Appointment Icon

St. Luke's Emergency Department

First Available Time :

Jones Regional Medical Center Urgent Care - Anamosa

1795 Highway 64 East
Anamosa, IA 52205

Closed Patients
Waiting Now

UnityPoint Clinic - Express (Lindale)

153 Collins Road Northeast
Cedar Rapids, IA 52402

Closed Patients
Waiting Now

UnityPoint Clinic - Express (Peck's Landing)

1940 Blairs Ferry Rd.
Hiawatha, IA 52233

Closed Patients
Waiting Now

UnityPoint Clinic Urgent Care - Marion

2992 7th Avenue
Marion, IA 52302

Closed Patients
Waiting Now

UnityPoint Clinic Urgent Care - Westside

2375 Edgewood Road Southwest
Cedar Rapids, IA 52404

Closed Patients
Waiting Now


Ep. 153 - LiveWell Talk On...Lung Cancer Diagnosis & Treatment (Dr. Nick Loudas)

episode 153

Ep. 153 - LiveWell Talk On...Lung Cancer Diagnosis & Treatment

   Subscribe so you never miss an episode!

   Apple Podcasts | Google Podcasts | Spotify | Pandora | iHeart Radio |   
   Google Play Music | Stitcher TuneIn SoundCloud 


Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Nick Loudasradiation oncologist, St. Luke's Nassif Radiation Center

Dr. Arnold:
This is LiveWell Talk On...Lung Cancer Diagnosis and Treatment. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. Many of you are planning on celebrating national peanut butter lovers month in November, but it's also lung cancer awareness month. And joining me today to discuss lung cancer treatment and diagnosis, is Dr. Nick Loudas, radiation oncologist with St. Luke's Nassif Radiation Center. Dr. Loudas, welcome to the podcast.

Dr. Loudas:
Thank you for having me.

Dr. Arnold:
I want to start off, you're a radiation oncologist, the people that meet you have cancer. Not a lot of people know what a radiation oncologist is. Could you tell us just what is a radiation oncologist?

Dr. Loudas:
Sure. It's a good question. There's a lot of—well, first of all, a lot of people have never heard of us. And then even those who have oftentimes don't know a lot about what we do. So, you know, we get confused with medical oncologists sometimes, or radiologists, but we're a distinct specialty. We are essentially responsible for treating cancer patients who need radiation as a part of their treatment. So we're the ones responsible for, you know, once someone already has a cancer diagnosis, they may be referred to us if one of their other cancer doctors feels that they may benefit from radiation. And we, our role is essentially to determine who needs radiation, how much radiation to give someone, and then we're also responsible for planning and managing patients during their radiation treatments and following them afterwards for any long-term side effects.

Dr. Arnold:
And it's definitely, I mean, I have a little inside baseball knowledge, but you play a big role in clinic safety. I mean, obviously if you have radiation in the clinic, you have to be cautious, you have to follow protocols, and I know you have a big role in that. And we're glad that you do. But when it comes to lung cancer, how do we screen for lung cancer?

Dr. Loudas:
Yeah. So a number of years ago, we began to develop a lung cancer screening program. It's gone through some evolution over that time. There were some studies that demonstrated that especially heavy smokers would actually benefit significantly from undergoing routine chest CT scans to detect early stage lung cancers before they become symptomatic. So currently, what we do, is we screen patients 55 to 77 who are either current smokers or have quit within the last 15 years and have at least cumulative 30 pack year history. So that's the number of packs of cigarettes per day multiplied by the number of years that they've smoked that amount. If that amounts to 30 or more, they're eligible for this lung cancer screening program and essentially what it involves, it's pretty slick. Basically they will undergo a low dose chest CT on an annual basis to search for any newer developing lung cancers. And so it's been shown that these cancer screening programs ultimately will diagnose patients at earlier stages when the cancer's more treatable and has shown to contribute to better outcomes in the long run. So it's a fairly non-invasive type of testing. And every once in a while, you know, most of these end up being negative, which is good. It means that, you know, the majority of our patients going through these programs do not have lung cancer. Occasionally, we'll find some findings that will require some further imaging down the road. And sometimes we'll find more suspicious findings that require biopsy right away. So depending on what we find at that time, there's a number of different pathways that we can go down.

