Episode 51

Early Detection, Better Outcomes: Lung and Esophageal Cancer with Dr. Shanda Blackmon

Episode Transcript

Dr. Randy Lehman [0:11 - 0:56]: Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more. We have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the chloraprep has dried, let's make our incision. Welcome back to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, and I am so honored today to have Dr. Shanda Blackmon with me. Thank you, Dr. Blackmon, for joining me.

Dr. Shanda Blackmon [0:56 - 0:58]: Thank you, Randy, for inviting me.

Dr. Randy Lehman [0:58 - 1:18]: My pleasure. And I know Dr. Blackmon from my training at Mayo Clinic. She was a thoracic surgeon. I did a whole dedicated rotation with you. It was one of the best rotations that I had, I gotta say, in residency. And since then, you've been doing great things, and I'm so glad that you took the time to come join us on the show.

Dr. Shanda Blackmon [1:18 - 1:28]: Well, it's great to join you. I love that we've stayed in touch over all the years and talked back and forth about cases. I've also enjoyed training you. You're one of the best residents I've ever trained.

Dr. Randy Lehman [1:29 - 1:45]: Oh, man. All of our head, we're not going to be able to get out of the room. Head's going to be too big. So why don't you start with just giving the listener a little introduction of yourself and your training path to kind of who you've become and what you're doing now and maybe even what you want to do in the future.

Dr. Shanda Blackmon [1:45 - 3:52]: Yeah. So I'm a minimally invasive thoracic surgeon. I first trained in general surgery, and once I completed my residency, I got really interested in cardiothoracic surgery. I came to Houston, Texas, where I finished my training there and became interested in complex esophageal reconstruction. So, I did a super fellowship, needed a few more years of training, and went over to MD Anderson and did a little bit more. Once I finished, I got recruited to go to a hospital in Houston called Houston Methodist Hospital. I practiced there for eight years, where I was chief of thoracic surgery. I trained all of the MD Anderson residents during that time and ended up hiring my partner, who became the chief there.

I decided to move over to Rochester, Minnesota, and became a professor of surgery at Mayo Clinic, where you and I met. I was at Mayo for 10 years. The weather was pretty cold, but it was a great hospital, ultimately. My husband was a golf pro, and he really loves to play golf. My family is here in Houston, and we decided to come back to Houston. Now, I'm at Baylor College of Medicine, which is where I did my cardiothoracic surgery residency. I go to multiple different hospitals, and I'm the director of the Lung Institute. I do esophageal, lung, mediastinum, anything inside the chest surgery today. I train residents and medical students, and a big part of my practice is innovating. I hold several patents. I developed an app that guides people for managing patients who've had any kind of foregut surgery. I continue to do research around that. I've developed some surgical instruments and I've written a book called The Support Group. I still run patient-focused support groups, which I've done for 20 years, and it's very near and dear to my heart.

Dr. Randy Lehman [3:54 - 3:56]: Well, there's also a book on esophageal surgery, right?

Dr. Shanda Blackmon [3:57 - 4:02]: That's true. There is a book about esophageal surgery published by Springer. Correct.

Dr. Randy Lehman [4:02 - 4:15]: Multiply published author. I mean, where do we start? Inventories. That's fantastic. So what surgical instrument? This little rabbit trail. What surgical instrument did you invent?

Dr. Shanda Blackmon [4:16 - 4:35]: Well, a couple of instruments. It's made by Scanlan, a company that builds minimally invasive surgery instruments. One is a vented sucker, and one is a knurled-tip sucker for decortications. We've worked on some other devices as well.

Dr. Randy Lehman [4:36 - 6:17]: Cool. Awesome. All right, so I have a one little interesting anecdotal story before we start on training. So, we had a mentorship model at Mayo, and in your rotation, I was on with a fellow and then myself. But it worked out great because the fellow had done so much foregut surgery that he was kind of over it. What he really wanted to do was the lung cancer surgery. So, we kind of divided, and I got to do a great foregut hiatal experience while he did most of the lung cancer resections.

And one case we were doing. Do you remember Jesse? Yes, I do. So where is she from? Somewhere in Southeast Asia. Yes, I want to say. So, she's a visiting surgeon, a full thoracic surgeon for like a decade herself back home, and was visiting and watching you. You were patiently waiting outside the room as I was getting the case started and carried on. I'm not sure if you know this story, so I wanted to say it. So, Jesse's standing behind me. She's handicapped because she can't scrub in, you know, so all she can do is stand there. But I used her as a resource, probably more than you know, on that rotation, because I would always be asking her, but she couldn't take over the operation. All she could do was talk me through.

Dr. Shanda Blackmon [6:17 - 6:19]: The perfect mentor, right?

Dr. Randy Lehman [6:19 - 6:32]: Yeah. So, I'm doing this thoracic lymph node dissection, and I remember you came to me afterwards and said you had watched the video in the lounge, like, down the hall.

Dr. Shanda Blackmon [6:32 - 7:23]: Yeah. So, we had a remote camera system where you could be at your desk and watching the surgery while you're working on a couple of other things. We also had the system where you could stand outside the room and watch through the window, because most of what I did was minimally invasive. It's projected up on a big screen. Then, of course, being in the room or being scrubbed. Those levels of observation are frequently determined by the skill of the resident, the amount of trust we have with the resident, and all the critical portions of the surgery we're always deeply involved in. But I would say, like some of the less critical parts, we want you to have an opportunity to do some independent decision-making and working. Yes.

Dr. Randy Lehman [7:23 - 7:46]: The way it was phrased to me was, as they're checking out the degree of the lymph node dissection, that four-hour lymph node resection was thorough and adequate. Most residents stop at a certain point and would not have really completed that portion. And it was like that was the compliment given to me.

Dr. Shanda Blackmon [7:46 - 7:46]: And.

Dr. Randy Lehman [7:46 - 8:06]: And in the back of my head, I knew that exactly what I had done was I had taken it probably to the point that most residents did. Then I turned to Jesse and I said, Jesse, what do you think? She goes, I think you can go a little bit further. So, I kept dissecting only because of Jesse, right? But I’m not going to tell you that, you know, ten years later. But not then.

Dr. Shanda Blackmon [8:06 - 8:46]: Yeah, well, I think it's really important. One of the reasons why that's important is now when you're doing a lung cancer surgery, picking out that one positive lymph node makes a huge change in somebody's survival. If you pick up that one positive lymph node, then they're going to get some adjuvant therapy nowadays. Maybe in the old days, if we took out a lung cancer and you had a positive single node, you may or may not get any treatment after surgery.

But now you're getting immunotherapy after surgery because we know it confers a survival advantage. And that's the thing that's different between today and how it was about 10 years ago.

Dr. Randy Lehman [8:47 - 9:07]: Yeah. And maybe that story helps because what we're going to specifically be talking about, November being Lung Cancer Awareness Month, we're going to talk extensively about some lung cancer stuff. But before we do, why don't we change up our usual question and ask: why is thoracic surgery special to you?

Dr. Shanda Blackmon [9:09 - 10:42]: Thoracic surgery is special to me because my grandfather died of lung cancer and I diagnosed him. I remember when he had bleeding and what he was coughing up, and my grandmother called. We brought him to the hospital where I was a resident, and we did a bronchoscopy. Now, because he's my family, I'm not allowed to do his bronchoscopy, and I'm not allowed to actually work him up. But I certainly was in the room when all the testing was being done and played a role in some of the decision-making.

