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The fourth episode of Moffitt Cancer Center's Cancer in our Community podcast focuses on digital health and features Dr. Jhanelle Gray. Tune in to hear from our experts working to create health equity. 

Dr. Blue: Hello everyone. My name is Dr. Brandon Blue. I'm an oncologist in the Department of Malignant Hematology at Moffitt Cancer Center.

I'd like to welcome you to our final episode in our current series of Cancer in our Community, where we have been having conversations about Black health equity. Today's episode is in honor of National Black Family Cancer Awareness Week. And our guest today is Dr. Jhanelle Gray. How are you doing today? Dr. Jhanelle? 

Dr. Gray: I am doing great. Wonderful to be here with you today. 

Dr. Blue: Thank you for coming.

We're so glad to have you with us today, and really I'm going to tell the audience a little bit of your background. So Jhanelle received her undergraduate from our local rivals in the states with the University of Florida in Gainesville, she got her medical degree from Cornell University Medical College, and actually stayed at Cornell for her internship and residency. 

Following she completed her hematology and medical oncology fellowship here at Moffitt Cancer Center in Tampa, Florida. And she's really one of our most accomplished guests so far on the podcast. And one of my favorite friends and most accomplished friends that I have here at Moffitt. So Jhanelle, today we'll talk about some things that are very important to you. And some of the things that we consider you to be an expert on, are you ready?

Dr. Gray: I am ready. Let's do this. 

Dr. Blue: So when we read about some of the things that you specialize in such as cancer, lung cancer, and things that affect the lungs such as mesothelioma, and thymoma, we know that these are kind of their own diseases.

Can you tell us more about some of these cancers that maybe we've heard of, but we really don't know how they get started. How do people present if they have some of these problems like lung cancer

Dr. Gray: Yeah. Well, that's a great question. I think it's also complex. I mean, I think at the end of the day, every patient presents, differently.

There are some main categories under which they can present. One is I have this subset of patients who are completely asymptomatic they maybe had an accident or had to go to the emergency room for something. And they got a chest x-ray and they find a nodule in their lung. We also have a subset of patients who can develop symptoms. So symptoms that we look out for in patients that are listening to this can look out for as well as their family members and caregivers. It's shortness of breath. And that can be whether they feel short of breath when they're resting, or when they after they exert themselves, that is more than what they normally, feel throughout their daily lives.

Cough can be a big symptom, especially coughing up blood that makes us tend to worry that there's some irritation in the airways. Weight loss is actually one of the big ways that patients can present, especially with lung cancer and thoracic malignancies. And it's usually unexplained and unintentional. So if you're dieting, that's great and you're losing weight. Congratulations. But it's really, you're just carrying out your normal daily routine and you're still continuing to lose weight. 

Some patients can present with back pain also as well as chest pain. And once we have something along those lines, we'll definitely want to take a deeper interrogation and make sure that patients are getting the proper workup. The workup could include CAT scans, PET scans, as well as MRIs. 

Dr. Blue: Here at Moffitt, we are a cancer center, but one of our main things that we try to focus on is not only curing cancer, but preventing cancer. So ideally we don't have a person with lung cancer and lung cancer doesn't even exist, but we know that's not true.

Could you maybe tell the listeners, are there any things that they could do to prevent themselves from getting lung cancer? 

Dr. Gray: That's another great question. To prevent patients from getting lung cancer, one of the main things that we have identified that is highly associated with lung cancer and other, other cancers as well, but in particular, lung cancer is smoking.

And so not smoking. Or if you're a smoker, quitting as soon as possible. Your risk of lung cancer is significantly proportional to not just being a smoker, but the number of cigarettes or what we call packs per day or cigarette packs that you have smoked over your lifetime. And so the less, the earlier you quit, the less that you smoked, the better.

The other thing that you can do is now with the national lung cancer screening study, which Moffitt was a big participant in, is that they have demonstrated through that study, that screening CT scans with in particular, what's called a low dose CT scan. So not a CAT scan that I would even order normally, but lower dose than that. Every year annually for those patients who have smoked at least 20 packs of cigarettes in their lifetime, your pack years of cigarettes and we've shown that we can reduce the mortality.

It's really about early detection. The definition of screening is a patient who has no symptoms at all coming in. So once you've become symptomatic, it's a little bit of a different diagnostic path that you do. But if you're asymptomatic, that's something that we definitely want to work with you. And especially if you're high risk to get you in, get your scans done. We have a whole lung cancer screening program here. It is something that we need to do and want to do better about, uh, to get more patients, appropriate patients screened. In the state of Florida, we have a huge opportunity. I almost don't want to say these numbers, but the fact is that in this COVID era only 3% of those patients in the state of Florida that are eligible to receive a low-dose CT scan actually receive it. That means 97% of patients who should be getting screened for lung cancer, do not get screened: a lot of work to do. 

