Onco-LIFE™ - Physician Comments

Dr. Stephen Lam, British Columbia Cancer Agency

“I’m Dr. Lam, Professor of Medicine at the University of British Columbia, and I chair the Lung Tumor Group at the British Columbia Cancer Agency. I perform lung screening in high risk subjects as well as doing clinical diagnosis in patients with suspected lung cancer.

Early pre-invasive lung cancer is very difficult to detect because they are usually very flat and very small and difficult to see by conventional white light bronchoscopy. Using autofluorescence we can improve the sensitivity of detecting these pre-invasive lung cancers readily. In our clinical practice we have found that in patients going for curative therapy, such as curative surgery, it is very useful to define the extent of the endobronchial spread and also to determine if there are any other sites of lung cancer, especially in very early in situ carcinoma elsewhere in the bronchial tree. These cancers, if we don’t detect them, they later on may become second primary cancers and can cause problems in the patient if discovered too late, because we cannot be cutting one part of the lung after another, to remove the cancers that way. The other groups of patients who are very high risk, they may be presenting abnormal sputum cells--- there are now newer sputum biomarkers or blood biomarkers that will indicate the presence of very early lung cancer. Fluorescence bronchoscopy with the Onco-LIFE device will help us to localize where these abnormal cells are coming from so that we can not only detect but treat these very early cancers. Nowadays we have a number of endobronchial therapies that can eradicate very early pre-invasive cancer such as electrocautery or cryotherapy treatment, so we do have the means to treat and not only detect these very early pre-invasive cancers.

Examination using the Onco-LIFE device is very simple. Essentially it is just a small camera attached to the eyepiece of a conventional fibre-optic bronchoscope. In our practice we usually do fluorescence bronchoscopy examination first using the blue light. The reason is we want to have a very clean surface that we can do the examination without any trauma or suctioning artifacts to the bronchial surface. So after a very careful examination with a blue light in the Onco-LIFE device we can just push a button and repeat the scanning of the same area using white light examination. In our experience, there actually very few things that we didn’t observe with fluorescence compared with white light examination, but just for completeness, we do both types of examination. The entire procedure only takes 20 minutes or so including the biopsies.”

Dr. Annette McWilliams, British Columbia Cancer Agency

“I’ve been using the Xillix technology and the autofluorescence bronchoscope for five years, since I’ve been working here, and for us we use it in both our research work and our clinical work and I really use it for all my bronchoscopies. And I very rarely do a bronchoscopy these days without using the autofluorescence.

Certainly for our research work, it’s very important to use the autofluorescence bronchoscopy to find pre-cancerous lesions and early cancer because we run a program where we are looking for early cancers and pre-malignant or pre-cancerous lesions. And these are virtually impossible to see with a normal white light bronchoscopy.

They are very hard to see and even most early cancers or central lung cancers are very difficult to detect with white light bronchoscopy.

So for our research side, finding early lung cancers and pre-cancerous changes, it makes a huge difference because we wouldn’t be able to do the research without autofluorescence.

With our clinical work it also has a big impact. We get a lot of referrals for diagnostic bronchoscopies, also we get a lot of referrals from respiratory colleagues, people they’ve found an abnormality on white light, they’re not quite sure what it is, and they send them to us for autofluorescence. So we can really have much greater detection rates of pre-malignant lesions and early cancers and we treat early cancers here as well through the bronchoscope, and the autofluorescence is really necessary to treat early central cancers as well. For a number of reasons, one, to see them properly, to measure them and make sure that you feel that you can cure it with endobronchial treatment and to see all of the visible margins.

In addition to helping to diagnosis and treatment of early lung cancers, we also use it in all of our patients who are going for lung cancer surgery, to ensure that they don’t have a synchronous lesion, because people who have one lung cancer are at risk at having another lung cancer, particularly who have central squamous cell carcinomas. So we like to ensure that they don’t have another lesion that might need treatment, or perhaps a moderate or severe dysplasia that will need follow up. And we also follow up our lung cancer patients with autofluorescence bronchoscopy as well.

So, for us it has a big impact, we use it all the time.”

Dr. Harvey Pass, Karmanos Cancer Institute, Wayne State University (Now, Department of Cardiothoracic Surgery, New York University Medical Center)

“I’m Harvey Pass. I performed a trial at the Karmanos Cancer Institute, Wayne State University. I’m presently Chief of Thoracic Surgery at the NYU University School of Medicine and Cancer Center.

I personally feel that the impact of autofluorescence technology in both bronchology as well as thoracic surgery is monumental. The reason I say that is because of the increased interest in defining pre-neoplastic lesions of the airway as part of a screening examination as well as be able to do chemo prevention trials looking at agents to see if you can actually reverse the airway carcinogenesis phenomenon. My impression is that this instrument is going to add to patient survival.

