Episode #34: A Rapidly Changing Landscape: Lung Cancer Detection & Treatment with Dr. Carolyn Presley

Dr. Albert Rizzo:
Welcome back to LungCast the monthly respiratory Health podcast series from the American Lung Association and medical news site HCP Live. I'm your host, Dr. Albert Rizzo, the chief medical officer of the American Lung Association.

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Over the last three years, we've built a great lineup of guests in the field of lung cancer, and today's expert certainly adds to that list. Dr. Carolyn Presley, an assistant professor and oncologist with the Ohio State University at the James Cancer Center, is here today to discuss gaps in knowledge and care delivery that burden patients with lung cancer, as well as the pivotal role that oncologists play in detecting and initiating care for lung cancer.

Thank you for joining me today, Dr. Presley.

Dr. Carolyn Presley:
Thank you for having me.

Dr. Albert Rizzo:
Just to level-set for our audience, will you please tell us a little bit about what your current role is at your practice and your institution regarding diagnosing and treating patients with lung cancer?

Dr. Carolyn Presley:
Absolutely. I'm a geriatric and thoracic oncologist at the Ohio State University and the James Cancer Hospital in Columbus, Ohio. We're in South Central Ohio, right in the middle of the country. I am a lung cancer doctor, but I'm also board certified in geriatrics, and I lead a research program that focuses on improving functional status and quality of life, particularly for older adults with lung cancer.

I'm also the associate medical director for our Onco-Geriatrics program at the Ohio State University.

Dr. Albert Rizzo:
Very good. You sound well-qualified to answer our questions today.

Let's start out: the patient diagnosed with lung cancer today often has a much different journey in their care than those diagnosed 15 or 20 years ago, with the advent of low-dose lung cancer screening hoping to shift the diagnosis to earlier, more curable, and treatable stages. As you know, there's been an explosion of new therapies, targeted mutations, and immunotherapy.

With this change, have you seen a change in the role of the medical oncologist when it comes to lung cancer care? And by that, I mean, there's a wide breadth of cancers—both hematologic and solid organ—and an oncologist is asked to deal with all of them. Do you see more medical oncologists specializing in lung cancer because of the amount of information, and is there a specific amount of training that has to be focused for individuals who want to go into thoracic cancers?

Dr. Carolyn Presley:
Wow, great question. First off, I think it's important to remember that in the United States, the majority of all cancer care is actually done in the community oncology setting, so it's not necessarily in the academic setting.

Really making sure that we are providing the gold standard for lung cancer diagnosis, screening, and treatment planning—there are really some critical components. In terms of screening, we still have a long way to go to improve screening rates and make sure that everyone who meets criteria is getting screened.

We know that lung cancer screening improves mortality, but not everybody who should be screened is. There are a lot of national efforts to continue to increase not only lung cancer screening but also smoking cessation rates. We like to say: anybody with lungs can get lung cancer.

There's still 20 percent of people who are never-smokers, and radon is the number one environmental exposure that we need to educate people about. Specifically, in the middle part of the country, radon levels and exposures are much higher. There’s still a public awareness gap about the risk of radon exposure and the importance of testing.

Once patients are screened or if they are having symptoms, making sure we get a good tissue diagnosis is key, because that will dictate next treatments and staging—whether it’s confined to the lung or involves the lymph nodes.

Over time, we hope to diagnose lung cancer earlier or even prevent it. Tumor boards have been around for a long time, but more recently we see the development of multi-disciplinary teams, especially around screening centers. Multi-disciplinary teams help decide surgery, radiation, chemotherapy, and treatment sequencing.

Dr. Albert Rizzo:
So how has the role of the medical oncologist changed a bit since screening came into place and with all the newer modalities?

Dr. Carolyn Presley:
The medical oncologist typically has been the quarterback of the team, and I see that role continuing, because systemic treatments are not just for the advanced setting. By systemic treatments, I mean pills by mouth or infusion of chemotherapy, immunotherapy, or a combination of both.

Multi-disciplinary tumor boards are critical, and treatment planning done in a multi-disciplinary way leads to better outcomes. We’re seeing rapid dissemination, including virtual tumor boards if in-person isn’t possible.

Sequencing of treatment is incredibly important. Some patients may need chemotherapy and immunotherapy before surgery, a combination of chemo and radiation prior to surgery, or oral tyrosine kinase inhibitors after surgery. The medical oncologist is the end-user of all pathology and imaging information, playing a crucial role in treatment planning regardless of stage.

Dr. Albert Rizzo:
Yes, that term “end-user”—I heard you use it at a talk, and I thought it was very appropriate.

Patients get to a medical oncologist in different ways. Sometimes their PCP suspects cancer and sends them, sometimes there’s a biopsy available, and sometimes it’s a second opinion. How do you handle these initial encounters, especially when patients don’t know why they’re there?