Dr. Arnold:
Will you elaborate, mostly just for me, because I'm not so sure I understand the difference when you say low dose. So obviously it's a lower does than a normal CT scan, but what does that actually mean?

Dr. Loudas:
Yeah, great question. So you know, a low dose chest CT is, it's called low dose because it's about one 10th of the radiation that is used in a normal diagnostic chest CT. So you know, we always try to limit the amount of unnecessary radiation that we give to patients. And these low dose chest CTs are still very sensitive. And we don't necessarily need the additional dose of radiation to the patient's chest to find these small tumors.

Dr. Arnold:
Okay. That question was really for me, because I've never really picked up on that. So we talked about the screening of the lung check and you told us who's eligible for that, but what sort of differences that make in the diagnosis? I mean, usually when the recommendations come out, they say: well, you know, you'll have too many false positives lead to biopsies and therefore it does more harm than good. But tell us how that's evolved, because I know it has. I know it has evolved. 15 years ago or 25 years ago when I started, if I said I wanted to do a low dose CT scan—first of all, they're like 16 slice back then. So, you know, you won't even recognize them. But they would have laughed at me. They would have just said no way. But now it's a standard, it's an expectation really. Tell us how that works.

Dr. Loudas:
Yeah, that's a great question. And you're absolutely right. We weren't doing these in the past. The reason we've started doing them now, is there have been a number of studies that have shown their efficacy at diagnosing these cancers at earlier stages. And the big finding is that, you know, when we take a population of patients who fit these criteria of being high risk, and we randomize them to either getting screened or not screened, we see that the patients who are getting screened actually will live longer on average. And so that's a big driver for why we do this, is patients who receive screening live longer than those who don't. And the thought is that we're catching some of these lung cancers at earlier stages when they're still treatable, as opposed to finding them late when they become incurable.

Dr. Arnold:
You know, while we're on that subject, I've got a question for you. Are you seeing cancers that anecdotally may be more advanced than they were because of the pandemic and how we quit doing routine imaging there for a while? Have you noticed that?

Dr. Loudas:
Yeah, absolutely. That's been a big problem here recently. There've been a lot of screening tests that got delayed as a result of the pandemic. And you know, some of that was necessary initially, but then you know after a certain time period, a lot of people kind of fell off our radar. You know, in terms of doing some of these screening tests with, especially you know, things like doing colonoscopies and cancer screenings and lung cancer screenings as well. Yeah, it's really hard to emphasize the importance of screening and early detection for many of these cancers. The difference in both the intensity of treatment and the effectiveness of treatment, can really differ drastically depending on how soon we can catch cancers.

Dr. Arnold:
Yeah. That's interesting because that's been my observation with diabetes, heart disease. You know, that patients are showing up more advanced or de-compensated. And I think it's from the pandemic and when we essentially suspended primary care for a period of time.

We'll return to discussing the treatment of lung cancer in just a minute, but first I want to tell listens about a new segment of the podcast, the Mailbag. If you have questions about COVID-19, the latest technologies, or other service lines at St. Luke's, you can submit your question to me at UnityPoint.org/mailbag, and they will be answered on a future podcast. Please note, the mailbag is obviously not an alternative to medical appointments and any questions about personal symptoms or conditions need to be directed to your primary care clinician, or an urgent care. In the case of medical emergency call 911, or go to your nearest emergency department. Once again, you can submit your questions to me at UnityPoint.org/mailbag. I look forward to hearing from our amazing listeners. They've presented some challenging questions thus far, and it'll keep me on my toes.

