[Lung Cancer Awareness Month] Exclusive interview with Professor Zhi Xiuyi - How to prevent and detect early lung cancer?

November 2021 is the 21st "International Lung Cancer Awareness Month". "International Lung Cancer Awareness Month" is a global initiative launched by the World Lung Cancer Alliance in 2001. November of each year is designated as "International Lung Cancer Awareness Month" with the aim of calling on countries around the world to pay attention to the prevention of lung cancer, raise people's awareness of lung cancer prevention and treatment, and popularize standardized diagnosis and treatment knowledge of lung cancer. Recently, Medical Forum Network interviewed Professor Zhi Xiuyi, a national health science expert and director of the Science Department of the China Anti-Cancer Association, on hot topics related to lung cancer prevention and treatment, such as how to prevent and detect lung cancer early.

【Expert Profile】

Professor Zhi Xiuyi

National Health Science Expert

Director of the Science Department of China Anti-Cancer Association

Director of Lung Cancer Diagnosis and Treatment Center, Capital Medical University

Q: It is reported that about 80% of patients are already in the middle or late stages when clinically diagnosed with lung cancer. Is it impossible to prevent lung cancer and detect it early?

Professor Zhi Xiuyi: Now the 80% ratio has been reversed. With the improvement of people's health awareness and the addition of chest CT items for comrades over 45 years old in health examinations by various enterprises and institutions, more and more early lung cancer screening has come into our view. Especially in the past two years of the COVID-19 pandemic, all hospitalized patients under the COVID-19 control measures have to undergo routine chest CT scans. As long as they are hospitalized for examination or hospitalization, they must undergo chest CT scans. As a result, millions of people have been found to have lung nodules, and 3% to 5% of small lung nodules are lung cancer, and most of them are early lung cancer.

Judging from the data of newly diagnosed lung cancer this year, the saying that "once lung cancer is diagnosed, 80% is in the middle and late stages" is no longer true. In more large cities, provincial capitals, and prefecture-level cities such as Beijing, Shanghai, and Guangzhou, early lung cancer even accounts for 70%-80%. In remote areas, grassroots areas, and other areas where chest CT screening is not covered, people still seek medical treatment only after clinical symptoms appear. Once these people are diagnosed, they may already have clinical middle and late stages of lung cancer, and have lost the best time for radical surgical treatment. I want to tell you that lung cancer has now entered our lives as a common, frequently occurring, chronic, and geriatric disease. We must not be overly afraid of lung cancer as we did decades ago.

We hope that the township health centers and urban community service centers below the county level will organize the health records of middle-aged and elderly friends in the community as soon as possible. We will also further expand the chest CT lung cancer screening survey project to allow more people in remote areas and middle-aged and elderly friends to participate in chest CT lung cancer screening. This will help improve the diagnosis capabilities of early lung cancer.

Question: What are the differences in the prognosis of lung cancer patients in my country compared with those in Europe, America and other Asian countries?

Professor Zhi Xiuyi: Overall, there is still a certain gap between my country's 5-year survival rate for lung cancer and those of the United States and Europe. The difference is 20% compared with the United States, and about 15% compared with Europe.

Therefore, we need to rely on lung cancer screening programs and health examinations to make more chest CT scans a routine physical examination item for middle-aged and elderly people, which will help to detect early lung cancer. In the past few decades, we have used chest X-rays and chest films to screen lung cancer, but this has not reduced the mortality rate of lung cancer or increased the 5-year survival rate of lung cancer. More and more evidence shows that only chest CT screening can help to detect more early lung cancers.

Through minimally invasive surgery, targeted and immune drug therapy, especially new treatment methods, the mortality rate of lung cancer can be greatly reduced and the 5-year survival rate of lung cancer can be improved. To this end, my country proposed in the "Healthy China 2030 Plan" that by 2030, the 5-year survival rate of our country's overall cancer will be increased by 15%, further narrowing the gap between my country and Europe and the United States. Therefore, early diagnosis and treatment of lung cancer is very important, and health examinations and lung cancer screening are very important. Using chest CT scans plus liquid biopsy projects to promote lung cancer screening, "refining" those small lung nodules that require clinical intervention and surgical treatment, and removing early lung cancer will greatly improve our country's overall 5-year survival, 10-year survival rate, and even longer survival for lung cancer.

Q: What are the special symptoms of early lung cancer that we need to pay attention to?

Professor Zhi Xiuyi: In medicine, lung cancer is divided into central lung cancer and peripheral lung cancer according to the location of the lesion. Central lung cancer is lung cancer that grows in the tracheal cavity, such as the trachea, the common bronchus, the lobar bronchus, and the segmental bronchus. As long as the lung cancer grows in the bronchial cavity, we call it central lung cancer.

Early central lung cancer has clinical symptoms, such as irritating cough, bloody sputum, and even blood clots in sputum. If the tumor continues to grow and blocks the segmental bronchus, it will cause atelectasis or pneumonia beyond the distal end of the segmental bronchus, resulting in symptoms of lung inflammation, such as cough, bloody sputum, fever, etc. These are the clinical symptoms of early central lung cancer.