When he had his bronchoscopy, I remember seeing the tumor inside his airway, and I remember watching the biopsy, and I remember how it felt on both sides—the doctor side as well as the patient and family side—of making that diagnosis of small cell lung cancer. I think this is important for rural surgeons because diagnosing early lung cancer is such a big game-changing event. Picking up on the signs and symptoms of lung cancer and knowing who needs to get screened for lung cancer is just about the best way to make the biggest difference in someone's life. And we know all the eligible patients are not screened for lung cancer. We do a terrible job in the United States screening people for lung cancer. November is Lung Cancer Screening Awareness Month, and we're really making a big push and an effort to get people screened heavily.

Dr. Randy Lehman [10:43 - 10:44]: Great.

Dr. Shanda Blackmon [10:44 - 12:07]: I decided to go into lung cancer surgery because of that event. It really shaped who I am. He was diagnosed with terminal lung cancer. He had small cell lung cancer, and it was really advanced. And, you know, as surgeons, we always want to go in and cut it out and operate. But he decided not to have surgery, and he knew he wasn't a candidate anyway. He also decided not to have chemotherapy. He knew it was only going to buy him extra time; it wasn't going to cure him. He wanted to die on his own terms at home in a very small rural town called Jasper, Georgia, surrounded by friends and family where they could visit, looking out the window from his home, watching the squirrels and the animals. He didn't want to be in a big city. He didn't want to be traveling back and forth at the end of his life. So we were all at home. I tell my patients that was one of the best deaths I've ever seen in my entire life. It was on his own terms, the way he wanted. Palliative care is a big part of what rural medicine doctors end up having to provide in restricted communities where they don't have the same resources as big cities. I think that is one of the most underutilized services. Our family is grateful to this day for the care that he got with at-home hospice.

Dr. Randy Lehman [12:08 - 15:07]: Yeah, it's interesting how the situation you find yourself in as a surgeon at, you know, Mayo Clinic, encountering helping counsel patients through the end of life is different than the ability that I'm able to counsel people on end-of-life decisions now. Mostly it's done in the clinic, very rarely in the hospital setting, and it's with some new diagnosis. They're seeing oncology, and oncology always recommends chemo. They never recommend pulling the plug. Like, very rarely or not pulling the plug, but I mean, just palliative. It's less about quality of life. You have a hammer, here's the problem—it’s a nail. It's like a very challenging but rewarding process, though not financially rewarding because you're not getting paid for doing this. You could, but it is one of my favorite parts of the job—helping a patient to really understand. A lot of these patients that I have, they're very practical people with a large amount of common sense, which I think is actually becoming more and more rare in the United States. But like, the people that live around me, they got it, you know, and so I can explain, like, this is what this looks like. I have a phrase to say, you know, if it ever feels like we as medical professionals are doing things to you rather than for you, that might be a sign where you might want to stop. The decision you make now doesn’t have to be long-term. I mean, everybody has their own little ways of saying this, but I guess I'm just echoing what you say.

When I was a resident, it was normally a call from the MICU because the patient's been kept alive artificially for months, and now their whole bowel is dead. You're not even talking to the patient. You're talking to the family. I remember another Mayo Clinic end-of-life discussion that I had when I was in the ICU, and the patient had metastatic cancer. I can't even remember the type. Maybe it might have been ovarian or something like that, but everywhere was in a rush, jumped on a plane, flew to Rochester, and, you know, stands up from her flight and saddle PE, looking for a Mayo miracle, so to speak, which doesn't exist. Now they're in my surgical ICU, and they're going to basically pass away from all of their friends, like, quite the opposite of the scenario you just described. It's going to happen precipitously in the next few days. You have to have those hard discussions. Those are not nearly as fun or rewarding as, like, guiding someone ahead of time by being close to home and being there for them through, you know, that next stage. So, yeah, I don't know anything else to add to that or?

Dr. Shanda Blackmon [15:08 - 17:02]: Yeah, I mean, I think the most important thing that we as providers need to understand is when you get a palliative care team involved sometimes, and this is published in the literature, the majority of the time, the patients will live longer, more frequently when you get palliative care involved. So, a lot of times people think that they're like the death squad, but they're not. They really spend time talking to you about what do you want, what are your goals of therapy, what's important to you? Some people want to live to see a grandchild born. Some people don't want to be in pain. Some people are terrified of being alone. Everyone has different things that prioritize their care. Having those conversations when people feel well enough to have them takes the burden of making those decisions off the family later in life, and that's really important.

In support groups, you see people at different stages of disease, and you get a chance to get inside that time machine and see what it's like from the other side when you get involved in support groups, and the caregivers get to help each other. My biggest advice to rural surgeons and patients in that community is when you get a big diagnosis like lung cancer or esophageal cancer, really spend time having these tough conversations about what's most important to you and really share a lot with your family. Pick a decision-maker, share that with everyone, find out how to tell people what you care about, what you want, what you don't want. Hopefully, we don't get there—we do early screening and pick it up when it's curable, and we're not going down this pathway. But I think if you do end up with a pretty advanced diagnosis, those are things you really want to think about.

Dr. Randy Lehman [17:03 - 18:06]: Yeah, very good. Well, let's move on to how I do it.

Dr. Randy Lehman [17:31 - 18:06]: And so we'll be talking, like I said, about lung cancer. Maybe the best way to start is to identify the at-risk screening populations and what screening is currently recommended. From there, I'd like to, you know, I don't do lung cancer, and I would say most rural surgeons are not doing lobectomies or lung cancer operations. I've done a couple of VATS for benign conditions. I've done a couple like de-cortications and biopsies. Of course, I do thoracentesis, but that's kind of the extent of what I do. Maybe other people are doing more, but I think what I'm doing is pretty common for my audience. So how should I then be involved? What I'm thinking of is maybe having a talk with the medical staff, you know, and maybe partnering even with oncology or a primary care physician to bring a talk about awareness of screening. And maybe you have other ideas as well as to what we can do.

Dr. Shanda Blackmon [18:06 - 18:36]: Yeah. I'm not sure if rural surgeons are involved in doing bronchoscopies, but I imagine that you would be. A lot of new technology that's coming out, navigational bronchoscopy, is very easy to learn. It's like playing a video game, driving a small camera out to the tumor and doing a biopsy, sometimes doing a needle biopsy of the lymph nodes to stage the cancer.

Dr. Shanda Blackmon [18:36 - 19:07]: I would say every rural doctor, whether you're a primary care or advanced surgeon working in a rural community, needs to understand the screening criteria for lung cancer. We've come a long way. Some of the criteria have changed over the years, but today we do have approval for lung cancer screening. It is paid for by private health insurance through USPSTF, which is the organization that guides that decision-making and enforcement. It is paid for by Medicare and Medicaid and has gone through a national coverage indication through CMS, Centers for Medicare & Medicaid Services.

Dr. Shanda Blackmon [19:07 - 19:39]: The criteria right now are if you're between 50 and 80 years old. A lot of people are arguing and looking at expanding those criteria because 80 now was what 70 was 10 years ago. If you're fit and 80 and you would be able to tolerate surgery, why couldn't you have the screening at 81? A lot of practitioners are sort of expanding those criteria. But today, what's covered is if you're 50 to 80 years old and have a 20 pack-year smoking history.

Dr. Shanda Blackmon [19:39 - 20:10]: Now that's moving a little bit as well. If you have a 20 pack year smoking history, that means you smoked a pack per day for 20 years. But what if you smoked, you know, a half a pack for 30 years? I think we get caught up on the nitty-gritty. So a lot of thoracic surgeons are advocating to say, did you smoke cigarettes for 20 years? And not get caught up on how much you smoked. If you smoked for 20 years, that's enough. So we're working on whether those criteria are going to be somewhat flexible.

