Robotic Bronchoscopy Roundtable, Part 3: What’s Next for Robotic Bronchoscopy?
Although advanced imaging with robotic bronchoscopy yields more precise diagnoses than traditional imaging modalities, a widening equity gap exists. As the imaging technology continues to improve, will we see more health care centers being divided between the "haves" with all of the tools and the "have nots"?
In this video, Jaspal Singh, MD, MHA, MHS, moderates a roundtable discussion with Bradley L. Icard, DO, Brian Shaller, MD, and Dominique Pepper, MD, MBChB, MHSc on whether advanced imaging with robotic bronchoscopy is worth the heavy investment, approaches for managing this value proposition, what's next for advanced imaging with robotic bronchoscopy, and more. This is part three of a three-part series.
For Part 1 of this 3-part series, click here.
For Part 2 of this 3-part series, click here.
Additional Resources:
- Agrawal A, Hogarth DK, Murgu S. Robotic bronchoscopy for pulmonary lesions: a review of existing technologies and clinical data. J Thorac Dis. 2020 Jun;12(6):3279-3286. doi: 10.21037/jtd.2020.03.35. PMID: 32642251; PMCID: PMC7330790.
- Kent AJ, Byrnes KA, Chang SH. State of the Art: Robotic Bronchoscopy. Semin Thorac Cardiovasc Surg. 2020;32(4):1030-1035. doi:10.1053/j.semtcvs.2020.08.008
- Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j.chest.2020.08.2047
TRANSCRIPTION:
Jaspal Singh, MD, MHA, MHS: Welcome everybody. I'm Dr. Jaspal Singh. On behalf of Consultant360, I wanted to welcome you to part three of our webinar series roundtable about robotic bronchoscopy. With me today are our three panelists again and we're just going to recap for the audience. Episode one: episode one was about robotic bronchoscopy where we talked about the importance of precise biopsies and how robotic bronchoscopy is really helping to revolutionize and become the first and best choice for many of our patients for lung biopsies and what that involves.
Then we went for part two, which was not just the robotic bronchoscopy, but then the imaging aspect of it, the idea of being precise in the nodules and the biopsies and the targets and really understanding how we're going to advance the field from that perspective. And with me today are our three panelists. I'm going to ask them to introduce themselves again. Start with Dr. Pepper.
Dominique Pepper, MD, MBChB, MHSc: Hi. I'm Dominic Pepper. I'm located in Olympia, Washington, and I'm an advanced bronchoscopist.
Dr Singh: Next, we'll have Dr. Shaller.
Brian Shaller, MD: My name is Brian Shaller, and I'm an interventional pulmonologist at Stanford University in California.
Dr Singh: Great, and then we have Dr. Icard.
Bradley L. Icard, DO: Nice to meet everybody, I'm Bradley Icard I'm an advanced bronchoscopist at Cone Health in Greensboro, North Carolina.
Dr Singh: Great, and thanks again for the three of you for joining again. So, we've talked a lot about robotic bronchoscopy and advanced imaging. So Dominique, we'll start with you. Where is this all going, and what is the evidence that all of this works.
Dr Pepper: Well, that's kind of the question that everyone's asking, you know, if you get a robotic bronchoscopy platform, it can set you back maybe half a million. You get advanced imaging.
Let's say you go for mobile combine CT and other 400K, you're looking close to a million dollars and the question is, is the juice worth the squeeze? So fortunately, we've had a number of publications out in the last year. The one that I'm in reference is by Dr. Ali and his colleagues and they did a systematic review looking at robotic bronchoscopy.
What is the diagnostic yield? And what was neat about it is that they actually separated the groups and they looked at robotic bronchoscopy just by itself and robotic bronchoscopy with advanced imaging. What they found was that the yield for robotic bronchoscopy was 82% and that of robotic bronchoscopy with advanced imaging was 86%. And people might say, oh my gosh, that's not such a big difference.
So why would you want to use advanced imaging? There's a lot of nuance, a lot of extra details in there. And what if people have realized is that with the advanced imaging combined with the robotic bronchoscopy, you can get to much smaller nodules, a lot more difficult ones as Brad and Brian were referencing, you know, stuff that's sitting right in the diaphragm, right in the pleura, right next to your order, we're getting to stuff that we would never have dreamt of getting to before. And do we have better data than that in terms of randomized clinical trials? No, but they're in the works and I'm pretty sure we'll get them soon.