However, if you are an old smoker, you usually have a chronic cough and sputum, but you often don't notice it, especially if you cough the sputum into a tree pit or a corner, you may not be able to see whether there is blood in the sputum or blood clots. I hope that smokers will stay away from smoking as soon as possible, and if you cough and have sputum, please cough the sputum onto a tissue, into a spittoon or toilet, and you can see the blood in the sputum.

Peripheral lung cancer is lung cancer that grows in the lung tissue and beyond the bronchial segments. It has no clinical symptoms in the early stages and can only be detected through health examinations and chest CT screening. If the tumor grows larger and invades the bronchial cavity inward, coughing and bloody sputum will occur. If it invades outward and invades the pleura and chest wall, pleural effusion will occur, which will compress the lung tissue and cause clinical symptoms of chest tightness and shortness of breath, which are no longer early symptoms of lung cancer.

Q: Which group of people are at higher risk of developing lung cancer?

Professor Zhi Xiuyi: When it comes to people at high risk of lung cancer, the following factors should be paid special attention to:

First, the age is over 45. Generally speaking, the incidence of lung cancer increases year by year starting from the age of 40, and reaches its peak at the age of 80. Therefore, when people over 45 and 50 years old have health checkups, many enterprises and institutions have replaced chest CT with chest X-rays.

Second, smoking. If you smoke more than 20 cigarettes a day for more than 20 years, your smoking index is greater than 400 (the calculation formula for the smoking index is: number of cigarettes smoked per day × number of years of smoking). If the smoking index is greater than 400, such as smoking more than 30 cigarettes a day for more than 30 years, the smoking index will reach 900 or even higher. The higher the smoking index, the higher the chance of developing lung cancer. People with a smoking index greater than 400 have a significantly higher chance of developing lung cancer than non-smokers.

Third, family history of cancer, especially family history of lung cancer. If your father, mother, grandparents, or grandparents have lung cancer, you are also at high risk of lung cancer.

Fourth, people with a history of lung diseases, such as tuberculosis, chronic obstructive pulmonary disease, or chronic lung inflammation, including pulmonary fibrosis, are at high risk of lung cancer.

Fifth, working in high-risk industries or living in specific areas. For example, areas with high dust, heavy metals, and strong odors that affect the air and environment, such as oil, cement, chemicals, coal, and asbestos. If you work and live in the above areas for a long time, your lung health will definitely be affected.

Question: What lesions appear during routine examinations that may indicate early lung cancer?

Professor Zhi Xiuyi: We currently use chest CT as the gold standard for lung cancer screening. We have identified high-risk groups for lung cancer and are conducting screening in areas with a high incidence of lung cancer. Chest CT can detect small lung nodules. We then analyze and evaluate the small lung nodules to determine which small lung nodules may be early lung cancer.

Now, we have added liquid biopsy projects. In the past few decades, we have used blood tumor markers for screening. In recent years, we have added seven lung cancer serum antibodies, circulating tumor cells, DNA methylation and other related molecular markers, which can help doctors determine which small lung nodules need intervention, which small lung nodules are suspected of early lung cancer or are early lung cancer and need surgical intervention as soon as possible.

I want to tell my friends that if you have a chest CT scan for the first time and find a small lung nodule, more than 95% of them are benign. Don't worry or panic, and don't rush to find someone to do surgery. Now, in terms of genetic testing, some testing packages can also help detect early lung cancer. In short, routine health check-up items, plus chest CT, plus liquid biopsy items, can help detect early lung cancer.

I hope that old smokers, especially those who are in their 50s, 60s, 70s, or 80s, who have never had a chest CT scan, will do a chest CT scan to give your lungs a baseline. If there are any problems, intervene and treat them as soon as possible, and keep a health record for future reference.

Here, I want to tell you that smoking is harmful to health. If your friends and colleagues are exposed to secondhand smoke and thirdhand smoke for a long time, it will also cause health damage to their lungs, and their risk of lung cancer will be higher than those who are not exposed to secondhand smoke and thirdhand smoke. If smokers smoke, they must go outside to smoke.

Question: Which types of lung nodules have a tendency to become malignant? What are their characteristics? How can we prevent them from becoming malignant?

Professor Zhi Xiuyi: We will identify which small lung nodules require clinical intervention based on the size, density, and margins of the lung nodules?

If the pulmonary nodule lesion is less than 2cm, it is a pure ground-glass lesion. The general treatment is to recheck the chest CT during a routine health check-up one year later. If the lesion is larger than 2cm and is not a pure ground-glass lesion, there are solid lesions with uneven density; or solid nodules with rough edges, burrs, lobes, vascular signs and other early lung cancer characteristics, you should consult with the thoracic surgery department in time. Multidisciplinary experts will make a multi-dimensional assessment of the lung nodules, based on the CT value of the lung nodules, especially based on the expert advice given by AI big data. For example, a group of small lung nodules that grow into this shape are suspected to be early lung cancer, combined with the test results of liquid biopsy for comprehensive analysis; blood tumor markers are elevated, 7 items of lung cancer serum antibodies are positive, and when the molecular markers sent for testing show an increase in value, such small lung nodules should be actively treated and medical intervention should be carried out as soon as possible.

