptoms other than shortness of breath and a cough. What happens is over time, the tumors in the lungs begin to grow. Then, in very advanced stages when the tumor becomes large enough to start eroding into the vessels and eroding into the airway, you start to get these advanced symptoms such as hemoptysis, which is coughing up blood. You can develop chest discomfort or chest pain when the masses started eroding into critical structures in the chest and the chest wall.

“Patients who develop symptoms in lung cancer, it’s often in stages that are so advanced that it’s hard to treat and cure those folks. So the important thing is to identify patients at risk for lung cancer. Remember one point: we do have a cure for lung cancer. It’s screening the patients and catching them in its earliest stages and then offering them appropriate surgical care.”

Dr. Fialkow: Does someone have to be symptomatic to qualify for screening?

Dr. Dylewski: “Absolutely not. The main criteria for screening is whether they are a tobacco user or not, whether they’ve smoked for more than 15 years, and whether they have quit less than 15 years prior to seeing their doctor. We’ve limited the age group up to between 55 and 80, knowing that patients who are younger than 55, if they’re actively smoking, are less likely to develop cancer until they reach the mid-50s. And patients over the age of 80 are less likely to acquire cancer and have it impact their longevity of survival.”

Dr. Fialkow: “What does screening entail?”

Dr. Dylewski: “The most sensitive and accurate is using what’s called the low-dose CT of the chest, a CAT scan of the chest. Typically, we recommend that being started after the age of 55 if you’re actively smoking or if you’ve stopped less than 15 years prior. That should be done annually as long as the original screening CT scan does not show an abnormality.”

Dr. Fialkow: “Javier, let’s take the same tack for COPD. In your practice, what’s the level of advanced COPD you see?”

Dr. Pérez-Fernández: “Unfortunately, the time that we typically see patients with COPD are when symptoms are well-developed. The typical symptoms are, again, the emphysema, which starts on exertion and goes up even when resting, the significant cough and spasms that affect people with production of mucus, and obviously, the inability to perform most of the normal activities or regular activities. That’s the moment people are seeking the medical attention, and they really hunger for air. They really need help to breathe.

“If you’ve been a smoker for over 15 years, whether you have symptoms or not there is a tool that we can use to identify patients at risk and also patients who develop early stages of COPD called a spirometry. It’s a simple test. It’s blowing into a little machine that most of the pulmonologists have in their offices.”

Dr. Fialkow: “You said earlier that COPD is not curable?”

Dr. Pérez-Fernández: “But even in those patients who have severe diseases, we can treat them. If we catch them earlier on the disease, we definitely can make the lifespan significantly higher. Mortality of COPD has been reduced. There’s no question about it.”

Dr. Fialkow: “How dangerous is smoking to our lungs?”

Dr. Pérez-Fernández: “Smoking has two components. One is the habit-creating component, which is the nicotine. The nicotine addiction is one of the strongest addictions that we know in pharmacology. The delivery system goes directly to your brain.

“The second aspect is the toxicity caused by the smoke inhalation. The products delivered through the smoking byproducts.”

Dr. Fialkow: “I think it’s very important to know that the nicotine gives you pleasure when you first take it. But as your brain becomes addicted, you have a plateau with nicotine and you feel terrible when you don’t have it.”

Dr. Dylewski: “One of the most important issues nowadays is the use of vape pens. These vape pens produce more nicotine per puff than a routine combustible cigarette. Our young folks are thinking that these vape pens are safer, less addictive, and it’s absolutely untrue.

“We do not believe that (nicotine) has any relationship to lung cancer. Lung cancer develops in patients as a result of the 6,000 to 7,000 co-carcinogens and carcinogens that are released from the tobacco leaf. You also have to have a genetic predisposition or some other element of viral infection that allows your genes to alter and grow unimpeded and grow exponentially into a tumor. So not everybody that smokes gets cancer, but a certain percentage — 10% to 20% — we know are predisposed to developing cancer if they are smokers.”

Dr. Fialkow: “What about non-smokers?”

Dr. Dylewski: “There is a significant percentage of people in this country, particularly women between the ages of 50 and 70, that are developing lung cancer for some reason that we’re not quite sure why. So just because you’re a non-smoker does not mean that you can’t develop lung cancer.”

Dr. Fialkow: “I want to finish up with a couple of COVID comments. What do we know about COVID and the lungs, Javier?”

Dr. Pérez-Fernández: “COVID is a viral disease that affects significantly, mostly the lungs. Those patients who get complicated, the first organ failure that they have is the lung organ failure.

“We think that COVID affects people in a subacute way. It tends to weaken a little bit the respiratory system and that might be there for significant weeks or months. And in some cases, it might have actually highlighted problems that were baseline on those patients. But there’s no certainty that COVID produces chronic lung disease at this point.”

Dr. Dylewski: “I have one other thing to add, Dr. Fialkow. If someone is told that they have an abnormal finding on an x-ray, don’t settle on one opinion. Get multiple opinions until you are absolutely certain that you’ve got the best opinion and you’ve received the best care. It’s extremely important when it comes to lung cancer.”