What I will say is that some of the publications that have come out recently, specifically Dr. Badra, is that they can get yields of 90% using robotic bronchoscopy, advanced imaging, a certain ventilation protocol, cryobiopsy. So we're getting to the point, are we at 95% or 100% yet? No, but we fast approaching.
Dr Singh: That's phenomenal. So we're getting close to really understanding the truth of these nodules and what their behaviors are. And I think that's fascinating. It's exciting for our patients. Brian, what's your take?
Dr Shaller: I agree with everything that Dominic said. And I think that something important to keep in mind in evaluating the literature is, you know, like Dominic said, it's very nuanced.
And I think one thing that we'll always see is that as we get better, we will reach farther and we will go after harder targets. And so, you know, you can find a paper out there that uses the latest and greatest technology and has a diagnostic yield of 90%. You can find one that has a yield of 80%.
But, you know, as I'm sure, you know, but everyone else on this call will agree that as you get better at using these tools and your yield goes up, you go after harder targets. And you're always going to hit a window at some, you know, hit a ceiling at some point and you're going to miss some. But, you know, having a yield of 80% or 90% when you're going after nodules that are, you know, of a median size less than a centimeter, for example, is very different from the old days with some of the more legacy platforms that didn't have advanced imaging where you looked at all comers and diagnostic yield, you know, barely breached 70%.
Dr Singh: No, that's great. So basically what you're both saying and is that with the advancements in technology, in skilled hands, and in great centers, we can get incredible accuracy, precision, right? Now, I'm going to change that. So Brad, talk to us. Are we just becoming a place of, are we widening the equity gap. You know, we're now we're getting people that are we have centers that are the haves, which have all the tools. And now we have the have nots, you know, the people that don't have all these things.
And for our audience, how do you reconcile that a little bit? Like, I can imagine like you shared earlier one of the stories of your this this is personal for you and your family. Yeah, right. Now, what do what does our audience take from this? Now, do they have to go to a specialized center? Is there something that they are not or is there some happy medium? Walk us through that a little bit.
Dr Icard: Well, you know, personally, I think as our community grows, and we are able to share the stories of the patients and how we help change that, and I think our societies help play a role in this too, and our primary care audience and referral basis, help play a role into this. But I take that back story to the patient, right? We can talk about all of the fancy imaging, how do you put a price on a person that can come in with a eight millimeter lesion that has grown over, found on a lung cancer screening CT, that now can get a tissue diagnosis, biopsy, potentially surgically cured, or even if they're not a surgical candidate, a chance at SBRT or some type of radiation therapy. So, to be able to put a price, you know, a million -dollar price tag on that when there's so many other things in healthcare that help, you know, that we have to pay for, and health care systems have to pay for.
I think that if we leverage our societies, our communities, our referral bases with including the primary care to understand that we're going to offer something that's minimally invasive and the patient can come in and leave the same day for with no cuts, no stitches, no pain and go home and know that we were able to do that for them and get an answer, you know, when I think about juice worth the squeeze, that's what I think about because, you know, I'm able to get these answers for these patients and they can go home be with their family the day of with none of those complications or problems.
Dr Singh: So you think it's a value proposition that it basically something that we should be demanding that our audience should be demanding this level of expertise and technology. Yes, it's expensive. Yes, it's uncomfortable conversations of finances in today's healthcare environment. But this is sort of where the field is going. It's what the public demands. Is that right?
Dr Icard: Exactly. And then regarding the equity gap, I 100% believe that we have to deliver that message into the communities where it exists, right? So when you think about even large city centers, it doesn't come close to the percent of Americans that are smoking in rural America, right? And in the area in which I practice in the tobacco belt of North Carolina, there is, if you have a lung nodule on your CT imaging, it is an adenocarcinoma until proven otherwise. And so like being in that space, we got to make sure that we are educating the community and educating the referral basis.
And then with that, as those programs grow and I think there's success in those programs, more and more community-based centers will be able to offer these types of procedures, you know, and not necessarily be in some of our bigger academic locations, but I think there needs to be effort to help narrow that gap and equity for sure.
Dr Pepper: And to answer that, I'm based in a community hospital. I'm not one of those fancy academic centers. And that's why this is so beautiful. You know, the fact that we are a group of six community pulmonologists not interventionally trained in a community hospital, we're able to utilize robotic bronchoscopy and advanced imaging and get answers. And to build on what Brad and Brian said, we were very fortunate to approach our foundation and had a benevolent donor who saw the gap that was there and was able to sponsor us the technology, both technologies, and we were able to show results.
