LOUISVILLE & NEW ALBANY, IND. Often, when it comes to heart and lung programs, it is the heart side of the equation that we hear most often about. In cardiology and cardiac surgery, new techniques and treatments with exciting possibilities abound. For pulmonology and thoracic surgery programs, their work is no less important, although perhaps more of a slow and steady mentality.
“In recent years there has not been a revolutionary advance in the treatment of lung cancer,” says Michael Bousamra, MD, thoracic surgeon with Baptist Health Floyd. “But progressive refinements have led to improved surgical outcomes, less patient morbidity, and more rapid return of function.”
However, Bousamra and his cohorts across the river at Baptist Health Louisville – Robert Linker, MD, and Jonathan Kraut, MD – have set out to establish full service thoracic surgery programs specializing in minimally invasive procedures and are implementing proven programs and techniques, as well as innovative clinical trials, to make patient care and outcomes incrementally better.
Linker, thoracic surgeon and medical director of the oncology program for Baptist Health Louisville, says, “We provide the full range of general thoracic surgical procedures with the emphasis on minimally invasive procedures. There isn’t much that we turn down or send away.”
Linker is originally from Louisville and attended medical school at the University of Louisville. He pursued his general surgery residency at the University of Cincinnati and his thoracic surgery residency at The Medical University of South Carolina. He returned to Louisville in 1986 and began practicing heart, vascular, and general thoracic surgery. It was not until 2001 that he began to focus solely on thoracic surgery.
Thoracic surgeon Kraut is from outside Philadelphia and moved to Louisville in 2006 to join Linker in practice. He attended medical school at St. George’s University in Grenada, West Indies, and completed his general surgery residency at Christiana Care Health System in Delaware and a fellowship in heart and lung at St. Luke’s Mid America Heart Institute in Kansas City, Mo.
Bousamra, who is from Michigan, attended medical school at the University of Michigan. He completed his general surgery residency at the Medical College of Virginia in Richmond and his thoracic surgery residency at Washington University in St. Louis. He came to Louisville in 1999 and spent 17 years practicing at U of L before joining Baptist Health Floyd in 2016.
At Baptist Health Floyd, Bousamra says, “We’re a full service thoracic surgery practice. We operate on all diseases of the lung, esophagus, and mediastinum.” Those diseases include lung and esophageal cancers, as well as benign diseases of esophagus such as achalasia or hiatal hernias.
Concurrent Approaches to Cancer Care
In both its locations on either side of the Ohio River, in Louisville and New Albany, Ind., Baptist Health’s thoracic surgery programs put particular emphasis on lung and esophageal cancer treatment. Linker estimates that 70 percent of their practice is oncologic, and with good reason. In the US, one out of every four cancer deaths is attributable to lung cancer, more than breast, colon, and prostate cancers combined1. Unfortunately, Kentucky leads the way. According to the CDC National Program of Cancer Registries, Kentucky ranked highest in the US in lung cancer incidence and deaths from 2009–20132. The American Cancer Society estimates Kentucky lung cancer deaths for 2017 will reach 3,560, up from 3,300 in 2009.
That’s why these surgeons have focused their careers on tactical, evidenced-based strategies to provide better treatments and outcomes for patients, such as streamlining patient pathways and access, refining minimally invasive techniques, and providing access to better tools for screening and early detection.
Baptist Health Louisville
Both Linker and Kraut were instrumental in starting the Multidisciplinary Lung Care Clinic at Baptist Health Louisville when their practice joined Baptist Health in 2008. The clinic allows patients to see a team of providers, including Linker and Kraut, medical oncologists, radiation oncologists, a nurse navigator, and psychosocial services. The clinic gets 12 to 15 new patients a week. While providers see patients two days a week in the clinic, they also meet once weekly in a multidisciplinary conference to discuss cases and optimal treatment. “The multidiscipline conference and clinic is instrumental in patient care. It has been shown nationally to provide the best outcomes for these patients,” says Kraut.
Supplementing the virtual experience provided by the clinic is the physical space afforded by the Charles and Mimi Osborn Cancer Center at Baptist Health Louisville, which opened in 2014. “We have concentrated all of our cancer programs across the Baptist campus in that one area,” says Linker.
