 There has been a lot that has come out in cancer DNA, can we discuss this a little bit first?

: this is an important topic, I'm so glad that you're asking that as a starting point. So when we're talking about cancer DNA, that's different than the regular DNA. And what happens is that cancer develops through mutations and changes in the DNA of those cells. And then that's how they become cancer cells. Now, in lung cancer, it turns out that there are various specific mutations, or we say genomic alterations, because sometimes the DNA changes are different than specific mutations. So I'm going to say genomic alterations can be kind of broader. This is in the cancer DNA, we've found that there are these genomic alterations that occur, where we've developed a treatment to them in many cases. It's a pill that can really specifically target those cells with those specific genomic alterations.

Now, just to highlight some of what's gone on in lung cancer research, because it is astonishing from 11 years ago, was really the first big study that demonstrated that with a specific mutation, and these were EGFR mutations, that there was a pill then called gefitinib. In that case, that worked really well, much better than chemotherapy. And that was the first of now five approved drugs that target EGFR. And since then, in the last 11 years, we have EGFR, ALK, rOS1, BRAF v600e, RE, MET, and TRK. So there have been a lot that have been identified with effective targeted therapy for each of these.

This is now something that makes it extremely important that we really get the full genomic testing of cancers, prior to any treatment in the setting of when we're talking about stage 4, or metastatic disease. In that setting, we're considering what's going to be the best treatment for knocking the cancer back, for really prolonging and in some cases, improving people's quality of life. And so at the time of diagnosis, sometimes it can take a little longer, in some cases, weeks to get back that DNA analysis from the cancer cells. But it is extremely important because these targeted therapies really work better in many cases than the chemotherapies, and are often less toxic. And some of them work really well in the brain, also, so we can hold off on radiation. And it's a little bit different with each of these. But just to make the point that doing that DNA analysis of the cancer cells is overwhelmingly important when we're at the time of starting treatment.

 We’re hearing that lung cancer is being diagnosed at earlier ages. Is there any insight into why we’re seeing this?

:There's a lot more awareness growing about this, which is wonderful because there needs to be awareness on this. There are multiple stories that are now known, who are young, who never smoked, and end up getting lung cancer. The impression of lung cancer, I think, for many years, has been someone who's older who smoked a lot. And the truth is that anybody who has longs can get lung cancer. So basically, anybody can get lung cancer.

Now, smoking rates have gone down, fortunately. And so the lung cancers diagnosed that are diagnosed have gone down. As far as younger people, this is still a very small number of people overall, who get lung cancer, but we're talking about people less than 30 years old. The numbers tend to be very, very low.

There was a study called the Genomics of Young Lung, looking at the younger population. I think in that study, it was 35 and younger, who got lung cancer. And in that study, we saw that the majority had some of these genomic alterations that can be targeted with targeted therapies. And that is kind of what we expect to see in younger people who never smoked. We expect there's a much higher likelihood of these genomic alterations that we can really target. And so that study really confirmed this. But the point also, it's important to make the point that even people who are older can have these genomic alterations. The oldest person I've treated was 92 years old, a woman who almost didn't even come to see me because people were telling her, “Hey, you don't want to go get chemotherapy, you're 92 years old.” And when I saw her, we talked about it, I sent off the genomics and she had an EGFR mutation, did really well on targeted therapy, improved her quality of life, got back to having wine with friends before dinner, and such and going to Bingo. So looking at this DNA is really important at all ages, but especially the younger population, it's even more important.

 How can we try to raise more awareness around these genomic alterations, so that patients understand how it will affect their treatment decisions?

: Well, you're doing it with these questions, and just getting this information out there. So I really appreciate that. There was a report that amongst people with lung cancer throughout the country, it actually was surprising the number of people not getting the full DNA analysis of their tumors. Now, this is something that is standard of care and should be done for everybody. But not everybody is having that done. And on top of that, not everybody who has a genomic alteration is being treated with that targeted therapy also. And I think there are various factors that play into that.