And after that, it's a smooth sailing. It's we just been able to get results after results after results. I think the issue of equity is also really important because, and I think Brad referenced this as well.
I mean, right now, there's a huge inequity gap because people with lung cancer are being diagnosed late. Stage 4, stage 3, they could have been caught a lot earlier. This technology allows you to get to a much earlier stage of cancer so that families can actually stay together. I think that's something that needs to be evaluated as well.
Dr Singh: That's great. I I think it's very important. Brian, you want to say something?
Dr Shaller: I couldn't agree with, I couldn't agree with both of you more. You know, you both pointed out the tangible outcomes in stage shift that your centers saw when you introduced advanced modalities. And I think that says everything.
And, you know, we don't like to, none of us went into healthcare because we wanted to, or we thought we'd have to lobby for resources and lobby for funds. But that's the kind of information that you take back to your executives and your C-suite and the people who control the flow of capital at your hospital and say, look what we can do for patients, look what we can do by way of downstream revenue. And we're talking about money, but we're talking about it because the end goal is, like Dominique said, help patients live longer, keep them within their families for longer, try to narrow the app, where health equity is concerned.
And I think these are conversations that, you know, dedicated pulmonologists and bronchoscopists are having all over the country at, you know, whether at academic centers or at small community hospitals to help get the equipment they need to take care of their patients.
Dr Singh: Yeah, I think I think that's great. I think those are important points. I think being centered around the patient. And I think one thing we forget, you know, sometimes forget is that lung cancer still kills more patients with cancer for men and women in this country than all the other major cancers combined. You know, when you talk about a major cancer killer, sorry, a major killer of the US population, and you talk about things like the cancer moonshot that the current administration is looking at, and you talk about sort of these goals, I don't see how personally from what you all are telling me that we're going to achieve those goals and serve our patients and populations without better tools and technologies.
So we're going to need them anyways. So the capital is the capital, the expertise is not there, all that stuff. It sounds like that should be the goal is to obtain that expertise, obtain the capital to get the tools that are needed, and to create space to get the work done because patients are demanding it. Is that about right?
Dr Icard: Absolutely. And you got to think about the underserved group of people that are not being screened, right? So lung cancer screening of itself is the lowest utilized cancer screening. The state of North Carolina, I believe, averages 8% of the eligible.
And I think California, Brian, correct me if I'm wrong, it's like 1% or 2% in California, right? It's pretty low. So, if you can imagine, 92% more eligible people for lung cancer screening in our state that the infrastructure that's needed to just manage the amount of imaging just doesn't exist. It doesn't exist with the number of radiologists that we have, right? You know, just with reading of the images.
So we've got to think about this in a broader context and text and then as this field changes, so does the technology regarding that, you know, our futures of blood tests and swabs and genomics and proteomics as we start evaluating lung nodules and how to figure out who actually needs the biopsy, which I think is going to be one of the next largest hurdles in this field, we're getting really good, as Dominic pointed out and Brian pointed out, we're getting really good at the procedure and being able to feel confident and doing it safely. But now I think one of the biggest hurdles is going to be who needs to get it. Because the volume of patients, I believe, are going to be so high in the future that we're going to have to do a better job in our filtering process.
Dr Singh: Right, so just to recap, so we basically say that you know what, we think that this is providing a fair amount of value. We think the evidence is increasing of the utility of this. We think that the tools and technologies are advancing in such a way that the becoming standard and the public should demand sort of expertise and knowledge and abilities to do more of this, especially as the field is evolving, that the patients need it, but that also that the idea of I think what Brad pointed out was the idea of that there's disparities already that we're not recognizing and not acknowledging and that's already happening in the space.
And yes, there are going to be disparities in technology and how we launch it, but keeping in mind that basically the patients we're going to oftentimes benefit from most are those same exact patients. So from these technologies, we have to find ways to serve them and deliver this technology. And then what you're kind of bringing up as well, Brad, is the idea of stewardship of these resources. And how do we properly get these resources, the people that need them, expediently and as possible, and hopefully not miss as many people who are already missing a lot of opportunities for better health. Is that all right?
Well, I can't thank you all three enough for spending the time with us today on Consultant360, on behalf of our listeners just want to thank you all for your generous use of our time. We look forward to working with you again in the future. And as always, on behalf of Consultant360, please look at all our resources on our website, and we wish you all the best. Thank you.