Dr. Shanda Blackmon [20:10 - 20:41]: Right now, what's covered is if you smoked a 20 pack-year smoking history, and the last criteria is really, did you smoke within the past 15 years? Now that's also being questioned and challenged because if you quit smoking 15 years ago, can you still get lung cancer? Yes. To qualify for lung cancer screening, no provider wants you to go outside and have a cigarette so that you qualify.

Dr. Shanda Blackmon [20:41 - 21:12]: We're really pushing, trying to enhance the screening criteria but not put more people at risk with radiation exposure. So if you're 50 to 80, 20 pack-year smoking history, smoked within the past 15 years, you clearly qualify. Some organizations are dropping that smoked within the past 15 years and recommending that you go ahead and screen. The American Cancer Society follows those guidelines as well, and they emphasize shared decision-making. The test that gets done to screen for it is a low-dose CT scan.

Dr. Randy Lehman [21:51 - 22:10]: Yep. So let me summarize. Understanding there's possible exceptions and you could expand, but smoking from ages 50—no. If you are ages 50 to 80, you had a 20 pack-year smoking history, and you smoked within the past 15 years, then you should get a low-dose CT scan.

Dr. Shanda Blackmon [22:10 - 23:08]: Correct. Everyone that meets that criteria should get a low-dose CT. How often? Once you get that, you follow what's called the Fleischner criteria or Lung-RADS, and it gets read out by a radiologist. If it's a tiny little 3-millimeter nodule, we usually aren't that concerned. But if it's bigger than 6 millimeters, there's frequently some follow-up that needs to happen. The follow-up depends on the degree of suspicion for it being invasive lung cancer. Sometimes it gets followed, and sometimes it gets a biopsy and you get staging. Working up a lung cancer can be scary for a patient but not as scary as being diagnosed with late lung cancer. If you don't get screened, you're more likely to get picked up with the lung cancer diagnosis late when you present with clinical signs and symptoms, and that's when it's not as easily curable.

Dr. Randy Lehman [23:10 - 23:24]: Got it. So the rate of developing lung cancer is about 1 per 2000 per population per year. Does that sound about right? Risk of 5% lifetime.

Dr. Shanda Blackmon [23:24 - 24:16]: Yeah. If you meet the criteria for lung cancer screening, then the rate goes up that first year to over 2%. So if you screen 100 patients, at least two patients are going to test positive for lung cancer. But the true benefit of lung cancer screening is, and the true cures come from those next four years of screening. You get screened every year, not just one year. That second year, if you get picked up with the diagnosis of early-stage lung cancer or a lung nodule, that's when you really benefit from the screening. That first time you're going to pick up people early stage, late stage, because nobody's really had any screening. But it's important, just like mammograms, that you go back year after year and get the repeat scanning to get the early lung cancer diagnosed.

Dr. Randy Lehman [24:18 - 24:27]: So even if the lung cancer screening CT is perfectly normal, the next time they should do that is in a year. Is that correct?

Dr. Shanda Blackmon [24:27 - 24:27]: Correct.

Dr. Randy Lehman [24:28 - 24:34]: And then when does that stop? Once you're 80 or once you have 10 years life expectancy or?

Dr. Shanda Blackmon [24:34 - 24:54]: I think it depends on when you stop smoking. If you stop smoking, then it can stop sooner than if you continue to smoke. I think you should be screened during that duration when you meet those criteria continuously. But if you stop smoking, then you keep getting screened until you're out of that window.

Dr. Randy Lehman [24:54 - 25:07]: Yep. Got it. To give a little color to my practice. So I came out intending to be able to do broncs, but I have never had to do a bronc in five years.

Dr. Shanda Blackmon [25:07 - 25:08]: Wow.

Dr. Randy Lehman [25:08 - 27:06]: Yeah. And part of that is because of the resources of my hospitals that I'm working in. It's a little different if you're a rural surgeon in Indiana. I'm choosing to work in critical access hospitals that don't have an ICU, right? So that's the big driver, because they don't have ICU patients and don't need to do broncs from an ICU perspective. And then for those, if you've got a one in 2000 per year, you know, risk of getting lung cancer. So in my community, in my county, maybe there's 30,000 people. So, you know, the number of people that are going to be diagnosed is quite small. In my situation, Lafayette, which has pulmonology, ICU, all those things, is 45 minutes down the interstate. That's different than being in, like, maybe Butte, Montana. Okay.

Speaker A: Or, like, you know, somewhere where it's like you're going to have an ICU, you know, you're not going to have. Like, in several of the places I'm at, there's very limited subspecialists. It's like primary care and a general surgeon. So I'll do things outside of the general surgery's usual scope of practice.

But then I don't do it if somebody comes in, and they're very sick. I mean, it would completely overwhelm our whole hospital. And so those patients, you know, it's not like they're that far away, so they should go kind of down there. So that's how things break down. The labor breaks down, basically, in my practice, and it turns out to be a lot of outpatient, you know, stuff, and high volume, low acuity, which honestly is fine for me.

I can kind of consider myself the surgical gatekeeper. I know who the people are in the state who do the other certain things, and I get people where they need to go. But just because you were saying it, I think it depends. A lot of general surgeons in rural America are probably doing bronchoscopy. I particularly haven't for so long that, at this point, I would probably send them for that.

Dr. Shanda Blackmon [27:07 - 27:52]: Yeah, yeah. Well, I think, you know, when you're screening people for your surgery, whether you're doing a vasectomy in a rural community or if you're doing a biopsy of a lymph node, I think as a surgeon, it's important to get history for your patient. You always want to coach your patients to stop smoking before you operate on them because we know it affects wound healing.

So if you're talking with your patients and you discover that they are active smokers or they smoked in the past 15 years, that's your moment to intervene and change their lives. So then they get a double bonus, right? You give them their vasectomy, and you diagnose them with early-stage lung cancer at the same time.

Dr. Randy Lehman [27:53 - 28:11]: There you go. Very good. So just thinking about those things, and colon cancer screening is the same way. And actually, while we're on it, something that most rural surgeons, I would say, are doing is a fair amount of endoscopy, like GI endoscopy. What about screening with an EGD? When do I need to consider that?

Dr. Shanda Blackmon [28:12 - 29:39]: So that's a great topic. I think if you have patients that have experienced reflux for more than five years, every single patient that's eligible, that is a good, reasonable candidate who has had reflux for five years, needs an upper endoscopy, and that is to rule out esophageal cancer.

There are some other new technologies coming down the pipeline. We talked about a sponge that you swallow; the capsule dissolves, the sponge expands, and you pull the string and pull it back out. Some of those are close to being ready for prime time but not FDA-approved yet.

But I would say when you have these new technologies, anything that can pick up early cancer is always going to be better, especially if the risk of the test is low. Because, you know, esophageal cancer and lung cancer are two of the highest fatality rates with a diagnosis. Lung cancer is the number one cancer killer in the nation, more than colon, breast, and prostate combined.

The death rate in esophageal cancer—usually not as many people get it, but the number of people dying every year is the same number of people that are getting diagnosed every year—which means there's a very high mortality rate associated with the diagnosis. So early detection is definitely the theme of the day.

Dr. Randy Lehman [29:40 - 29:47]: If you have that patient, five years of reflux, you do an EGD and it's normal. Do you recommend them to have an EGD at any point again in the future?

Dr. Shanda Blackmon [29:48 - 31:14]: I think if they continue to have reflux and another five years go by, definitely you should do it again. I think if you see anything, if they get, say, Barrett's, then you need to start following the Barrett's protocol. If you see low-grade dysplasia, you need to have a shared decision-making conversation with them about whether or not to ablate that lining to try to change it back to a normal lining.