One, when somebody gets diagnosed with lung cancer, understandably, they want to be on treatment immediately. And so they go to the oncologist and say, “Hey, let's start something right now.” And what I often tell people is first of all, let me say, if there are people who are having a lot of symptoms, sometimes people really need to be treated right now. And in those cases, I'll start chemotherapy alone. But in other people, the majority of people, we can still wait some weeks to get back all the data. And so what I often say to them is, “Listen, I want to do the full analysis so we can get you started on the best treatment, not just the first treatment.” And I think that statement resonates for a lot of people that, of course, people want to be on the best treatment.

Then others is that this is something we're continuing to talk throughout the country and really raise more awareness about the other thing is going and being seen at one of the major academic centers in the region, just getting a quick opinion. Has everything been done that really helps to not only make sure that all that testing has been done, but also a consideration for what clinical trials options might really be available. Because there are sometimes some really good options. I just want to highlight anybody with non-squamous non-small cell lung cancer, or adenocarcinoma, is the most common non-small cell lung cancer. Anybody with that diagnosis should get genomic testing. Anybody who didn't smoke in the past, whether that be squamous cell lung cancer, which is a non-small cell lung cancer, or even small cell lung cancer, individuals who've never smoked, should have all of that genomic testing done.

 What would you say is your biggest piece of advice for a patient who is newly diagnosed with lung cancer?

: So, getting a second opinion is a good way of just making sure that you really are aware of all of your options, but making sure that you talk to your physician about genomic testing. If you're somebody who never smoked, it is right for you. If you're somebody with nonsquamous non-small cell lung cancer, or adenocarcinoma, then genomic testing is right for you. The other thing is making sure that they got an extensive panel of these. So you want to make sure that all of the genomics for any approved therapies has been done.

Now, that is a minimum, I would also advocate really that doing a broader panel gets more information, which maybe doesn't have FDA approved options right now, but does have clinical trials options right now. At the same time, there may be trials that come up down the line that that one is eligible for, and I have a couple of people who had their tumors had a RET fusion. At the time that I did their initial testing, that was not a thing. We now have two FDA approved drugs that were approved this year, and patients that went on trial, because at the time that that trial started all of a sudden, you know, we found out these patients are eligible, but at the time of the initial testing, that that wasn't a thing. So a broader panel not only captures anything that is an option right now, but as things advanced down the line, other options may become available that aren't currently.

 Can you discuss what the rate of lung cancer diagnosis is, in particular amongst African Americans?

 Lung cancer is the number one cancer killer of all Americans. It kills more men and women than breast cancer, colon cancer and prostate cancer combined. But also lung cancer is the number one cancer killer for blacks, African Americans as well.

 On the plus side, we have seen that these rates are dropping faster compared to white patients, since 1990. So what can we attribute to these rates dropping faster?

Well, luckily, lung cancer mortality has decreased in the last several years. We see that in the report from the American Cancer Society journal, where we see mortality decreasing. Over the past decade or so, in the upcoming 2020 American Lung Association State of Lung Cancer report. We also have evidence that cancer mortality has been decreasing. And that's been lung cancer-specific mortality decreasing across the board, both for Black African Americans, as well as for white Americans as well. However, the rate of lung cancer death is still higher in communities of color, specifically Black and African Americans compared to white Americans. And there are reasons for that.

On the positive side, the reasons for the decrease in mortality for lung cancer is multifactorial. We have things like lung cancer screening, we have interventions such as a smoking cessation programs, policy measures throughout our regions for increasing the age of tobacco use, from 18 to 21, and also flavored tobacco bans in our communities. In regards to therapies, we have better surgery, more minimally invasive surgery, and now about 80% of board certified thoracic surgeons who are doing long resection for cancer, about 80% of those cases are done minimally invasively. And we have new, really exciting therapeutics, specifically in precision medicine, as well as immunotherapy. When you take the constellation of those interventions, we see a decrease in mortality. However, when we look at our Black African American communities, we find that those communities are diagnosed at later stages are less likely to undergo lung cancer screening, and less likely to go specific therapeutic interventions such as surgery and enrollment into therapy to clinical trials.

 What are we kind of doing to negate these challenges moving forward?

