A burning problem. The challenges of lung cancer. Episode 17

Monika Rachtan
Good morning. I would like to welcome you to another episode of the podcast "Firstly the Patient". Today my guest, and above all your guest, is Dr Maciej Głogowski, MD. Welcome, doctor.

Maciej Głogowski
Good morning.

Monika Rachtan
We will be talking to the doctor about lung cancer, and his speciality is actually surgery. You are a thoracic oncology surgeon. But at the beginning of the conversation I would like to ask: who is a thoracic surgeon? I think a lot of people don't know.

Maciej Głogowski
A thoracic surgeon is first and foremost a surgeon, but a surgeon who specialises in the diagnosis and surgical, or operative, treatment of all diseases in the thoracic region, except the heart. The treatment of the heart surgically is carried out by cardiothoracic surgeons. Our diagnosis and treatment concerns diseases of the lungs, mediastinum, oesophagus, pleura and chest wall. This also includes tumours of the chest wall and ribs, as well as the diaphragm. I hope I have not forgotten anything.

Monika Rachtan
I think it is good that there is such a specialisation, because if there is the possibility of surgery with radical intent, it means that many patients are cured.

Maciej Głogowski
We would like to see more of them. When we talk about lung cancer, the number of people who can be treated with surgery is limited by the stage of the disease. For more advanced lung cancer, surgical treatment, colloquially speaking, does not make sense. It is inefficient. Other treatment methods must then be used to treat the patient effectively and sometimes even cure the disease. Thoracic surgery is a local treatment method. So the disease must be localised, not generalised, extending beyond the organ in question.

Monika Rachtan
A lot of difficult topics and terms, I think especially for patients. I would like to ask you straight away about your doctor's observations. There is a lack of health education in Poland, so many of us, for example young women, do not think about oncology at all. They do not even know that there are thoracic surgeons or something like systemic and surgical treatment. It is only when someone is on the oncology pathway that they start to understand these difficult terms. Are patients then better informed?

Maciej Głogowski
Over time, yes. We try to bring these terms closer to patients. Sometimes we simplify them in our vocabulary, calling, for example, systemic treatment chemotherapy, although nowadays other methods, such as targeted treatment, molecular treatment or immunotherapy, are also included under this term.

Monika Rachtan
I also try to explain what systemic treatment is, because sometimes journalists ask about it. I then say that it is a treatment that reaches every part of our body.

Maciej Głogowski
Exactly, this is true. Whether the drug is administered orally or intravenously, it gets everywhere.

Maciej Głogowski
This means that we treat the disease wherever it is. Local treatment, on the other hand, deals with a specific part of a particular organ or an entire organ.

Monika Rachtan
In the context of this programme, I said that the patient is the most important thing. I collect questions from patients on various Facebook groups. All I ask is that they don't ask questions about diagnosis or diagnosis. I have a specific question that I found. "In my family, my father and grandfather died from lung cancer. They were both big smokers. I don't smoke because I don't want to end up like them. Could this type of lung cancer be hereditary? Should I do some research?"

Maciej Głogowski
First of all, it is a good thing that a person who has two smokers and lung cancer in their family does not smoke themselves. This reduces the risk of developing the disease significantly. Among a hundred lung cancer patients, about 90 are smokers. This person therefore does not need to have regular examinations and is not even included in the lung cancer early detection programme. Any tests are only carried out if there are any symptoms. There is no form of inheritance here, so he or she does not inherit a propensity for lung cancer.

Monika Rachtan
The most important thing is that he does not inherit a propensity to smoke.

Maciej Głogowski
Exactly, this is the most important thing. If he doesn't smoke, even though his parents or grandparents smoked, he has already achieved great success.

Monika Rachtan
I have another question, this time from a woman. What does the notation "percentage of tumour cells in the test material: 40%"?

Maciej Głogowski
As far as this entry is concerned, it probably refers to the biopsy material and means that the 40% cells in this material are cancer cells. The rest are other elements, such as inflammatory cells. This indicator in itself has no direct relevance to the diagnosis, but may be important for further molecular diagnosis or choice of treatment. These are already more technical aspects.