If you see high-grade dysplasia, they absolutely have to get radiofrequency ablation with Halo or some type of technology to ablate that inner lining of the esophagus and try to change it to a normal lining. Absolutely. The conversation that you need to have with your patients is getting them on PPI therapy, testing them for H. Pylori, treating them appropriately if they test positive, and then preventing all that acid reflux.

Sometimes they might need lifestyle modifications; they might be overweight, need to lose weight, and that might help with the reflux. Or they might have their whole stomach up in their chest and they're symptomatic, so they might need anti-reflux surgery. All of these factors start to play a role when you start looking at people who have terrible reflux.

Dr. Randy Lehman [31:15 - 31:38]: Yeah, I'm getting sidetracked, but this is something that's a little bit more of my everyday. Right. So naturally. Just a quick web search says 20% of the population has GERD. So this means that potentially up to 20% of the population should be having an EGD every 5 years just for that reason alone. But then you're going to find a lot of other things. I feel like EGD is underutilized.

Dr. Shanda Blackmon [31:38 - 33:17]: I think you're right. The rural surgeon can play a key role in moving the dialogue and the health of your patient when you're doing these upper endoscopies. A lot of people choose to have it done at the same time that they're having their colonoscopy—we call it two-for-one. But definitely, people need to meet the criteria. Just because you have reflux, it's not necessarily an indication. It's—have you had reflux for five years?

One of the scariest things that I hear—I'm on the other end of the spectrum. I'm seeing people with esophageal cancer that requires surgery and esophagectomy and reconstruction. One of the things that I hear is, "Oh, well, I had reflux and then it went away." We know that when you have really bad reflux, that inner lining of your esophagus can change from what we call squamous to columnar.

When you get that metaplasia, that metaplastic change on the inside, and you go from a squamous to columnar lining, it doesn't burn as much, and you might not feel it as much, and you might not have as many symptoms as you had originally when it was burning. So if that burning goes away and you haven't done anything, you're not on a proton pump inhibitor, you're not on antacid therapy, and the burning suddenly goes away and you didn't get your hernia fixed, you may want to ask your primary care provider, "Well, I had terrible reflux, and it just went away. What do you think that is?" Maybe the answer is because the lining is changing.

Dr. Randy Lehman [33:20 - 33:40]: That one's not something I think about every day. Very good point. I've got a sort of, I don't know if this is a controversial question, or I think it's a question that has had different answers from different people over time, and I'd like to get your take on it before we hop back to lung cancer. Does anti-reflux surgery protect against esophageal cancer?

Dr. Shanda Blackmon [33:40 - 34:59]: Oh, that's a great question, and it comes up all the time. There isn't a really good large randomized trial that I'm aware of that says doing anti-reflux surgery is going to move the dial and change things. It's not standard of care for everyone with reflux. It is risky. There are bad things that happen when you have anti-reflux surgery. Typically, I only recommend anti-reflux surgery for people who have started on PPI therapy and they continue to have bad reflux symptoms or epigastric pain, or they're at risk for volvulus.

So if they fail medical therapy and they still have symptoms and they're a surgical candidate, then I think they're a good candidate for anti-reflux surgery. But again, that's more shared decision-making, more complicated discussions. I think all of us that do anti-reflux surgery remember the one case that didn't go the way we wanted, and someone had a bad outcome. You always need to remember those cases in the back of your head and remember it's not a risk-free surgery, so the risk-reward benefit has to be worth it.

Dr. Randy Lehman [34:59 - 35:17]: So we talked a great deal about the screening. Honestly, the workup, I feel once the screening happens and you find things, it's pretty familiar. Bronchoscopic versus CT-guided biopsy, staging. Could you discuss staging a little bit for me?

Dr. Shanda Blackmon [35:17 - 35:48]: Yeah. So what we do when we do staging of really any thoracic cancer is we go wide and focus narrow. That means we look for metastatic disease first, rule that out, and then do procedural staging. You don't ever want to do a navigational bronchoscopy, an endobronchial ultrasound with transbronchial needle aspiration in a patient who has brain metastasis or disease in their liver.

Dr. Shanda Blackmon [35:48 - 36:18]: The first thing we start with is a CT. We look to see if there are big lymph nodes, if there's disease outside the chest, or if there's disease in the abdomen and the liver. Then we go with a PET scan. The PET scan can give us an idea of how FDG, avid or hot the tumor is. FDG is a sugar form. Anytime you have a high metabolic turnover of cells, the sugar concentrates and lights up bright on that area of the scan.

Dr. Shanda Blackmon [36:18 - 36:49]: We look to see if something typically has to be bigger than 0.8 or a centimeter to be bright on a PET scan. If you have a tumor that is about a centimeter and you get a PET scan and see tumor lighting up outside of the chest or in the lymph nodes, that is something you have to investigate, and we usually want to get a biopsy.

Dr. Shanda Blackmon [36:49 - 37:20]: If there's metastatic disease, you then go through the metastatic workup. Depending on how somebody presents, you may or may not want to get brain imaging to rule out metastatic disease to the brain. We follow the NCCN guidelines for working up a patient. Once you're able to get metastatic disease ruled out, you start working on the staging inside the chest. If there's just a tumor on one side and it's a big tumor, or you're worried about its centrality, you might do the endobronchial ultrasound.

Dr. Shanda Blackmon [37:20 - 37:50]: Needle aspiration of the lymph nodes. You want to check all the N2 lymph nodes, station 2R, 2L, 4R, 4L, and 7. These are the nodes that you want to know if there's cancer or not. Today, it's changing some. If we know that there's disease in the lymph node, we might treat with chemoradiation or chemoimmunotherapy. Chemoimmunotherapy now is the standard of care for patients who have some type of advanced disease before surgery, especially if it's in the lymph nodes.

Dr. Shanda Blackmon [37:50 - 38:21]: New clinical trials are coming out almost daily. By the time you look at one guideline, it's extinct and a new guideline is coming out. In general, we need to completely stage our disease, have a multidisciplinary tumor board meeting, and do shared decision-making. We go through the up-to-date NCCN guidelines and offer patients upfront therapy to try to reduce their burden of disease before we offer surgery if it's locally advanced.

Dr. Randy Lehman [38:38 - 38:47]: Thank you. I have a few quick-hit follow-up questions. What are the most common places for lung cancer to metastasize? Number one would be thoracic lymph nodes.

Dr. Shanda Blackmon [38:48 - 38:48]: Yes.

Dr. Randy Lehman [38:49 - 38:49]: And then what?

Dr. Shanda Blackmon [38:50 - 39:02]: Then it might go to the other side. It can go to the liver, it can go to the bone, and it can go to the brain. Those are the main places where you're going to see lung cancer metastasize.

Dr. Randy Lehman [39:02 - 39:04]: Very unlikely to go to the extremities, right?

Dr. Shanda Blackmon [39:04 - 39:05]: Very unlikely.

Dr. Randy Lehman [39:05 - 39:19]: The reason I'm asking this is, in the point of staging, you obviously don't do a PET scan of the brain. So, you do a brain MRI if you think that they might have mets to the brain, and you only do that if they're having neurologic symptoms.

Dr. Shanda Blackmon [39:20 - 39:27]: But you have to do a very thorough neuro exam, and if you don't, they should have brain imaging.

Dr. Randy Lehman [39:28 - 39:33]: So, okay, fair enough. And then the other thing is, this is...

Dr. Shanda Blackmon [39:33 - 39:40]: And I would say there are some institutions that do PET MRI instead of PET CT.