The other thing to note is that Florida's 40th of the states that are getting patients screened. So we need to, whatever your competitive state is out there, look at theirs and we want to do better, but ultimately it's really about reaching more patients locally, regionally, as well as nationally. 

Dr. Blue: You brought up a good point about smoking. So I want to just clear the air.

If I'm a person and I do not smoke, can I still get lung cancer? 

Dr. Gray: Yes you can. 

Dr. Blue: Can you talk to me more about that? 

Dr. Gray: We have about 80% or so, or 85%, I should say on average of patients that are diagnosed with lung cancer, have a history of smoking. There are about 15% of patients who do not have a personal history of smoking.

When we take deeper dives into that, we've seen that it's about 10% of men who are diagnosed with lung cancer. Our non what we call non-smokers and about 20% of women are non-smokers. So that means that more women who are non-smokers are going to get diagnosed with lung cancer. So it's definitely an area of focus for us.

The other thing to note is that when you start taking deeper dives into the non-smoking, individual who comes in and gets diagnosed with lung cancer, your history is a key part of that. A lot of times in their history, they had somebody else in their family who smoked. And so there's this long-standing history of what we call secondhand smoke exposure.

You know, back in the day before the Surgeon General's report, it was very PC. It was okay. Right. You smoked. We smoked in restaurants. We smoked at the dinner table, long car rides going on vacations with the family windows rolled up. We didn't really understand the implications. I think one of the nicest things I've seen is that with that education that's come out there and the public forums we've seen a nice decrease in the rates of smoking and the diagnoses of lung cancer have subsequently proportionately started to decrease.

If we talk about screening, we talk about prevention. I wholeheartedly agree with you that that is really where we can make some of our biggest strides to improving, having an impact and improving patient lives. 

Dr. Blue: One of the things that I hear all the time, and I'm glad we have you here today to kind of clarify this as an expert, sometimes people tell me, they say, well, I've been smoking my whole life. I got lung cancer, now, why should I stop? Right. I've been smoking. I've already got it. Let me just keep smoking. This is my thing that I do. Should they keep smoking? Does it matter? Does it not matter? Can you clarify a little bit to the listeners? 

Dr. Gray: Absolutely. You should stop smoking. And there are a couple of reasons for it.

One is that the more you smoke, you're actually doing more damage and causing injury to your lungs. And so as you go through your treatments, whether that has to do with surgery, whether it has to do with radiation or what we call systemic therapies, such as chemotherapy or targeted therapies or immunotherapy significantly increases your chances of having some sort of side effects, or adverse events or morbidity associated with one of those therapies. That means you may not be able to get through all of the therapy and therefore you're getting suboptimal care and not what we would want you to get and where the data supports that you can have the best outcome. 

The other thing is not only the injury to the lungs, and having side effects is that it also increases your risk of having an infectious process develop in the lungs while you're on these therapies because the therapies are putting your immune system at risk, many of them and just different procedures can. And on top of that, you're adding insult to injury by continuing to smoke. And we also have some data here in the lab led by Dr. Kumar Chellappan one of our premier lung cancer researchers. And he has demonstrated that actually when you continue to smoke that your outcomes from these therapies are less. And so there are multiple, multiple reasons why you should, you should stop on top of the health benefit that you will gain just by stopping. 

Dr. Blue: There you have it folks. So that straight out of the expert's mouth, even if you have lung cancer and you're still smoking it's good to stop. One thing that I think people might be a little unclear about because there's so much information out there is, is lung cancer curable? And if it is curable, can you talk about how people get cured of this cancer?

Dr. Gray: Lung cancer is 100% curative and it is something that we need to get out there. So I'm really glad you asked this question because I think there's this almost stigma and some information out there that, oh, if you have lung cancer, you should be referred directly to hospice.

And you know, a lot of times where you're going to get diagnosed or be seen is going to be with your primary care physicians, your pulmonologist, you know, if I have shortness of breath, I have a cough. I'm going to go to those individuals to help me navigate, to see what is the etiology, what is the cause behind that? Is it just my reflux? Is it that I have post-nasal drip? Do I have pneumonia? Could I have a cancer? 

And so once you navigate through that, that route and go through those individuals, then you can really start to see where you get to the right individuals. Then you get a proper diagnosis and you get on the right, you get on the right treatment. 