Question: Our country now pays more attention to the publicity of COPD. Are COPD patients also a high-risk group for lung cancer?

Professor Zhi Xiuyi: Actually, I am not worried about people with COPD, because they have to go to the respiratory department of various hospitals every year and need to do chest CT frequently. During the whole process of COPD follow-up, chest CT can help to detect early lung cancer.

I am worried about those old smokers who have never had a chest CT scan in the hospital, who do not have COPD, and who have no previous lung disease. There are also people who are exposed to other outdoor or indoor environmental or occupational pathogenic factors. These people with COPD should pay attention to annual chest CT scans, which can help detect early lung cancer.

This year is International Lung Cancer Awareness Month. We hope that more thoracic surgeons, respiratory physicians, and oncologists can step out of their clinics, into the community, out of the hospital, and into media interview rooms to tell people that lung cancer is actually a preventable disease, that lung cancer can be diagnosed early through early screening with chest CT, and that early lung cancer diagnosed early can be clinically cured through minimally invasive surgery.

For stage II, III and IV non-small cell lung cancer, corresponding and effective targeted therapeutic drugs can be found through genetic testing, just like hypertension patients take antihypertensive drugs and diabetes patients take hypoglycemic drugs. Currently, many targeted drugs can effectively control lung cancer, including advanced non-small cell lung cancer. Now there is immunotherapy, which has greatly changed the history of lung cancer treatment.

I especially hope that people will pay rational attention to the diagnosis and treatment of lung cancer, and not be overly afraid of lung nodules and lung cancer, and believe in science. We will use these new technologies, new methods, and new drugs for the diagnosis and treatment of lung cancer to enable more people to face lung cancer calmly and treat lung cancer scientifically.

Question: What is the current level of internal medicine treatment for lung cancer in my country?

Professor Zhi Xiuyi: Lung cancer is divided into stages I, II, III and IV. Stage I lung cancer can be clinically cured through minimally invasive surgery. Stage II and III lung cancer with hilar lymph node metastasis and mediastinal lymph node metastasis cannot rely solely on surgery. Lung cancer treatment cannot rely on "one knife" alone, but also requires other auxiliary drug treatments, including auxiliary radiotherapy. In the past, auxiliary treatments used chemical drugs and cytotoxic drugs, but now there are auxiliary targeted drugs and auxiliary immune drugs. These auxiliary targeted therapies have refreshed the history of lung cancer treatment, and immunotherapy drugs have further refreshed the history of lung cancer treatment.

I want to emphasize that if targeted drugs and immune drugs are to be used, the genes must be routinely tested first to find the right targets. We have entered the era of targeted therapy. All patients diagnosed with lung cancer must first undergo routine testing of lung cancer-related genes before targeted therapy. If there is a gene mutation, we recommend targeted therapy on the front line to avoid many toxic side effects such as nausea, vomiting, bone marrow suppression, leukopenia, and hair loss caused by chemotherapy. If the patient has a target mutation, targeted therapy can allow the patient to receive treatment with dignity. I hope that during the Lung Cancer Awareness Month, more oncologists and grassroots medical staff will tell the public about the new progress in these targeted drug therapies and new radiofrequency ablation technologies through the media.

Q: What do you think about International Lung Cancer Awareness Month?

Professor Zhi Xiuyi: November of each year is the International Lung Cancer Awareness Month, and it has been 21 years now. Every year, our China Anti-Cancer Association organizes various popular science activities to inform the public about how to prevent and treat lung cancer scientifically through public opinion propaganda and popular science education. When there is no COVID-19 pandemic, we can also use offline free clinics and expert consultations to get more doctors out of the hospital, out of the clinic, and into the patient room, so that everyone can talk about lung cancer openly and treat lung cancer scientifically.

This year, we will unite more mainstream media to spread the message that lung cancer can be prevented and can be detected early through screening. Currently, precision treatment of lung cancer has entered a new era. We hope that lung cancer treatment can be further standardized. Whether in Beijing, Shanghai, Guangdong, provincial capitals, or prefecture-level cities, we hope that the quality of lung cancer treatment should be homogeneous.

In addition, we must pay attention to and strengthen the management of the whole process of patients' rehabilitation. On April 15 this year (China Anti-Cancer Day), the National Cancer Prevention and Treatment Publicity Week, the China Anti-Cancer Association delivered the core popular science information of "prevention, screening, diagnosis, treatment, and health" to the society. I hope that the doctors in front of the camera will tell our society and the people the concepts and methods of "prevention, screening, diagnosis, treatment, and health". I hope that the ordinary people who hear our program will tell this information to your relatives and family members around you. Of course, I hope that more media can interview more doctors, and inform the society and the people of the concepts, technologies, drugs and norms of "prevention, screening, diagnosis, treatment, and health", so that we can jointly prevent and treat lung cancer. In the prevention and treatment of lung cancer, you and I will go together!