Dr. Randy Lehman [39:40 - 39:41]: Okay.

Dr. Shanda Blackmon [39:41 - 39:51]: In cases where a PET MRI is performed, the brain imaging can rule out metastatic disease without having separate brain scans.

Dr. Randy Lehman [39:52 - 40:12]: Sure, that makes sense. This is something you don't think about as a resident. That's why I'm asking this question. There are, to my knowledge, essentially two types of PET scans you may want to do for mets throughout the body. One would be a skull base to mid-thigh, and one would be a whole body.

Dr. Shanda Blackmon [40:13 - 40:13]: Yeah.

Dr. Randy Lehman [40:13 - 40:15]: Is there anything else besides that I'm missing?

Dr. Shanda Blackmon [40:16 - 40:24]: There are multiple different types of PET scans. You have a Dotatate PET scan and you have an FDG PET scan.

Dr. Randy Lehman [40:24 - 40:36]: Yeah, I guess I'm talking about FDG PET CT scan for cancer staging, whether it's lung or otherwise. I think mostly what you would get is a skull base to mid-thigh, right?

Dr. Shanda Blackmon [40:36 - 40:45]: Correct. Because the whole brain lights up on a PET scan, a skull base to mid-thigh is adequate for lung cancer screening. Correct.

Dr. Randy Lehman [40:45 - 40:53]: And you don't need the extremities. So you're not doing the "whole body." I once ordered a whole body one, and then radiology called me to confirm. Do you really want a whole body? That's why I'm trying to share my...

Dr. Shanda Blackmon [40:54 - 40:58]: An extremity PET would be indicated for something like...

Dr. Randy Lehman [40:58 - 41:07]: Yes, obviously advanced skin cancer, like melanoma, stuff like that. All that. Okay, very good. Thanks for letting me go down that.

Dr. Shanda Blackmon [41:07 - 42:08]: I just want to add one more thing for lung cancer. Whole genome exome sequencing, genetic testing is so important, because we now have data that if you have certain driver mutations, fusions, alterations, deletions, those need to be identified early because early delivery of therapy can save lives. What that means is if you have an EGFR-mutated lung cancer, you're going to treat that very differently than if you have a wild-type lung cancer. If you have an EML4-ALK fusion, that will be treated very differently than a wild-type lung cancer. Identifying these driver mutations is very important and a key part of the early evaluation of lung cancer.

Dr. Randy Lehman [42:09 - 42:15]: Interesting. And not something I would have necessarily thought of, especially with the smoking influence.

Dr. Shanda Blackmon [42:16 - 43:26]: You have a lot of different types of lung cancer. You have a carcinoid tumor, well-differentiated, poorly differentiated, typical, atypical. If you have an atypical carcinoid tumor, then getting an FDG PET is good.

If you have typical carcinoid and you think it's metastatic, a dotatate PET is indicated, and there is some therapy called lutetium that can be used to target that metastatic typical carcinoid tumor. Carcinoid typically doesn't really respond to other types of treatment like radiation. And then if you have lung cancer, you might have squamous cell lung cancer or adenocarcinoma, or small cell lung cancer, or large cell lung cancer, and all of those behave differently and are treated vastly differently. Most of the genetic mutations, fusions, alterations, deletions that we were talking about, that are actionable driver mutations, exist with adenocarcinoma.

Dr. Randy Lehman [43:28 - 43:34]: Is smoking the most common reason for all those types of lung cancer that you just mentioned?

Dr. Shanda Blackmon [43:35 - 44:13]: It is the majority. There are different parts of the world that have different rates. Asia has a higher proportion of genetically derived lung cancer or environmental exposure compared to the United States. But certainly radon, environment, different radiation exposures, you know, people who had mantle cell or mantle radiation for Hodgkin's lymphoma when they were young, or women who are survivors of breast cancer who had radiation, those are patient populations that now are at high risk for lung cancer. It's not just smoking.

Dr. Randy Lehman [44:13 - 44:19]: If there's a, if you take all the patients. Is the most common type of tumor a metastatic tumor?

Dr. Shanda Blackmon [44:21 - 44:48]: That's a great question. I think the number one tumor in the lung is a metastatic tumor, and that's called a secondary lung cancer. And then you have primary lung cancer. So colorectal cancer very frequently goes to the lung. Sarcoma goes to the lung. There are definitely specific types of cancers that go into the lung; the lung is the filter of the body.

Dr. Randy Lehman [44:49 - 45:06]: Yep, sure. And maybe if you're willing to take us back to med school for just a second. And the types of lung cancer, like carcinoid, small cell, and then the various types of non-small cell. What cell did they start from?

Dr. Shanda Blackmon [45:08 - 46:14]: Wow. Okay. So you have type 1 pneumocytes and type 2 pneumocytes, and you have different ways that it develops, like a mutation. If you have, like, P53, ROS1 mutation, you can have different types of lung cancer than if you have an EGFR mutation. But basically, you've got epithelial cells that sort of line the respiratory tract, and then you have those that are like bronchial or bronchiolar or alveolar epithelium. About 85% of non-small cell lung cancer comes from that lining. And I think a minority, like 10 to 15%, of small cell lung cancer comes from those types of cells. So adenocarcinoma. And you're really stretching my knowledge here.

Dr. Randy Lehman [46:14 - 46:15]: Yeah. And I'm sorry, put you on the spotlight.

Dr. Shanda Blackmon [46:15 - 46:17]: This is from the type 2 pneumocytes.

Dr. Randy Lehman [46:17 - 46:18]: Okay.

Dr. Shanda Blackmon [46:18 - 47:35]: But squamous cell really kind of comes from, like, those basal cells coming from the bronchial epithelium. Large cell carcinoma is very different from adenocarcinoma or squamous cell carcinoma, and that's really, I think, derived from undifferentiated epithelial cells. Those can either come from adenocarcinoma or a squamous lineage. Small cell lung cancer, I think the only reason why I know this is because I looked it up when my grandfather got diagnosed. Those really come from neuroendocrine cells, or what we call Kulchitsky cells. And those are like immune precursor uptake and decarboxylation system. So those APUD or Kulchitsky cells are the origins of how we develop small cell lung cancer, and those are really more often central near the main bronchi. And that's why when you get diagnosed with, we used to call it oat cell carcinoma, when you get diagnosed with small cell lung cancer, and it's more frequently spread, so we have a different staging system than adenocarcinoma or squamous cell.

Dr. Randy Lehman [47:36 - 47:37]: Okay.

Dr. Shanda Blackmon [47:37 - 47:38]: It's about the extent of my knowledge.

Dr. Randy Lehman [47:38 - 47:48]: On the lung cancer and then carcinoid tumor in the lung, much like carcinoid tumor of the appendix or other places, comes from a neuroendocrine.

Dr. Shanda Blackmon [47:48 - 48:12]: Yes. And it's sort of on a spectrum. You know, you have small cell lung cancer; it's also a neuroendocrine tumor. Carcinoid is a neuroendocrine tumor. You can have a single focus of neuroendocrine tumors in the lung, just a single carcinoid tumor, or you can have a disease entity called DIPNECH, which is diffuse multifocal carcinoid tumors in the lung.

Dr. Randy Lehman [48:13 - 48:17]: Very good. Okay, let's leave that behind us.

Dr. Shanda Blackmon [48:17 - 48:19]: Here goes the basic science.