Monika Rachtan
I understand, which is why there are many different questions on these groups. I just picked two, but the patients are very supportive. I think it is interesting to see what happens at a group like this. It shows how patients form a community. If someone is struggling with an illness, the support at a group like this can be very helpful.

Maciej Głogowski
Correct, but it is important to remember that in this group information is sometimes given in the wrong way. Patients compare their situations, which is not a good idea. Each case is individual, even though treatment follows certain patterns. It cannot be assumed that if it helped one patient, it will help another.

Monika Rachtan
Agreed, this is very important.

Maciej Głogowski
It is estimated that between 85 and 90% cases of lung cancer are linked to smoking.

Monika Rachtan
I wonder why there is no strong anti-smoking campaign in Poland. Smoking has been banned at bus stops and in public places, but still, in restaurants, someone near me smokes. As a society, we just accept it. Do the experts, which you are, advocate restricting smoking?

Maciej Głogowski
Of course, there are such proposals for legislators. There are different bans in the European Union and in different countries. For example, in Strasbourg you cannot smoke in parks, in Amsterdam in the streets, and in Spain on the beaches. I have even heard that in some countries there is a proposal to ban smoking in private cars.

Monika Rachtan
It's interesting. It always sickens me when I see someone smoking in a closed car window.

Maciej Głogowski
We can't talk on the mobile phone while driving because we risk a fine. But we can theoretically smoke.

Monika Rachtan
Exactly. We have to hold a cigarette after all. It's interesting, especially in the context of Poland.

Maciej Głogowski
There is no such ban in Poland, although such proposals do exist. However, they would have to go through a legislative procedure. Currently in Poland there are bans in public places, workplaces or bus stops. I am in favour of these bans being extended to other aspects of life. After all, no one today can imagine someone smoking on a bus.

Monika Rachtan
Or in hospital.

Maciej Głogowski
Exactly, but it used to be that way. I can't remember exactly which year the law introducing the smoking ban came from, but it was relatively recent.

Monika Rachtan
Probably from the 2000s.

Maciej Głogowski
Yes, it's not that long ago at all. And if we consider the recent increase in the number of smokers, it is worrying. After some decline and a period of stagnation from 2021 onwards, we see an increase. This means that the current bans are not working and we need to go a step further. But this requires new laws and regulations. So the ball is in the government's court.

Monika Rachtan
What do you think of the opinion you often read on the internet that patients who have smoked should pay for their cancer treatment themselves? The argument is that if they were foolish enough to smoke, they should now bear the cost of treatment themselves. Why should such patients be treated with my taxes?

Maciej Głogowski
This patient's taxes also fund various services, so one could make a similar argument for obese people who are more likely to have hypertension or diabetes. This is completely absurd. The Constitution guarantees access to healthcare. Of course, one might wonder whether some tax money on cigarettes should be used to treat smoking-related illnesses. But that is already a matter of allocation by the National Health Fund.

Monika Rachtan
I asked this question because I encounter such opinions on the internet.

Maciej Głogowski
This is simply absurd. There is nothing more to add.

Monika Rachtan
At the beginning of the interview, you mentioned that smoking is a major cause of lung cancer. But what about people who have never smoked? Are they also at risk?

Maciej Głogowski
About 10% of people who have never smoked also develop lung cancer. Added to this is the risk of passive smoking, which is lower but also significant. Of course, environmental pollution also plays a role. There are various carcinogens in the air, such as heavy metals or polyunsaturated aromatic hydrocarbons, which can also affect the risk of developing the disease.


Monika Rachtan
So there is a whole list of factors, such as ionising radiation, that can cause cancer. But the most important of these is cigarettes, as they contain dozens of carcinogenic substances.

Maciej Głogowski
Exactly, cigarettes are the most important known factor.

Monika Rachtan
Is it worth investing in research packages that promise to detect cancer or cancer risk? At the beginning of the interview, you mentioned that there are no studies that clearly answer this question.