One thing that is important for us to understand is that race, ethnicity is a social construct and not a genetic manifestation. So when we look at those disparities, we have to look at our health care structure, and how is that health care structure providing access to people of color. And what we find is that if you take something like lung cancer screening per se, the American Lung Association in lung cancer report shows in 2019, that only of the 8 million Americans, regardless of race, who are eligible for lung cancer screening, only about 4% gets screened. And that varies between states. So for instance, where I practice in the state of California, only 2% of eligible Californians get screened. When you compare that to mammography for breast cancer, about 70% of women are eligible for breast cancer get screened. Their upcoming 2020 report that lung cancer screening number will be a little bit higher than 4%. But still markedly lower than what it should be. And we do know that African Americans are screened less than white Americans. So how can we fix that?

One is through education of our care providers. In the American Lung Association’s lung barometer, it found only 15% of individuals knew that lung cancer screening was an essential health benefit to them. And so we need to empower our primary care providers to enroll their patients into lung cancer screening. Also, patients themselves need to understand that this is a benefit for them. At UC Davis Comprehensive Cancer Center, we partnered with private industry to really increase that awareness amongst our African American communities in our Sacramento region, and that includes billboards on highways and roads in the African American communities, and also advertisements in areas such as public transportation, as we know that people of color utilize public transportation more than other communities as well. So those type of interventions, lung cancer screening is just one example. Another example, in how can we reduce those disparities, is really on the policy side. For instance, in our Sacramento area, we had legislation that banned flavored tobacco products. And we do know that the tobacco industry has targeted the African American community with flavored tobacco, specifically menthol. And the idea is that banning those flavored products not only helps our youth, but also helps our targeted communities of color.

 What would you say is your biggest piece of advice for an individual who may be facing any of these challenges with access to care?

 Ask your care provider, “What's the standard of care treatment for me?” If you are a former smoker, ask your care provider, “Can I undergo lung cancer screening with a low dose CT scan?” If you're diagnosed with lung cancer, ask your care provider, “Is there a clinical trial that's open to me?” And if it's not open at the at the center that you're being treated, “Where near me? Are there clinical trials that could benefit for me? Am I a surgical candidate? Can I undergo surgery to remove this lung cancer from my body?”

So, really be well informed. And there's many ways for our communities to be well informed. They could go to the American Lung Association website, lung.org, they could go to the National Cancer Institute's website, cancer.gov, or they could look to see if there's a comprehensive cancer center within their community and seek to obtain care at that center of excellence.

Genomic Alterations in Lung Cancer

Racial Disparities in Lung Cancer

 To start, why would you say it's important for patients to consider joining a clinical trial?

: Anytime I'm talking about clinical trials with a patient, it is entirely in the context of what is the best option for that individual. I think people come in or I witness people come in with various ideas and preconceived notions about what clinical trials mean. And there are a lot of people that are wonderful individuals that want to see progress. So you know, they say, “Oh, if there's anything I can do, that's going to help other people.” And I have to kind of bring them back, when we're talking about an option for you. This is deciding what's the best option for you. So we always hope that a clinical trial therapy is going to work really well for somebody. And if we can demonstrate that a drug works well, hopefully there are other people that will then benefit down the line.

As far as making a decision about clinical trials for an individual, it's all about what is the best option for that person. Any drugs that come up in a clinical trial are something that has been very promising in early development and other trials. So I do have patients where they came in, they were going to start a guy I'm thinking of was going to start chemotherapy with his oncologist, but he came in and had a genomic alteration, where there was a clinical trial available, it was a drug that we've been using for quite a while on that trial, it was more on the tail end, we'd seen great results with it. So I was able to say to him, “Hey, we have this drug on trial. It's something we're still studying, but I can tell you that it's been working really well for people.” And he continues now on this drug, where this is now an FDA approved drug at this point. But he's still on that trial. It's just been working so long for him. So clinical trials are all about what is the best option for that individual. And, and that's what we weigh out. But then, of course, you know, we're still studying those outcomes and side effects and such, but the conversation should always be focused on what's the best treatment option for that person.

 How can patients learn if they're even eligible for a trial?

: So getting an opinion from one of the major academic centers is a way of getting a sense of what trials are available there. But community hospitals may have trials open, community hospitals, many do have trials open. And so there may be trials available in those centers as well, the larger academic centers are going to have more trials available and some of the earlier drugs. So that's in phase 1 or earlier development, some of the newest drugs. But there are so talk to your oncologist to consider an opinion and you are being seen at one of the major centers. You can also visit clinical trials.gov or lung.org has a site with information about clinical trials to get more information there as well. So there are various places, but I think sometimes when looking at all the stuff online, really then bring that to your oncologist to them to discuss that further.