Dr. Randy Lehman [48:20 - 48:58]: Sometimes it helps me to think, like, in some of the stuff I didn't even realize until, like, after the fact. I'm like thinking about it and, you know, like, for example, Barrett's, like, it helps to know the underlying cell type. And then I treat a lot of skin cancer, and so to be able to explain to people from a basic science perspective the difference. Obviously basal cell, squamous cell, melanoma, totally different, you know, cell origins. It kind of helps you think about it. Anyway, let's talk about treatment, and then if there's anything, I have one last one other question which has to do with my upcoming board recertification. So first, let's talk about treatment.

Dr. Shanda Blackmon [48:59 - 51:45]: Okay. Well, the treatment for lung cancer is so complicated nowadays. I would say in general, you want to go to the NCCN guidelines. Right now, treatment depends on whether you have non-small cell or small cell. Small cell is almost exclusively treated with chemotherapy or chemo-immunotherapy. The only type of small cell that's treated with surgery is early stage tiny peripheral small cell. Honestly, that you thought was non-small cell, and you accidentally took it out and you later on found out that it was small cell. Sometimes you might know, but it's just got to be tiny and peripheral and not in the lymph nodes. Now the way that we decide how to treat lung cancer depends on, like I said, that mutation analysis. You want to get early genetic testing. We look for something called PD-L1 status. That really helps us to know if people will respond to immune checkpoint inhibitors, which is really what I would say is moving the dial the most with lung cancer. So it depends on histology, it depends on the stage, it depends on your molecular genetics, and then it depends on your performance status. If you're always in bed, you might not be fit to have surgery or intervention. And then it depends on if the tumor is resectable or not. So early stage lung cancer is most frequently treated with minimally invasive surgery after staging. If it's stage one A, we go straight to surgery, usually for non-small cell lung cancer not metastasized to the lymph nodes. Stage 1B to stage 2, that's where it might have gone to the lymph nodes, or it's a very large tumor. That's where we consider treating with some type of treatment either before or after surgery. And we always want to try targeted immunotherapy. So if it's an EGFR mutant, we offer them Osimertinib. And the Osimertinib was really defined in what was called the ADURA trial. So if you test positive for an EGFR mutation, you want to get that patient on Osimertinib as quickly as possible. And then we look at PD-L1 status, and the IMpower trial taught us a lot about that. And typically those patients get atezolizumab. And those patients are more frequently going to be treated based on their stage and their genetics. Slightly different than those people that don't have those mutations, the group that we call wild type.

Dr. Randy Lehman [51:45 - 51:48]: Those people also getting real chemo in.

Dr. Shanda Blackmon [51:48 - 53:41]: In addition to those targeted therapies, the advanced stage, you know, if you're stage 3A to stage 3B, those people typically have tumors that have gone to the mediastinal lymph nodes. And if it's resectable, surgery might still play a role. However, the Checkmate 816 trial came out, and that really taught us that moving the dial with neoadjuvant nivolumab plus platinum-based chemotherapy is the best way to get improvement.

The Pacific trial really taught us that if they're unresectable, they get concurrent chemo-radiation and then consolidation durvalumab for a year. If they are resectable, they might get nivolumab plus platinum-based chemotherapy. That's the Checkmate 816 trial therapy regimen. And then, they get evaluated to see if they've had a pathologic complete response and if they benefit from surgery.

The last group is metastatic, and the metastatic tumors are still changing too. The MD Anderson group published a really interesting paper a while back looking at people who present with what we call oligometastatic disease. Those are patients who have one metastasis to the brain, one to a mediastinal lymph node, one to another part of the lung on the same side. Those patients do live longer if you treat them with curative intent for all sites of disease.

Now that's oligometastatic: only one site, they might have more disease outside of those sites. In that case, it's considered truly metastatic, not oligometastatic. We might treat them with what we call definitive treatment, which means we're never planning on surgery.

Dr. Randy Lehman [53:41 - 53:42]: What about oligomets to the brain?

Dr. Shanda Blackmon [53:43 - 53:51]: If you have a single oligometastasis to the brain, for the past 10 to 15 years, we've always treated those patients with curative intent.

Dr. Randy Lehman [53:52 - 53:57]: And is the brain treatment surgical or radiation?

Dr. Shanda Blackmon [53:57 - 54:10]: It depends on the location, the patient's performance status, the other comorbidities, and what's going on in the rest of the body. But more frequently, it's treated with stereotactic brain radiation.

Dr. Randy Lehman [54:10 - 54:29]: Yeah, okay. And the most common, so let's jump back just real quick. So for patients that are early non-metastatic, small stage 1A lung cancer, going straight to surgery, do they get follow-up chemo or anything else?

Dr. Shanda Blackmon [54:29 - 55:12]: It depends. If they have incidental lymph nodes that are positive, then they get treatment after surgery. If they have incidental tumors that are discovered in the lung, that advances their stage. So it depends on what they come out with, pathologic stage. If they are a resected clinical stage 1A lung cancer and they come out with a pathologic stage 1A lung cancer, they are just treated with surgery and don't need any more treatment. But if they end up with more disease than we thought they had, then they'll get adjuvant treatment. That depends on what we find and what the genetics are of what we find.

Dr. Randy Lehman [55:12 - 55:19]: Yep. And then one B, which would be a big tumor, and two, which would be mets to the lymph nodes, generally.

Dr. Shanda Blackmon [55:19 - 55:26]: Have metastatic disease in the lymph nodes. You're almost always going to be offered some type of treatment after.

Dr. Randy Lehman [55:26 - 55:30]: Yeah, well, it's neoadjuvant, right? For the most part.

Dr. Shanda Blackmon [55:30 - 55:39]: Clinically, yes. You get neoadjuvant therapy; you want to get that before you get surgery. If anybody gets radiation before surgery, then you get adjuvant.

Dr. Randy Lehman [55:39 - 55:42]: Does anybody get radiation before surgery?

Dr. Shanda Blackmon [55:43 - 56:29]: So in the past, we used to give neoadjuvant chemoradiation for stage 3A lung cancer with intent to go to surgery. Today, that's changing. Right. So now it depends on what your genetics are; that would change it. It depends on if you are resectable. Typically, if we know that you have 3A disease, you might get the Checkmate 816 protocol, which is nivolumab with the platinum chemotherapy doublet, or if you're unresectable, then you get the consolidation durvalumab after concurrent chemo-radiation. So you would still get chemo-radiation and then adjuvant durvalumab for a year. And that's the Pacific regimen.

Dr. Randy Lehman [56:29 - 57:17]: So some people do, but it's like nuanced situation, very nuanced nowadays. And it's not those people, not those people that just have a couple mets to the lymph nodes. And then the last question on this is, and what I really love to talk about, is how you actually do the operation, how you hold the instrument, how you position them, how you make transitions. But we're spending a lot of time on this, which is totally fine. And it's actually just stuff that, I mean, you can't know it all. So asking from an entry-level perspective is kind of where I'm at. But if you're at a, if you're getting stage 1B, stage 2, you're getting neoadjuvant chemo and your targeted therapy, if you're a candidate for it, or...

Dr. Shanda Blackmon [57:17 - 57:29]: Are you usually getting just targeted therapy and not chemotherapy if you have an EGFR mutation or if you're EML for ALK? So it just depends.

Dr. Randy Lehman [57:29 - 57:40]: Okay. Okay. Well, what I was asking is what chemo are they usually getting? Is it a single agent like cisplatin or carboplatin, or is there some other chemo as well?

Dr. Shanda Blackmon [57:40 - 57:43]: Typically, cisplatin doublet or carboplatin.

Dr. Randy Lehman [57:44 - 57:49]: Okay, got it. I don't know if we want to...

Dr. Shanda Blackmon [57:50 - 57:51]: Do you want to talk about surgery?