Now back to Dr. Loudas. So my lung cancer is diagnosed, the biopsy shows it is, and now I need treatment. But now it's not just one doctor. I mean, and I think we need to give more credit to that collaborative team approach you have. So kind of take me through what that looks like over at the cancer center.

Dr. Loudas:
Yeah, so you're absolutely right. It takes a whole team of doctors in both the diagnosis and the treatment of lung cancer. That's part of the reason why we have a multidisciplinary tumor board that meets on a weekly basis where we review new cancer diagnoses. And even sometimes patients who have been treated who may have new findings on imaging, there are a number of specialties that are involved. Radiation oncology obviously is one of them. So I attend these meetings along with pulmonologists who treat lung diseases like COPD and perform procedures like bronchoscopies, and biopsies, and so forth. They oftentimes are very well plugged in with some of these patients who already have underlying lung disease. There's also usually thoracic surgeons that play a part as surgery oftentimes plays a role in the treatment of early stage lung cancer. And then there are medical oncologists, who are the doctors that give chemotherapy. As that oftentimes will play a role, especially in more advanced lung cancers as well. So all of those participants, as well as there, we have nurses and care coordinators and therapists that are all important parts of the team as well. It really takes a collaborative environment to determine the best way to treat patients and then to make sure they have all the resources available as they go through treatment.

Dr. Arnold:
And let's not forget, you also have the receptionist, Joan, who's like the sweetest person in the entire world.

Dr. Loudas:
That's absolutely right. Yeah. She makes our job here a lot easier.

Dr. Arnold:
Yes, she does. She's a great person. Great family, too. So, okay, I have lung cancer. I can have surgery to have it cut out. I can go to Dr. Buntinas and get some chemotherapy to keep it from spreading. But now they say: hey, you need to have radiation. Take me kind of through what that would look like.

Dr. Loudas:
Yeah. So and that brings up a really important point that there's a lot of differences in people's lung cancer treatments, depending on their stage primarily. So a lot of pieces go into determining the best way to approach a treatment. So, you know, I tend to divide up my lung cancer treatment into two broad categories. So the first treatment that I offer and the one that I prefer to use most often if possible is called SBRT, which stands for stereotactic body radiotherapy. And essentially it's a fancy way of saying using high dose radiation in a very focused manner to essentially accomplish the same thing that surgery does. So we use this technique when a patient has an early stage lung cancer, like a stage one lung cancer without any lymph node involvement, but they're not able to undergo surgery for any number of reasons. Whether it's, you know, underlying lung disease or some other medical issue that would prevent them from doing a surgery like a lobectomy. So in this case, we use high dose radiation over the course of usually about one to two weeks. And we give somewhere in the range of three to five fractions most of the time, to really burn away at that tumor. It's generally a very well tolerated procedure. Patients often will experience some fatigue, but usually that's about it. And then after that, we follow the patient and make sure that the area does not continue to grow afterwards. Most of the time, patients do not have big issues with long-term side effects from that treatment either. So it's a very effective way of treating lung cancer and it's becoming more and more utilized as it has become more mainstream. So that's just one of the treatments that I do.

Other patients who have more advanced disease who are potentially too advanced for surgery, will then come to me and I'll treat them with a combination of chemotherapy and radiation. So in that case, we usually involve our medical oncology colleagues to give the chemotherapy portion. And then from my perspective, I'm giving usually about six weeks of radiation in that situation. So patients are coming in on a daily basis for six weeks. And it's another treatment that, you know, I would say is relatively well tolerated. It's a little bit more intense than the SBRT treatment that I was previously describing, because it's usually larger field because of the more advanced nature of the cancer. And it's usually a little longer, more exposure, to radiation over a longer time period as well. So those patients, again you know, oftentimes experience fatigue. They can also run into some swallowing difficulties towards the end of treatment as well. And then, you know, a number of side effects that go along with the chemotherapy can come into play too. So those are sort of the two general broad categories of treatments that I do for localized lung cancer when it can be potentially cured. And then sometimes we also will play a role in the palliation, or the the treatment of symptomatic metastatic lesions. So if someone has very advanced disease that spreads to other areas of the body, radiation is often very effective at alleviating symptoms like pain and so forth.