Maciej Głogowski
No, this is not a good idea. There are no genetic tests or cancer markers that can answer this question unequivocally. There is no need to invest in such packages. There are a few studies on substances that may be helpful in the future, but these will be additional studies to the existing ones now, like low-dose CT scans. So, ladies and gentlemen, there is no such research. I don't want to call it taking money out, but....

Monika Rachtan
It sounds like they are pulling money out. In Poland, everyone is afraid of cancer and various companies take advantage of this.

Maciej Głogowski
And what do we learn from this? Often we find out absurd things that don't do anything for us. Instead, anxiety grows in us and our mental health deteriorates. There are only a few cancers in which one can speak of heredity and an increased risk of developing the disease. This applies, for example, to hereditary breast cancer or thyroid cancer, but this is a small percentage of the total population with these cancers.

Monika Rachtan
So it is not worth succumbing to fads in medicine, especially when it comes to our health.

Maciej Głogowski
Exactly. Unfortunately, what happens in the world is that some people try to profit from things that are not scientifically proven.

Monika Rachtan
That being said, how about discussing what is really worth doing. Is it worth getting screened in a lung cancer prevention programme if you are at risk? Who is this programme aimed at?

Maciej Głogowski
Definitely worth it. The Lung Cancer Early Detection Programme, otherwise known as the Lung Cancer Screening Programme or Lung Cancer Screening, is for people who have smoked for at least 20 years. This means, for example, one pack a day for 20 years or two packs for 10 years. This includes people who are still smoking, but also those who quit no more than 15 years ago. In the original, this referred to people who stopped smoking up to 20 years back, but in Poland this time was reduced to 15 years. If someone stopped smoking more than 15 years ago, they are no longer eligible for this programme.

Maciej Głogowski
The programme targets those aged 55-74, although it can be lowered to 50 if there are additional risk factors such as asbestos exposure, occupational exposures or a previous family history of lung cancer. These are the main eligibility criteria for the screening programme in Poland.

Monika Rachtan
So if you're listening to our programme and wondering where you can get this test done, how to find the right centre, what can you do?

Maciej Głogowski
It's really simple. You will find a full list of centres with telephone numbers on the internet at patientow.co.uk, under 'Screening programmes'. You can choose your nearest centre, call and see if the programme is currently running. If you qualify as being at risk, the screening is free of charge, provided the centre still has spaces available for reimbursement. However, if you prefer to do it commercially, many other centres also offer this test, only that there is a fee.

Monika Rachtan
Therefore, the most important thing for patients is to know that such a programme exists and is worth taking advantage of.

Maciej Głogowski
Exactly. It's worth checking which centre in your province coordinates the programme and calling them. It is even possible that the centre performing the CT scan will be closer than you think.

Monika Rachtan
I also want to emphasise that the prevention programme is aimed at healthy people, i.e. asymptomatic people.

Maciej Głogowski
Yes, this is very important. The programme is aimed at people who do not have any symptoms.

Monika Rachtan
If we already notice symptoms in ourselves that may indicate lung cancer, what might these symptoms be?

Maciej Głogowski
In the context of lung cancer, the symptoms are usually related to the respiratory system. We are talking about a cough, which in smokers can change its character and be sometimes with an admixture of blood. Other symptoms include recurrent respiratory infections, chest pain, shortness of breath that increases, and general symptoms such as weight loss.

Monika Rachtan
If a patient notices these symptoms in themselves, which doctor should they see?

Maciej Głogowski
The best thing to do is to see your primary care physician, or PCP. He or she will interpret the symptoms and carry out an initial examination, usually a chest X-ray. From 2022, PCPs also have the option to refer for a CT scan of the chest if there is any doubt about the diagnosis. If the tests show any abnormalities, the patient is then referred to specialists.

Monika Rachtan
More than 20,000 new cases of lung cancer are diagnosed annually in Poland. What are the key stages in the diagnostic pathway that patients should pay particular attention to in order to receive the best individual treatment?

Maciej Głogowski
Indeed, the patient should not have to 'look after' anything himself. It is the task of the healthcare system to ensure correct diagnosis and treatment.