Dr. Randy Lehman [57:53 - 57:53]: How much time do you have?

Dr. Shanda Blackmon [57:54 - 59:21]: I have all the time in the world. I'll tell you one of the things that's really interesting: as a thoracic surgeon who loves to operate and loves surgery, I feel like at our meetings we hardly ever talk about surgery now. And I would say surgery is more important now than ever because, as a thoracic surgeon, all of this immunotherapy totally screws up what's going on in the chest. For a surgeon, everything is sticky. The lymph nodes are harder to get out. The tumor is harder to get out. We have things that we call pseudo-progression, which is where the immune system attacks the tumor. Imagine this big inflammatory response is like a bomb going off inside the chest, and now we're supposed to go in and do this surgery.

So I think what used to be an early lung cancer that would go in and remove and there weren't a lot of adhesions, and the lymph nodes were easy to pluck out; those days are gone. When we are doing more lung cancer screening and we're diagnosing more stage 1A lung cancer, certainly we're going to continue to see those. But more often than not, a larger proportion of our patients are going to be presenting to us after chemo, immunotherapy, or immunotherapy. In that patient population, there's going to be more inflammation, more tumor response, more stickiness of the lymph nodes, more adhesions, and more difficult surgery, maybe even more surgical complications.

Dr. Randy Lehman [59:22 - 59:50]: So here's my other question about my boards. So I have to do the 40-question open book online test. It's open right now. I have to take it. What if you were going to give me, say, five hits that are going to show up on boards for a general surgeon that I need to know, maybe things that have happened in the last five years or something? How do you think it's going to show up on general surgery boards?

Dr. Shanda Blackmon [59:51 - 1:00:35]: General surgery boards. So the most important thing for lung cancer that people taking their general surgery boards need to know is that we are now doing genetic testing, and we are completely staging people, and we have to give neoadjuvant therapy as indicated. So I think that would be one of the most important things that people need to know.

It's no longer, you know, only taking people with stage 3A for neoadjuvant therapy and operating after they've completed therapy. It's anybody with 1B to stage two that now constitutes the new group that's gonna need something different done before they go for any type of surgical resection.

Dr. Randy Lehman [1:00:36 - 1:00:39]: What's the size difference from 1A to 1B? Is it 2 cm?

Dr. Shanda Blackmon [1:00:40 - 1:00:41]: It's 3 cm.

Dr. Randy Lehman [1:00:41 - 1:00:42]: 3 cm.

Dr. Shanda Blackmon [1:00:42 - 1:00:42]: Thank you.

Dr. Randy Lehman [1:00:42 - 1:00:46]: The next segment of the show is the financial corner. Do you have a money tip for our listeners?

Dr. Shanda Blackmon [1:00:47 - 1:02:21]: Yeah. So I think, you know, one of the biggest financial things that has made a big difference for us is the free gift that you can give to your children by establishing a Roth account. It's tax-free, and it's something you can automatically do and put away. Building the ability to save money early on, always putting 10 to 15% away and saving it for retirement is something no one would regret. Sometimes it's hard to put that much away.

But I believe in, when I am investing, taking a small amount and doing high risk and another amount for safe investments. With that high-risk portfolio, you never want to look at it week to week or even year to year. What you really want to be looking at are the average trends over a series of years. If the economy starts to tank and you pull all your investments out and start making rapid movements, I think you put yourself at some risk. Part of good investing is having the confidence to stick with your investment portfolio, making sure you don't put all your eggs in one basket, and, if you have some percentage of your investments in a risky portfolio, avoiding rapid changes. Instead, make slow, methodical, more than year-to-year changes.

Dr. Randy Lehman [1:02:21 - 1:02:23]: Yeah, love it.

Dr. Shanda Blackmon [1:02:24 - 1:03:05]: And nobody has said anything about the staging and size for lung cancer, but we didn't talk about, you know, there's T1A, T1B, T1C. That's kind of the difference between the seventh edition and the eighth edition. Everybody knows T1A is less than a centimeter. T2 is where you're getting bigger than 3 centimeters. But there's now T1A, T1B, and T1C. So, T1A is a centimeter or less, T1B is 1 to 2, and T1C is 2 to 3. So, T2 starts at 3 or bigger.

Dr. Randy Lehman [1:03:05 - 1:03:17]: Okay, let me say that again, so I've got it. T1A less than a centimeter, T1B, 1 to 2, T1C, 2 to 3. And then T2 is greater than 3. Yeah, sound right?

Dr. Shanda Blackmon [1:03:17 - 1:03:22]: Yeah, just to make sure, T3 is if it's bigger than 5 cm.

Dr. Randy Lehman [1:03:22 - 1:04:05]: Nobody has mentioned on the show yet about gifting to your kids for an IRA. So, I have two follow-up questions. Number one, do you have someone who records these gifts for you? Because I basically have a lifetime gift tax exemption, which is $27.98 million for a couple or half of that for an individual in 2025. So you should be recording that, and that comes off your estate later on. Anything above that would be subject to estate tax. And all that can change. It's most likely going to change by the time you die, so it's kind of hard to plan. But I was just wondering, do you have a person or a process to track those gifts?

Dr. Shanda Blackmon [1:04:05 - 1:04:56]: Yeah. So you can't directly gift an IRA account to a child; that's not legal. It has to be owned by the individual whose name is on it. You can't transfer or gift a part of your own IRA to someone, as far as I know. But you can fund your child's own IRA if they're eligible. The IRS, I think, only allows IRA contributions to be given from earned income, but you have to set that up in advance. Unearned income, like gifts, allowances, or investment income, doesn't qualify. So you can gift the money to your kid, but they must have earned the income to make the contribution.

Dr. Randy Lehman [1:04:57 - 1:04:59]: Okay, so then how do your kids work?

Dr. Shanda Blackmon [1:05:01 - 1:05:31]: So if you have a child that's under 18, they can't open their own IRA. But we opened up a custodial IRA, called a minor Roth IRA, on their behalf. You act as the custodian for your child, but the child is the legal owner. You can contribute up to the child's earned income or the annual IRA limit. The 2025 limit was $7,000 per year.

Dr. Randy Lehman [1:05:34 - 1:06:09]: But do your kids then have to show that earned income? For example, with my kids, I sent out a big mailer with my kids' faces all over it. They do videos and stuff for me on our farm website and on the Liberty Clinic website and Facebook. So basically, I pay them for that. I pay them for some sort of marketing. I was just wondering, do you have your kids working in any capacity like that before they actually go and get their first, maybe like, outside the house job?

Dr. Shanda Blackmon [1:06:11 - 1:07:37]: I have not done that. But I can say my son, Sam Blackman, the day he turned 14, got on his skateboard and went to McDonald's and, without telling us, got a job. He was frustrated that he couldn't have what he wanted and wanted to get things we said no to, mostly things for his skateboards. He was highly motivated financially, so he skated down to the McDonald's you're aware of and worked there from age 14 to 15. Now, Jake got a job bagging groceries at the Hy-Vee next to McDonald's. My children really enjoyed working; they worked as lifeguards and at concession stands. They almost always had an odd job. A lot of times, we weren't paying them; they were getting their own money. So, say you have a 14-year-old like Sam, and he's working at McDonald's; he makes $3,000. He can put that money into a custodial Roth IRA in his name; that's his earned income contribution. They won't pay tax, and it can potentially grow tax-free for 50 years. Trying to talk a 14-year-old into putting money into a Roth IRA, that's a different story.

Dr. Randy Lehman [1:07:37 - 1:07:39]: So that's where you make it up with a gift.