 Are there any misconceptions that we can try to help negate and encourage patients to join a trial?

: Yeah, this is a really important one to get out there. I think a lot of people have this impression, just like you're saying that trials are where they're going to get a great treatment or something that looks like a great treatment, or they might get no treatment at all with a placebo. And that's really not the way these trials are done. So at the bare minimum patients are going to be treated on the best standard of care treatment. Anything that includes a placebo would be the best standard of care treatment plus a placebo, or the best standard of care treatment plus something new that's being added to it. If somebody is going to go on a trial available, just a standalone new drug that compared our arm would be the best known standard of care treatment. So this idea that people might end up on just a placebo is really kind of an older idea. And I think it just harkens back to when we didn't have a lot of treatment options for cancer. But in this day and age, especially in lung cancer, we have an array of different treatments. And so placebo controlled, would not be just placebo alone.

 Can you just discuss the types of trials that we're evaluating these drug combinations or alone?

: We go through phases. So, we have phase 1, when drugs are first being brought into the clinic. So this is a tip for a drug to be brought into a phase 1 trial. It means that it has been a standout, really promising drug, when looking at it in the lab, and in many cases, in testing in animals, showing that the drug is really effective in knocking back the cancer. And so, in phase 1, we're seeing what is a dose that is tolerable when treating humans. And we'll start with a very low dose, and then based on different things we're measuring, we'll increase that dose until we find the point at which it appears that it might be causing more in the way of side effects. And then we back it down. Now, that can happen in different ways. But that's essentially how phase 1 goes.

Phase 2 is where we say, “Okay, this drug has been well tolerated. And there's a sign in treating people that it looks like it probably works when we're seeing very promising results. But we need to see more results at the dose that really appears like it's the one to bring far, which is what is the one dose to further evaluate, or sometimes two doses, and then bring those forward and enroll more patients on that trial. So that's where we say, “Okay, this is well tolerated, it's promising.” So now people are being treated with this promising drug. And we collect more to see how effective it really is, if it's really effective in that those are often single arm studies. There can be phase two randomized studies where you’re on the experimental drug, or on the best standard of care and so that we have a comparator arm, sometimes it's just everybody gets enrolled, and ends up on that that experimental drug to see how effective it really is, and better understand the side effect profile. If it's very promising in that, then we say, “Okay, this really looks like a good drug. Now let's do a large trial, where we compare it to the best standard of care.”

And so sometimes the drug is so effective in a single arm study, that it does lead to FDA approval. And we've seen some of that this year with some of the targeted therapies for lung cancer. But in many cases, it goes to a large trial, where it's compared versus the best standard of care, to see if it really beats the best standard of care, and to then lead to FDA approval. Now, it's also important to mention that some clinical trials are with FDA approved drugs. So it may be a drug that we know works really well, where we say, “Gosh, this is so effective for metastatic cancer, for example, why don't we test it in earlier stages when we're really going for cure?” And so I have a trial that I'm leading in non-small cell lung cancer, where patients who get surgery and then they're getting the chemotherapy after surgery, we're adding an immunotherapy to see if it's more effective in that setting, because we know it is in this stage four metastatic setting, particularly for people that don't have a targeted therapy option.

 What would you say is your biggest piece of advice for a patient who's interested in joining a clinical trial?

: Well, so one is talk to your doctor about this because this topic is much more broad than we have time to really discuss. Not everybody qualifies for treatment and a trial is not the best option for everybody either. If somebody had a recent other cancer, sometimes that can make them not a trial candidate or other things depending on the drug being studied as well. And then also be evaluated at a major academic center that's nearby. I'll tell you I have people where they do drive quite a distance to go on clinical trial, but that's only if the trial is really just so good. That it's really worth that drive. I have some people where I see them from where they live in Destin. And for anything else going on with them say, “Yes, we have this trial. But given all of these other factors that that are in play for you, maybe it's better to go on the best standard of care.” And then somewhere down the line, we can reevaluate for what's next one. One important point I do want to make sure that people understand also is that when you're starting treatment, or after that treatments not working, you're starting another treatment. If you have started a therapy, then it's very unlikely that you could go on to a clinical trial. At that time, you'd have to wait until the cancer has grown again. And I just want to get that out there. Because sometimes I see people come in where they say, “Oh, I've now been on this new this new therapy for a month. But what clinical trials could I do. I'd love to switch to something or look, and that's not an option.” So the clinical trials are something that decision point is really before you're starting that next line of treatment.