Monika Rachtan
Ideally, of course, this would indeed be the case. But unfortunately, for various reasons, it is worthwhile for the patient to be aware of the diagnostic and treatment stages that await them.

Maciej Głogowski
Our role as doctors is first and foremost to oversee the entire diagnostic and treatment process. If a patient has doubts, he or she can always seek a second opinion, a practice that is widely accepted worldwide. None of us doctors should be offended if a patient wants to consult another specialist about their situation.

Monika Rachtan
You are right.

Maciej Głogowski
This is scary for the patient, but a well-educated patient who wants the best possible treatment for themselves deserves praise. Two things are crucial in determining the treatment method: the diagnosis and the stage of the disease. On this basis, we select the appropriate treatment method, the range of which can be wide. We are not just talking about chemotherapy, but also targeted, molecular treatment, depending on the specific case.

Monika Rachtan
I understand. I asked because I often hear about problems related to the small amount of material taken during the biopsy, which then prolongs the whole diagnostic process.

Maciej Głogowski
Such situations unfortunately do occur, but it is not always the result of negligence. Sometimes the amount of material available is limited and requires additional testing. When it comes to lost samples, this is already negligence. But as for the amount of material, this is not always within our control. The final decision is made by the histopathologist and sometimes it turns out that additional tests are necessary. This is particularly important in the context of selecting a treatment method, the effectiveness of which can significantly affect the patient's prognosis.

Monika Rachtan
My understanding. Recently, a new role has been introduced in the healthcare system - the oncology treatment coordinator. It seems to me that in the case of units treating lung cancer, this role is particularly important. What can I expect from this coordinator?

Maciej Głogowski
This is linked to the National Cancer Network Act. The coordinator acts as an intermediary between the doctor and the patient. He or she can also be referred to as an informant for the patient, who helps to orient the patient to the system. This works differently in different institutions, but in general, the coordinator's role is to help the patient navigate the health system.

Monika Rachtan
Is it true that the coordinator is particularly important for older people? I am thinking of patients in their 70s, 75s or 80s who come to large cancer centres. There, just filling in the first form can already be a challenge for them.

Maciej Głogowski
Documentation is necessary from a legal point of view, so you have to deal with it. But whatever their age, patients are often lost. Sometimes a patient comes in, listens to what we have to say, is given instructions for tests and forgets everything after five minutes.

Monika Rachtan
It really is a huge stress for patients.

Maciej Głogowski
Unsurprisingly, it really is a huge stress. If the patient knows they have someone they can call, it certainly makes things easier. The coordinator can discuss everything with the patient again and, if necessary, set a new appointment for the examination. This certainly makes life easier for the patient.

Monika Rachtan
That is, the coordinator is available by telephone.

Maciej Głogowski
Yes, the coordinator takes care of organising all the tests that the patient has to undergo, as well as where they are performed.

Monika Rachtan
When diagnosing and treating lung cancer, the patient meets many specialists. Can you explain why there are so many of them? Wouldn't one doctor be enough?

Maciej Głogowski
No, one doctor is not enough. Cancer treatment is a complex matter that requires the cooperation of many specialists. Decisions are made by a so-called multidisciplinary team and are individualised. It is not only about diagnosis, but also about systemic treatment, such as chemotherapy. This approach was already established in the 1990s. In addition, many patients with lung cancer have other lung diseases at the same time, which also requires coordination. In addition to clinical oncologists, radio-oncologists are also involved in the treatment process.

Monika Rachtan
I understand, so the patient will really get to know many specialists. I would now like to touch on the individual procedures performed in diagnostics. What does that look like?

Maciej Głogowski
When it comes to diagnostics to make a diagnosis, a lot depends on which centre, province or hospital these tests are performed in.

Monika Rachtan
I am thinking, for example, of a mesh biopsy. The very thought of this procedure scares me because I associate it with pain. How do patients experience this?