Dr. Carolyn Presley:
There is a big variety. Especially older adults may be wary of biopsies or bronchoscopies. Sometimes we only know there’s a nodule, and they want to understand treatment options first. Nothing is risk-free, and healthcare interactions involve costs and travel.

Often, I start with explaining that a tissue diagnosis is needed to appropriately plan treatment. Depending on comorbidities, we can discuss options. If tissue isn’t immediately available, I may get a blood test to perform tumor genomic testing. Circulating tumor DNA in peripheral blood can give results in about a week, allowing us to start thinking about treatment options.

Safety of biopsy—bronchoscopy vs. CT-guided—must be considered. Even in advanced settings, or with neoadjuvant chemo/immunotherapy, we need PD-L1 testing to determine upfront immunotherapy use, sequencing before/after surgery, and monitoring for brain metastases.

Dr. Albert Rizzo:
You outlined many options depending on the situation. Where does the role of clinical trials fit in, and how do you bring that up with patients?

Dr. Carolyn Presley:
At the first new patient visit, we ask if they’re interested in clinical trials—either treatment trials with new drugs or supportive care trials. My research program designs interventions like nutrition, physical therapy, and relaxation to improve immune response and functional status.

Right away, patients are asked if they want information on treatment trials, sequencing, or supportive care interventions. Many say yes—knowledge is power.

As a geriatric oncologist, I focus on ensuring eligibility criteria aren’t too strict, because older adults are often underrepresented. Including them improves generalizability, as the average diagnosis age is around 70, but the average trial age is 62–65. Academic centers are a hub for trials, but community settings are increasingly involved, which is critical since most patients are treated there.

Dr. Albert Rizzo:
Thank you. I mentioned earlier the explosion in therapies, mostly for non-small cell lung cancer. Have there been advances in small cell lung cancer, and if not, why?

Dr. Carolyn Presley:
Progress has been slower, but there are advances, especially using immunotherapy in extensive-stage small cell in combination with chemo. Long-term survivors (3–4 years) are now being seen. There are also new chemotherapies, antibody-drug conjugates, and cellular therapies moving into the space, in addition to chemo and immunotherapy.

Dr. Albert Rizzo:
NCCN guidelines list 11 targeted mutations with specific therapy recommendations. Can you speak about the significance of these advances in targeted therapies?

Dr. Carolyn Presley:
Every patient with advanced non-small cell lung cancer needs tumor genomic testing. It’s now important post-operatively too, since some drugs are approved in that setting.

Targeted therapies can replace IV chemo with oral pills, dramatically changing prognosis. Brain metastasis risks vary depending on mutation. Tumor genomic testing is now a cornerstone of treatment.

Dr. Albert Rizzo:
Where a patient begins treatment and the timeline are important. Can you expand on that?

Dr. Carolyn Presley:
Tumor genomic and PD-L1 testing is crucial before treatment. Patients want immediate therapy, but starting without information risks wrong treatment and worsened side effects. Explaining the importance of the right treatment, not just the fastest, helps patients and care partners understand.

Dr. Albert Rizzo:
What should a PCP or pulmonologist do when first seeing a patient diagnosed with lung cancer?

Dr. Carolyn Presley:
Screening should be top of mind—low-dose CT scan, not just mammogram or colonoscopy. Appropriate referral for bronchoscopy or biopsy is critical. Many programs follow lung nodules over time. Follow-up is key, as incidental nodules can get lost in the system. Navigation bronchoscopy allows access to smaller nodules than before.

Dr. Albert Rizzo:
Excellent advice. How do equity and access issues affect care, and what about age?

Dr. Carolyn Presley:
There should be no age cutoff for conversation. I don’t turn anyone away from discussing treatment. Shared decision-making is critical. Chronologic age isn’t equivalent to physiologic age—someone 50 could be frail, someone 80 could be fully functional.

Clinicians should assess daily function, ADLs, mobility, and use geriatric assessments to reduce treatment-related toxicities in older adults.

Dr. Albert Rizzo:
You’re at the cutting edge of treatment. What do you see for the future of lung cancer care?

Dr. Carolyn Presley:
I hope everyone who needs screening gets screened, diagnosis happens earlier, and we deliver precision and personalized medicine. Survivorship starts at diagnosis, addressing mental and physical health, overall function, and quality of life. The goal is living well with lung cancer.

Dr. Albert Rizzo:
Great concluding comments. Thanks again to Dr. Presley.

As I mentioned, we have a great archive of lung cancer discussions, including talks with Dr. David Cook, a thoracic surgeon, and Dr. Carla Lamb, reflecting on decades of advances. Subscribe and rate Lungcast on your preferred platform, and visit lung.org and hcplive.com for more news and resources.

Until next time, I’m Dr. Albert Rizzo, reminding you: if you can’t breathe, nothing else matters.