Dr. Arnold:
Over the years, you know, I have had patients who have had it to the spine and it's very painful. You guys take care of them and obviously don't cure the cancer, but really alleviate their pain.

Dr. Loudas:
Yeah. And it's very important, you know, with lung cancer has a very much a propensity to spread and to spread early. So just, you know, again to emphasize the importance of early detection, it really plays an important role at limiting some of the negative consequences of letting these tumors go for too long.

Dr. Arnold:
And there's also an element of, I learned this over at the hospital, because sometimes we'd have a patient undergoing radiation and they get admitted for something else. You know, they're due for radiation and you call over the clinic and they're like: no, that's okay. They can miss. Or they're like: nope, unequivocally, we've got to get them over here. And it was explained to me, that it's the timing related to the chemotherapy. You know, sometimes you just can't miss your appointment. Other times, it's not as significant, correct?

Dr. Loudas:
That's right. That's on a patient by patient basis actually. And it'll depend on a number of factors. Both the disease factors and also, you know, what else is going on with them in the hospital. So that's an important part of my job, is to determine, you know, when do we continue treatment or when do we put a patient on hold.

Dr. Arnold:
Yeah. And we're always grateful for your assistance, as a hospitalist. One last question. Why did you choose radiation oncology?

Dr. Loudas:
Well, that's kind of a long roundabout answer. But you know, I'll try to give you the brief version of it. You know, I had a little bit of exposure to it actually before medical school.

Dr. Arnold:
That's a pun intended there, right? Exposure, really?

Dr. Loudas:
It wasn't intended, but it.

Dr. Arnold:
Oh alright, take credit for it.

Dr. Loudas:
Yeah, so I knew about it beforehand and it kind of piqued my interest. It just, it seemed like a really cool kind of technical specialty. I have a background in, you know, math and physics a little bit. And it's one of those specialties where it's fairly physics heavy as a medical specialty. And that as I'm sure you know, is not the favorite subject amongst most medical students. So it's sort of a unique niche within medicine. And, you know, what really got me to enjoy it in terms of the day-to-day practice, is primarily the relationships I get to build with my patients. As you know, the way medicine works in most arenas is, you know, there's an incentive to move patients through fairly quickly and to see them and then to get on to the next thing. You know, there's a lot of patients who need treatment and evaluation, and not enough providers to do that and give them the time that they really deserve. But fortunately here, we have a little bit more luxury of time. It's very important to educate patients thoroughly before they go through a radiation treatment. And so, you know, I typically will spend at least an hour with a patient upfront to get to know them and review the details of their case. And so then once they start as well, generally most of these treatments go for a number of weeks. And so you know, it's not generally a field in which I see someone and then don't see them again for another year or half a year. You know, we have kind of an intense period where I'm seeing them on a weekly basis and developing a relationship with them. And so it's a very unique, you know, patient experience in that respect, which I enjoy a lot. And then, you know, just the science behind both the development of cancer and the treatment of cancer is very fascinating to me as well. So it's hard for me to imagine myself in another specialty at this point.

Dr. Arnold:
So, so basically the nerdy medical students go into radiation oncology.

Dr. Loudas:
I didn't want to say it, but yeah absolutely.

Dr. Arnold:
Just kidding. Thank you for joining me today. This was great information. Once again, this is Dr. Nick Loudas, radiation oncologist with St. Luke's Nassif Radiation Center. For more information on lung cancer screening and treatment, visit CommunityCancerCenter.org/lung.

Dr. Loudas:
Thanks so much for having me.

Dr. Arnold:
Thank you for listening LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe, and if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcasts, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.