Maciej Głogowski
Any invasive procedure involves some risk, including pain or discomfort. Biopsies, especially those performed through the chest wall, can be painful, especially if there are complications. Then a drain needs to be inserted and this too is associated with pain. Of course, we try to minimise risk and pain, but this should not be an obstacle to undergoing such procedures, which are necessary for diagnosis and further treatment.

Monika Rachtan
While we are on the subject of choosing a centre, patients on various groups often recommend to each other: "Go there because there is a better doctor there". How do you find that ideal centre for treatment? What should you pay attention to? What features are important?

Maciej Głogowski
In answering this question, I must admit that there is no clear-cut answer. We have many excellent lung cancer treatment centres in Poland. Some of them are part of larger cancer centres and others operate as independent facilities. It is important for patients to choose a centre close to their home, but each patient has different criteria for selection. I believe that we all treat equally well. However, sometimes the lack of drug programmes at a centre can be a limitation.

Maciej Głogowski
It is not possible to say unequivocally that one centre is better and another is worse. I hope that treatment quality surveys will be introduced to help with this issue.

Monika Rachtan
I would now like to touch on the prognosis and treatment of patients. Is a diagnosis of lung cancer always tantamount to a death sentence? Can the doctor boast of any patient who has lived a really long time with a diagnosis of lung cancer?

Maciej Głogowski
I have been working in the field of thoracic surgery for more than 30 years and have patients who are now living 30 years after diagnosis.

Monika Rachtan
This is really good news for patients. So if the cancer is cut out at an early stage, the patient can live a long time?

Maciej Głogowski
Yes, many of them live really long and in good health, although unfortunately this cannot be said of everyone. It depends on the biology of the particular patient's cancer. I would like the survival rate to be as close as possible to 100%, but I realise that this is impossible.

Monika Rachtan
I would like to return to the social issues surrounding smoking. It is recorded that smoking is a major modifiable factor in the occurrence of lung cancer and other cancers. Cigarette packets indicate that they contain about 70 carcinogenic compounds. The doctor mentioned earlier that in 2021, 26% people in Poland smoked cigarettes, and now it is 29%. How do you assess the country's policy on reducing the number of smokers?

Maciej Głogowski
Let me answer briefly: badly, or even fatally.

Monika Rachtan
We are not dealing with this problem in Poland. I saw a billboard in the centre of Warsaw yesterday with the slogan "Don't burn your life". But is that enough?

Maciej Głogowski
If we want to be a cigarette-free country, as envisaged in the 2035 or 2040 strategy, so that there are less than 5% smokers, then health education needs to start at pre-school age. This requires a generation, or 15-20 years, to achieve results comparable to those in New Zealand or Sweden. There are also measures that can be taken now to reduce smoking rates.

Monika Rachtan
So what can we do in this situation?

Maciej Głogowski
We have a lot to do. I have brought with me an expert opinion by Professor Andrzej Fan, president of the Polish Public Health Association. It is an opinion on cigarette addiction in Poland and its economic and social aspects. This opinion was written at the request of the chairman of the Health Committee in our parliament and is available on the Sejm website, so it is not secret. There is a detailed analysis there, based on which we can estimate what savings can result from the reduction of smoking.

Maciej Głogowski
In short, the education programme must be multi-year and start as early as kindergarten. It is to be continued up to the age of majority. In this way, we will raise a society that never starts smoking. But we must also have good role models, i.e. people who have quit smoking. Currently more than 28% of Poles smoke, so we have a lot to do.

Monika Rachtan
Is it possible to find a link to this publication?

Maciej Głogowski
To answer what needs to be done: there should be at least one prevention clinic in every county. In 2021, around 750,000 PLN will be spent on prevention and several billion on cancer treatment. Such an outpatient clinic, headed by a specialist, should employ nurses, public health assistants, therapists, etc. The counselling centre would have full access to anti-smoking therapy and harm reduction programmes. All this, of course, within the framework of a campaign in the district concerned.

Monika Rachtan
Colourful shelves, right?