Kraut adds, “One of the benefits of having a cancer center and a multidiscipline clinic is that you are able to provide convenient, compassionate, expedient, and comprehensive care in one facility. It allows our patients to see multiple different specialists at one time. It saves additional appointments down the road and helps us get our patients to more definitive therapy much more quickly.”
At Baptist Health Louisville, about 60 percent of lung cancer surgeries are performed minimally invasively. Linker specializes in robotic lobectomies with the da Vinci® Surgical System. Kraut performs video-assisted thoracic surgery (VATS). Both techniques result in quicker recovery, shorter hospital stays, minimal blood loss, minimized scarring, and less pain as compared to open thoracotomy.
One way to improve outcomes is to reduce the severity of cases that appear in the thoracic surgery clinic. In July 2013, the US Preventive Services Task Force (USPSTF) issued guidelines recommending annual CT screening for individuals at high risk for lung cancer. Linker and Kraut also initiated a low-dose CT screening program. Since Medicare has approved payment for screenings, guidelines have changed. The biggest change for physicians and hospitals is that patients must undergo pre- and post-test counseling about radiation exposure. Baptist Health has a nurse practitioner that meets with patients pre-test to ensure they meet Medicare criteria and to explain the screening. After the CT scan, a radiologist and Linker examine the scan, and the patient is counseled about their result.
Outside of cancer surgery, the surgeons treat conditions such as pleural effusions, hiatal hernias and reflux, and chest wall problems. Linker has a special interest in thoracic outlet surgery. To relieve compression and brachial plexus, Linker uses thoracoscopy for first rib resection, which reduces hospital stay and recovery time over standard chest surgery. Kraut specializes in chest wall reconstruction and trauma, where he is “using a plates and screws rib system for rigid fixation of rib fractures,” he says.
Baptist Health Floyd
At Baptist Health Floyd, Bousamra has assembled his own team. “From a surgical perspective, we have a focused team that’s devoted to taking care of patients with lung cancer and esophageal cancer and working up spots in the lung. We have a tumor board that’s robust and meets regularly,” he says.
Like Kraut, Bousamra performs the minimally invasive VATS procedure. And while there have not been revolutionary advances in thoracic surgery, he believes minimally invasive surgery and efforts to minimize air leaks and bleeding and reduce chest tube time result in better outcomes for patients.
Medical oncology and radiation oncology, along with a full complement of cancer services, are available at the Cancer Center of Indiana, which is in very close proximity to the hospital.
Bousamra is also involved in a research project – breath analysis to diagnose cancer – a project he developed while at U of L and has brought with him to Baptist Health Floyd. “A patient breathes one breath into a non-reactive plastic bag, and we pass that breath across the patented silicone microchip. It captures a certain subset of compounds that are specific for cancer, and then we analyze those compounds,” says Bousamra, who has identified four lung cancer markers.
“We’ve embarked on a study at Floyd where we’ve done CT scans on patients and breath analysis studies on the same patients and found that the breath analysis study is a more accurate test for detecting lung cancer than is the CT scanner. It doesn’t produce as many false positives,” says Bousamra.
He has submitted an NIH grant to study further at Floyd and Baptist Health Louisville. “We’re a ways away from having a breath analysis test as a primary screening for lung cancer, but that’s the long-term goal,” he says.
Whether through multidisciplinary teams and conferences, state-of-the art screening, or minimally invasive surgical techniques, the thoracic surgeons of Baptist Health demonstrate a commitment to collaborative, refined, evidence-based care.
Linker points to one final example of teamwork as he shares the role he believes thoracic surgeons will play as new medical therapies, which are showing promise in certain subgroups of patients, continue to evolve. “With these minimally invasive techniques, we’re able to get a significant amount of tissue for diagnosis and testing. The big trend now is toward individualized treatment. With DNA markers and newer drugs we’re getting into specific treatments for specific tumors. I think our role is going to be getting enough tissue to draw these tests on so patients can be treated with immunotherapy and various new drugs coming out, such as Opdivo® and Keytruda®,” he concludes.
1American Cancer Society. (2017, January 5). Key Statistics for Lung Cancer. Retrieved from American Cancer Society: https://www.cancer.org/cancer/non-small-cell-lung-cancer/about/key-statistics.html
2U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2016. Available at: www.cdc.gov/uscs.