Dr. Shanda Blackmon [1:07:39 - 1:07:41]: Yeah, you can make it up with a gift.

Dr. Randy Lehman [1:07:41 - 1:08:02]: Yeah, but it's not the gift money; they're living off the gift money. They're buying their skateboard stuff with the gift money and taking their earned income and putting it in. That answers my question, so thank you. The last question I was gonna ask you, which you kind of answered already, is, I've got a six-year-old and an eight-year-old. My question was, do your kids know about these IRAs that you're setting up for them? Maybe the better question is, at what age is the right time to tell them?

Dr. Shanda Blackmon [1:08:02 - 1:09:05]: I think it depends on the amount and the type of account. I hope my children don't listen to this podcast, but my mother has been putting money into an account that matures when they turn 21. My twin boys are now 21 and have full access to those accounts. Now, we haven't told them they have full access to those accounts. We get money withdrawn from those accounts to help pay for college. There are other types of gifts, like our will. We just redid our last will and testament. In our will, there are certain gifts that won't be freely accessible to children; they don't have full custody of their trusts until they're in their 30s. So there are different types of regulations you can put on gifts to your children.

And I think that's, you know, really important to be discretionary about what you tell your children that you're doing for them, depending on how responsible you think they are.

Dr. Randy Lehman [1:09:06 - 1:09:27]: Right, I agree. It's almost like you don't want to give them the... you don't. It's like you don't want to give them anything until they don't really need it. That's exactly the hard part about raising kids. Like you want to give them everything and, you know, give them a leg up. But it's almost like that rite of passage to become successful on their own. You're crippling them if you take that away from them. I mean, I don't know, that's summary.

Dr. Shanda Blackmon [1:09:27 - 1:10:21]: But no, I told... I mean, I worked as an artist for a year and nobody would buy my paintings. I don't think I was very good. I was living off of macaroni and cheese, and my mom would have to buy a painting from me to pay rent. I was pretty hungry and poor and sad, and it gave me that fire in my belly. And I was like, you know, I think I'm gonna try a different job. Maybe I'm gonna go to medical school. You know, I definitely would not have had the same drive that I have today if I hadn't felt pain. So it's like, how do you give your kids that pain, the burning in their stomach to want more? If your kid always has everything laid out in front of them, they're not going to be hungry. They're not going to know. Not that you should starve your children, but you have to let them suffer a little bit to get that drive.

Dr. Randy Lehman [1:10:22 - 1:10:35]: Great. I love it. Classic rural surgery stories. Did you have another story that you wanted to share with us besides that story about your dad—maybe just something crazy that's happened recently or in your practice that you would not believe ever happened?

Dr. Shanda Blackmon [1:10:36 - 1:12:54]: Well, I will tell you the best thing that happened to me today. It's one of my favorite things in the world that happened. I try to call my patients as soon as their path report comes back. Thirty percent of the time when we take out an esophageal cancer, all the cancer is gone. Now, my big dream is that we're going to come up with something like cell-free DNA or some type of blood test that tells us when all the cancer is gone. So, we don't put them through a big surgery, but when we put someone through esophageal cancer resection, it's removing their entire esophagus, part of their stomach, stapling the stomach in the shape of a tube, pulling it up and connecting it. It's a pretty brutal surgery. Sometimes people find out that they had pretty advanced disease; it's devastating news, and they have to take treatment after.

But this morning, as I was drinking my first cup of coffee, I got online and looked at my test results for my patient. I discovered that he had what we call a complete pathologic response, meaning he went through chemotherapy. The Matterhorn trial has just come out. It shows that for patients who have a certain type of esophageal cancer, if they now get durvalumab added to the chemotherapy, they have a better response. This patient had it. He had flat chemotherapy plus durvalumab therapy, and all of the cancer was dead. We took it out; it grew into his pericardium, the sac around his heart, and we had to take even that out. Now today, he is about as cancer-free as a human can be, but I won't use the word cure. It's been completely resected; all the margins are negative. We did a radical resection. We took out a huge part of the sac around the heart in conjunction with the esophagus. He's not had a leak; he's at home recovering, he's feeling great, and I just can't wait to see what happens to him. It just made my day. It's like the best way to wake up and have your first cup of coffee is seeing all of the things that we do coming together to give that amazing response. The only thing better than that is picking up an early lung cancer and taking it out.

Dr. Randy Lehman [1:12:55 - 1:13:01]: Yep. Yeah. That cure, curing cancer. I mean, that's, I mean, why would you want to be a thoracic surgeon, besides that?

Dr. Shanda Blackmon [1:13:01 - 1:13:02]: Yeah, that's it.

Dr. Randy Lehman [1:13:02 - 1:13:19]: That's beautiful. Last segment of the show, resources for the busy rural surgeon. So, how can people use, first off, your resources, I'd like to hear, and any other resources that you think would be useful for a practicing rural surgeon as they come across these things like colon cancer and esophageal cancer.

Dr. Shanda Blackmon [1:13:20 - 1:14:23]: So, AJCC staging is really important. I'm on the education committee for AJCC, so it's very important that you have access to staging that's up to date. We have the eighth edition. Now, instead of having one moment in time where we switch from eight to nine, we're going to have a rolling enrollment where different tumor sites are going to have updated staging. NCCN guidelines are also really important when you're looking at doing the right thing for the right stage at the right time. Involvement of palliative care and palliative resources for that multi-dimensional approach. I think when it comes to other guidelines, a lot of our societies have guidelines. I think the most important thing is to look at what is being approved by USPSTF, what's being approved by CMS, and at a minimum, following those guidelines.

Dr. Randy Lehman [1:14:24 - 1:14:30]: Okay, AJCC staging, how do you access it?

Dr. Shanda Blackmon [1:14:30 - 1:14:52]: Through the American College of Surgeons. Any rural surgeon should have access through that mechanism. Your cancer committee within your hospital, if they follow the Commission on Cancer standards or if they're submitting data to the National Cancer Database (NCDB), they would have access to AJCC staging.

Dr. Randy Lehman [1:14:53 - 1:15:38]: Okay. And then on the NCCN, just for like residents, I would say, you know, you get a free... just plug in your email and create an account. I would recommend to residents to do that early and often and then review any cancer that you come across. That's great practice for your own practice later to just look up if it's just you. You know, the best way to be a trainee is kind of just imagine that all of a sudden all the other doctors just died and then it's just you and the patient left over. Now, what are you going to do? Come up with your best guess— it’ll probably be wrong— but then making a wrong choice and then hearing why it's correct, not only will you learn it better, but your staff is going to be impressed because you actually thought about it, you tried.

Dr. Shanda Blackmon [1:15:38 - 1:15:49]: Yeah, that's so impressive to me. The worst thing is just to have somebody who comes along for the ride. I want people to try to offer solutions, and even if they're wrong, it gives an opportunity to teach.

Dr. Randy Lehman [1:15:50 - 1:16:10]: Yes, exactly. So, this has been a great course through what is a very important topic with the number one cause of cancer-related death with lung cancer in a very timely point in November to be able to go through this. Thank you very much for joining us, Dr. Blackman. It's just been my pleasure and honor.

Dr. Shanda Blackmon [1:16:10 - 1:16:22]: Thank you. It's really been a true honor to be with you. Thanks, Randy. So great to see how great you're doing. Love your podcast. I've listened to three this morning. Very good, thank you.

Dr. Randy Lehman [1:16:22 - 1:16:32]: All right, well, and thank you very much to the listener as well for this episode of The Rural American Surgeon. I am your host, Dr. Randy Lehman. We will see you on the next episode of the show.