I think that it is going to be used in the pre-operative setting to make sure that you are not missing undisclosed areas in the airway that you may not know of with white light. I think that it is going to be used in the post operative setting for following patients to make sure that either the bronchial margin looks fine or that they are not developing occult lesion in the airway, that you can’t see on CT scans or chest x-rays.

The new system is easier to use, it is smaller, it is more portable, and for the every day physician who is sort of a little bit scared of the technology, and the instrumentation before; now can see the new system that is so small and so easy to use without having to change the head of the bronchoscope and you can just use it with a click you can go from fluorescence to white light. It is such a major advance that I think that the use of this is going to be almost standard practice, in my opinion.

The cost of autofluorescence technology now is such that it can be expanded to the every day bronchoscopists and thoracic surgeon without a great burden on the hospital or the practice and when you compare the decreased cost to the added benefit to the patients, you really have to say that this is a machine that you have to have.

I think that the great interest in lung cancer right now is to be able to define who the patients are that we can detect earlier, who are at high risk for the development of lung cancer that can potentially get curative options earlier. I think that the ability to find those patients using autofluorescence technology, and the expansion of that technology, is going to be assisted by the new Onco-LIFE system. I think that by using it as a means of following patients also, because we all know that after we do curative options for patients who have a primary lung cancer they still have a significant chance of developing a second primary lung cancer, by combining the post operative follow up of these patients with the scope, as well as with the pre-operative work up, as well as using it in high risk patients, you are going to get your bang for the buck for the scope and it’s also going to translate into patient survival.”

Dr. Thomas Sutedja, Vrije University Hospital, Amsterdam

“I’m Dr. Tom Sutedja, I’m a pulmonary oncologist working at Vrije University, in Amsterdam. I’ve been working since 1987 to start a program on interventional pulmonology in the broadest term. It was meant that this field fully integrate minimally invasive techniques in the broadest care of lung cancer patients. As we are a referral institute in the northern part of Holland but actually the whole part of Holland, so we are a tertiary referral institute.

…It took a while because we were involved in the first program because of with all forms of new techniques, obviously in terms of early clinical application, you want to be sure that the additional information that you get for any kind of technique will have any benefit in the clinical decision making, but also in terms of outcome. And that was of course a daunting task as we knew already at the time, when moving towards early stage cancer, the problem has been that the earliest lesions are invisible to be seen by the doctor as it is either through the endoscope through rigid optics or fibreoptic, because we know from the pathologists at a time when we took lesions by chance and it seemed to be early cancer that in retrospect that you could not see that on the fibreoptic bronchoscopy. So, the first step was to see whether indeed you can discriminate this lesion early on, while you miss it on the conventional white light bronchoscopy. And that took one year that we were quite convinced that it was much more sensitive.

…It was not Onco-LIFE at the time, it was the first generation: (Xillix) LIFE (Lung).

…after about half a year, we thought we better start with the fluorescence imaging first and then take a biopsy as soon as you can with precision. And then if you are not sure, you switch back to white light.

…the images in general are getting better and better and that it is easier to switch from one system to the other, in what following order you want and look back at the autofluorescence and that makes it easier in all kinds of early intervention because we were not only using that in trying to detect more early lesion, but also in trying to delineate the lesions margin prior to applying the local treatment because we do a lot of local treatment with electrocautery and everything, so it does help that too.

…in terms of my daily practice, I need it in almost all patients because they are referred for surgery.

…in my practice, we always use it, because it is such an important clinical decision before the treatment is supplied to know whether this highly at risk categories are amenable for surgery because of their high risk. Surgeons are not likely to say, lets operate and we will take the risk but they want to know, are we targeting the right approach right now, so that just makes it easier. The risk and the satisfaction is done already by the other pulmonologist and I just confirm or diffuse the anxiety about other problems.

…we get many patients who are unfortunately detected or being suspected of having second or third primary, also being involved in the total clinical care of this lung cancer patient, we are a cancer center.

…those kind of things add to a quite high yield of what we found as second, third primary, fourth primaries.

You find them early, you cure them, and then they are still at risk, they can get a second one and as you detect them early, you cure them again, they get the third one, and then the fourth one. So alluding to this patient, he had a pacemaker, he was 72 at the time, he had two synchronous lesions to start with. He had two second primaries and then the third primary came after we treated with photodynamic therapy and then the third cancer came, then the fourth and the fifth together, and then the six and the seventh, by that time, it was seven years later. And I remember I said to him at the fourth or the fifth cancer, the pacemaker needs to be taken out because there is a new generation pacemaker he came to me and asked, my cardiologist lets me ask you, whether its worth while to have a second pacemaker. I said just please put it, because then I don’t have to resuscitate you when you have a cardiac arrest during these kind of procedures to cure you more.

…I am not to say that it is for early detection, I am in it to say that it is for early intervention and early intervention means the whole cascade of seeing what you miss. Accurately targeting what you do what you don’t know where the borders are. Accurately targeting while you are doing treatment and also in terms of follow up, that you know where you have been, and what you have treated.”