Learning About Lung Cancer Clinical Trials

 Can you explain what Lung cancer screening actually consists of?

Lung cancer screening is a wonderful tool that is really saving Americans from lung cancer. As we know, lung cancer diagnosed in this country is mostly diagnosis at more advanced stages. We are now diagnosing patients who are at the highest risk for lung cancer at the earlier stages, with a better chance for cure.

So what lung cancer screening is, it's lung cancer screening with low dose CT scan. A CT scan is basically a really advanced level X ray machine, it looks like a doughnut, you lie on a table. And literally less than five minutes you roll through that doughnut, and it scans your chest and upper abdomen and with low dose radiation, ideally looking for things that are suggestive of lung cancer. And lung cancer screening is similar to screening and other cancer modalities such as mammography for breast cancer or colonoscopy for colon cancer. Now, lung cancer screening is reserved for those individuals who are defined as at the highest risk for developing lung cancer. So those are aged 55 to 80. Those who have what's called a 30-pack year smoking history. So the way you define a pack year is to take the number of years you have smoked, times a number of packs per day that you smoke. So if I smoke two packs a day for 15 years, that's 30 pack years, if I smoke one pack per day for 30 years, that's 30 pack years. And if you have quit smoking, then you've quit within a 15-year period. If you satisfied those four things, then you qualify for lung cancer screening.

Now, the reason why that lung cancer screening is a benefit as an essential health benefit in the United States is because there's been a large randomized clinical trial that was published in the 

, that's called the NLST, the National Lung Screening Trial. And what that trial did was paired individuals with low-dose CT scans with chest X ray. And when you compare low-dose CT scan to chest X ray, there was a 20% lung cancer specific reduction in death in those patients. And then there was what's called a stage shift. So, as I said earlier, the majority of patients are diagnosed at advanced stage 3 or 4 out of a 1 to 4 stage scale. And that trial, the majority of patients, about 75% were diagnosed at early stage disease with the highest chance for cure. And so that was a game changer in the lung cancer treatment paradigm. And that led the United States Preventive Services Task Force to give a grade B recommendation for lung cancer screening. And what that means is when the US Preventive Services Task Force gives a grade B or higher, then it's required by law that private insurance offers lung cancer screening as enhanced essential health benefit at no cost to patients. And that led the Centers for Medicare and Medicaid Services to recommend lung cancer screening and covered lung cancer screening for ages 55 to 77 for CMS. And so that's a that was a game changer.

 How much are these screening options actually utilized across the United States?

So unfortunately, not very much. So there are about 8 million Americans who are eligible for lung cancer screening and are considered at the highest risk for developing lung cancer. So as we mentioned before, ages 55 to 80, 30-pack years and if they had quit smoking within 15 years. Of those 8 million, if you look at the American Lung Association's 2019 State of Lung Cancer report, only about 4% of eligible Americans actually get screened. And you compare that to women who are eligible for mammography screening for breast cancer, about 70% get screened. And that varies from state to state. The highest level of screening is in Massachusetts. However, I practice in California, and only about 2% of eligible Californians get screened. And that's a terribly low number. And we do know that in Black and indigenous and other communities of color, the screening rates are lower, and so we must do better.

 So what are some reasons that may be contributing to the fact that people aren't getting screened?

So the American Lung Association published what was called a Lung Health Barometer. And what they found was that if you look at patients who might benefit from screening, only about 15% knew about lung cancer screening, and had these conversations with their doctor with their care, their primary care provider. So what we can do is educate our most educated people, which are our primary care providers, into having these conversations with their patients are at the highest risk for developing lung cancer. But I'm also a believer empowering the individual empowering patients themselves to do health care education. And so for patients to understand, are they at how are they at the highest risk for developing lung cancer? And could they benefit from lung cancer screening with low dose CT scan and a patient ask their doctor? Can I get a lung cancer screening exam, then that should increase our rates as well?