Maciej Głogowski
Yes, this is advertising that shines and speaks. You can see it at petrol stations, for example. In my opinion, this should be abolished and licensing should be introduced. Like in Spain or Italy, where you can only buy cigarettes in designated shops. This makes it easier to control sales and even control illegal imports. I am therefore in favour of raising excise duties and prices on cigarettes.

Monika Rachtan
It is certainly a placebo, of course.

Maciej Głogowski
There are a lot of substitute cigarette products on the market. We have a huge legislative mess on this issue. In my opinion, a special group of experts from various fields: medicine, economics, public health, should be set up to assess the current state of knowledge on this subject. This group could also monitor studies on the efficacy and safety of these products. If it concludes that there is a lack of evidence, the legislation would have to be revised so that all smoking and nicotine-related products are subject to the same rules of restrictions on sale and promotion. Once these studies have been carried out, excise duties should be adjusted according to the level of harmfulness of the product. I would like to emphasise that any harm reduction programmes should be targeted only at people who want to break the habit.


Monika Rachtan
I understand these remedial tips for the system. The professor has really put forward a lot. I think that if at least some of them were implemented, something good could happen. And let me also ask, is nicotine itself a carcinogen?

Maciej Głogowski
Nicotine is a highly addictive substance, but there is no scientific evidence that it is carcinogenic. It is this substance that makes people addicted.

Monika Rachtan
That is, it causes us to reach for cigarettes.

Maciej Głogowski
Exactly, and we cannot give it up afterwards. What is carcinogenic, however, are all the other substances found in cigarette smoke or in the aerosols in electronic cigarettes, which are now very popular.

Monika Rachtan
What are the three most important things from our conversation today that our listeners should remember?

Maciej Głogowski
First and foremost, primary prevention, i.e. not starting to smoke at all. If one already smokes, early detection programmes are worthwhile. But the most important thing is to quit smoking, because the risk of the disease decreases with each year of not smoking. It will not fall to zero, but it will be comparable to the risk in the non-smoking population after a few decades. From a treatment point of view, the most important thing is diagnosis, diagnosis and trust in doctors. Treatment is no fun, but it should not be feared. We are here to guide the patient through this stage.

Monika Rachtan
The Institute for Patients' Rights and Health Education is a partner in this programme, which talks a lot about the humanisation of medicine. And what is humanisation for you?

Maciej Głogowski
Humanisation, which we talked about at the end, is about creating bonds between doctor and patient. A bond based on collaboration, empathy, understanding and respect for the different aspects of the patient's life, including cultural aspects. In this sense, we are partners.

Monika Rachtan
So we are never on the same side?

Maciej Głogowski
We are just aiming for the same thing. If we can create such a relationship, it leads to the humanisation of medicine. The patient will feel comfortable. Of course, by treating the patient, I cannot guarantee that the disease will not return. But if we are on the same side and understand each other, the patient is more likely to return to a normal life and even do a lot of good for society and his family.

Monika Rachtan
Thank you for this positive note at the end of our conversation. In Poland, people are often frightened by cancer, but there are also stories that show that it can be cured if diagnosed early. We wish all our listeners good health, but if they notice anything worrying, we recommend that they visit their GP as soon as possible. If something is wrong, all hands on deck - it can and should be treated.

Maciej Głogowski
Of course, if the GP has doubts, he refers the patient to specialist care. In Poland, it is the case that you don't get to some specialists without a referral. It is not for me to judge, but you can go to an oncologist without a referral. In this situation, however, the oncologist is likely to refer the patient further because he or she is unable to make a diagnosis.

Monika Rachtan
So the oncologist treats if necessary?

Maciej Głogowski
Yes, the oncologist can take some action, but if he or she decides that invasive diagnosis is needed, then he or she refers the patient to an appropriate centre. For example, this may be a diagnosis carried out by a thoracic surgeon, as we do. Patients are quickly referred to us and we carry out the diagnosis. Based on this, we establish the diagnosis and stage of the disease, and then the patient is treated according to this data.

Monika Rachtan
Doctor, thank you very much for talking to us today. Also, thank you very much to our viewers and listeners. Thank you.