 How can we help raise more awareness so that individuals are aware that they should or should not be getting screened right now?

So there are different things are going on. One is our actual scientific edge, health care communities becoming more educated and more aware. In July of 2020, the United States Preventive Services Task Force changed their recommendations for lung cancer screening. So they dropped the age of eligibility from 55 to 50. And they dropped the pack-year eligibility from 30 to 20. And that's a recommendation by them. And the reason why they did that is because there's more data out there, one from a large European trial, that shows that the dose rate or pack year could be lower and age rate could be lower. And there is disparity data that shows that many African Americans develop lung cancer via a lower dose of tobacco use, and many women are light smokers as well. So they're at risk because they're smokers, although all you need are lungs to get lung cancer. But by lowering that dose rate, the pack years, you would include more women and more African Americans into lung cancer screening. So that shows you that our health care communities are in our scientists are becoming more educated. But why would say is for patients to go to really key trusted information websites to learn more, such as the website, American Lung Association, long.org, as well as the website of the National Cancer Institute cancer.gov, and really learn what's new, what's available to them in lung cancer screening, as well as lung cancer treatment, and also look to see where there is an American College of Radiology, certified lung cancer screening program that's near you.

 So what would you say is your biggest piece of advice for someone who thinks they should be getting screened?

Ask your doctor or your primary care provider, go to them and say, “Look, I am worried that I'm at risk for developing lung cancer, should I get screened?” And they will sit down with you and have a shared decision-making conversation and go through the criteria and see whether you are eligible for lung cancer screening. And even if you're not eligible for lung cancer screening, they can go over with you best practices to improve your lung health. And that could be smoking cessation. That could be looking at your local environment and looking into air quality in that environment. But just starting that conversation, is the key to improving your lung health.

Addressing Disparities in Lung Cancer Screening

 Can you explain the effect that COVID-19 and the pandemic have had on lung cancer patients?

 So we all have been affected by this terrible global pandemic, with COVID-19. And it's changed all of our lives. And that is for individuals at each walk of life in each community, especially for our cancer community as well, with COVID-19, we've had too many health care centers and medical centers and cancer centers had to adjust their practices to make the environment safe for their patients. And we worried that that could affect cancer disparities, and cancer treatment access.

 What is the risk associated with lung cancer and contracting the coronavirus?

 Well, as of this writing, we don't have a direct relate link to COVID-19 and lung cancer. But we do have data that suggests that some patients who are being treated for cancer, whether it's lung cancer or other types of cancers, can be at high risk for contracting the virus. And at high risk for dying from the virus once contracted. Now, why is that? We don't have high level data to explain that. One, it could just be exposure to other COVID-19 infected individuals in a group setting, right? Or their lungs could be at risk, whether it's a damage long, or whether it's a at risk immune system from treatment that makes them higher risk for developing COVID-19 or dying from COVID-19. There's a lot of data and publications that are out there. And it's difficult to sift through that data to see what is high-level evidence.

 How has the pandemic affected patients and how they're receiving their treatment?

So the head of the National Cancer Institute has worried that with the COVID-19 global pandemic, we will have delays in the diagnosis of cancer delays, in the treatment of cancer, and that we might have increased mortality. Compared to the good news that we've had, prior to the pandemic, where mortality from cancer, specifically lung cancer was diminishing. Now, why would we have delays? One is that based on the local area of COVID-19, incidence, some elective or non-urgent imaging has been temporarily delayed, and that might include lung cancer screening. In addition, in the beginning part of the United States pandemic, specifically in March, there was a recommendation for reducing or eliminating elective surgery across the board. Now, we all know or intuitively know that cancer surgery is really not elective, and in many cases, it should be considered as urgent. At the very minimum, it should be considered as essential. And so for that brief period, we had a dip in cancer-related surgery. However, the American College of Surgeons has partnered with other clinical leaders in surgery for lung cancers. Specifically, they partnered with the Thoracic Surgery Outcomes Research Network to publish guidelines for the management of essential thoracic oncology surgery during the National COVID-19 pandemic. And what those guidelines looked at was what was happening in your local area on the ground in regards to COVID-19. What percentage of your hospital beds and ICU were dedicated to COVID-19 patients? And there we define those into tiers tier 1, tier 2 and tier 3. So if you are a tier 1 hospital, with just a modest impact of COVID-19, then lung cancer should be considered an essential surgery. You should move forward. If you're a tier 2, then you should look at your environment. And are you able to provide that surgical care for lung cancer patients. And if you're tier 3, then you need to find another Medical Center to help or an alternative therapy to help you treat those patients with lung cancer. And because of that, we've been able to provide this essential care for our lung cancer communities during the COVID-19 pandemic. And that goes beyond surgery. It goes with radiation oncology, medical oncology, treatment, and enrollment and clinical trials as well.

 Can you discuss a little bit further about how telemedicine is now playing a role in patient care?

 Telemedicine is defined as an interaction between a provider and a patient. And it's real time face to face or video visits. And now, real time, telephone audio visits as well or telephone encounter. Now with the Cures Act as part of the federal government's response to the COVID-19 pandemic, they have deregulated telemedicine during the COVID-19 pandemic. And because of that, we've seen an increase in telemedicine usage amongst our patients. So the Centers for Medicare and Medicaid Services recently released their data for Medicare beneficiaries and use of telemedicine and what they found was that for Medicare beneficiaries, the use of telemedicine was about 25% to 29%, which is extremely high compared to the 1% to 2%. That was prior to the COVID-19 pandemic. Now, what's fascinating with that CMS data is that the telemedicine usage amongst communities of color, such as Black African Americans, and Hispanics and Asian Americans is similar to the use of telemedicine amongst white Americans. So that is exciting because it may point to telemedicine as a way to fighting disparities within specificity, especially cancer care. What we do know about COVID-19 is that it disproportionately affects communities of color.

So you look at Black and African Americans, when dependent upon the age bracket, we see the mortality of after COVID-19 infection is about six to nine times higher depending on the age bracket as a white Americans. So when you look at the usage of telemedicine when it's about equal, that is an opportunity to care for all Americans, but also our communities of color in a safe manner. So no longer bringing them into an environment where they might be at risk for COVID-19 whether it's the hospital environment, or whether it's the transportation environment to get to the hospital, such as public transportation. And we can do cancer care via telemedicine. For instance, if you look at my practice, which is a thoracic surgical oncology lung cancer practice, about 25% to 30% of my practice currently, is via telemedicine and I can do a telemedicine workup, exam all the way to the point of care for me, which is surgery. And so I'm minimizing that exposure of that lung cancer patient to a potentially COVID-19 environment, bringing them into our hospital for surgery, which has multiple layers of COVID-19 precautions for our patients during doing that potentially life-saving standard of care, minimally invasive surgical resection of their lung cancer and then putting them into a cancer survivorship surveillance program that's based on telemedicine and then also talking to them about both neoadjuvant before surgery, as well as after surgery, therapy to clinical trials, all in a safe manner. So that shows you that telemedicine is a really key intervention during this COVID-19 pandemic. Currently at UC Davis Comprehensive Cancer Center. We are looking at patient-centered outcomes research to boost telemedicine usage in our vulnerable communities of color, specifically African Americans as well.

 Do you have any advice for lung cancer patients and how they can still stay safe and healthy throughout all of this?

 What I would recommend is having lung cancer patients talk to their care provider about the uses of telemedicine. Can they undergo their visits via telemedicine, whether it's face to face video, or whether it's audio encounter that is oftentimes built in to the electronic health record patient portals that are accessible by patients, or now with the cares act, even commercial smartphone. video conferencing apps can be used for telemedicine as well, but check with your care provider, regardless of COVID-19 as your care provider, what resources are available to me? Is lung cancer screening still available to me coming in for standard care therapy, such as surgery, is that still available to me? So this is the essential surgery and not elective surgery? And are there therapeutic clinical trials that are available to me, and I encourage those individuals to look at those opportunities and ask your care provider what's going on with COVID-19 at the local level, and if their medical center cannot cannot provide those cancer, specifically lung cancer treatments because of the COVID-19 rate at that hospital. Can they send you to another Medical Center that has high level of care, high level lung cancer care, and it's not overwhelmed by the COVID-19 pandemic.

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