Dr. Blue: So what were some of those treatments be? 

Dr. Gray: It's really about triaging the patients accordingly. If you have an early-stage lung cancer surgery is absolutely the best way to go to get that proper treatment, and get you cured of your cancer. We have demonstrated recently that adding things such as radiation therapy, chemotherapy, immunotherapy, or targeted therapy can improve those cure rates. The real thing again is about catching the cancer early and driving that home. 

I do want to say there are multiple options on the table and that personalized care precision oncology is very much needed. That individualized care, every patient that comes here is an individual and your treatment plan should, and likely will look very different to those individuals sitting next to you. And that's, what's going to give you the best outcome. 

Dr. Blue: So I hear you mentioned surgery. Sometimes it's been brought up to my attention that some people are scared to get surgery. They say, Hey, if I expose my cancer to the open air, right? Like they cut on me and they're trying to remove this, then that will increase the risk of my cancer spreading to somewhere else by undergoing a surgery. How safe is lung cancer surgery? And is that really a problem that people should be worried about, 

Dr. Gray: So for lung cancer, surgery is very safe. The key thing there is going to an expert, and I advise this regardless of your medical condition. You want to go to the top experts to get a consultation and evaluation from them. That is very key. Data has shown consistently that if you go to those individuals who are treating multiple patients with a certain condition, you're going to have a better outcome because they have that expertise. Surgery for lung cancer is not one where we worry really about what's called seeding, right? You're worried that if you open the cancer to air that there's a potential that it can land in other places. There are some cancers that, that is a higher concern, but not with lung cancer.

The other thing with lung cancer is that we have advanced significantly in that field to robotic surgery, to minimally invasive surgery, especially here at Moffitt. This is what our surgical team focuses on. So it's not only about resecting the cancer, resecting all of the cancer. You also want to, you want to heal after your surgery. You want to get out of the hospital. 

We used to have postop days where five, six days patients were still in the hospital. Now, postop day one, two patients are going home. And their scars, they're recovering. And from a medical oncology standpoint, I'm seeing that in a clinic, by the time somebody comes back to me rom the surgery from the operating room into my clinic, and I'm talking to them about what's your next steps. And I always have to check the surgical scar to look for any potential problems with wound healing. Unbelievable. Unbelievable. It is night and day from when I started here 15 years ago to where we are now. Patients are coming in they're back to running they're back to activities even before they land in my clinic. Fantastic.

Dr. Blue: Good. You know, is there anything with all these different advancements in surgery and radiation and chemotherapy? Is there anything that you're the most excited about, like in lung cancer treatment that you say, this is the way this is the new hot thing that's really kind of gets you excited about where the field is going?

Dr. Gray: Well, there are a couple of things. I don't know that I can just pick one. I think screening. You know, I know it's not treatment, it's not so sexy, but it is absolutely what we need. We have to get more patients screened. And that ultimately to me, is how we are going to make an impact again, with that early detection. 

Then there are two areas that I'm very excited about from the therapeutic standpoint.

One is immunotherapy looking at things along the lines of immune checkpoint blockade. Thinking about things like vaccines, leveraging the patient's immune system to really, have it help us fight off the cancer. 

There are also targeted therapies where there are some markers on lung cancer that are well known. And some that I frankly believe we have yet to discover. And what we do is we identify that marker, and we are able to shut down that marker and shut down the tumor cells. There are multiple areas within that setting. I highly recommend that anybody that's diagnosed with lung cancer, talk to their physicians or provider teams about making sure that we are typing and subtyping their cancers. Not only at a pathologic level, but also at a molecular level. A key part of your discussion. 

Dr. Blue: Now, when people hear this, and you used the word vaccine, you know, the first thing that comes to people's mind is COVID vaccine. Right. That's really what's out in the news, but really how vaccines kill cancer.

I think that's something that people may not have heard of before. So if you can, can you speak to the people listening, like vaccines for infection? Yeah. But vaccines for cancer. How does that work? 

Dr. Gray: It's actually the same process, right? Same thought process. We are all about leveraging and triggering that immune system to identify at the end of the day, if you have an infection, the infection is a foreign, basically a foreign body. It doesn't belong there. Your immune system will come in and identify that it's foreign. Sometimes your immune system can recognize things a little bit better. At the end of the day, cancer cells are not your normal cells. And they are also abnormal. And so how is your immune system identifying those as abnormal?

Sometimes they need a little help and the vaccines can do that. One of the vaccines, similar to the prototype for the COVID vaccines that have been used by a couple of the pharmaceutical companies, is an mRNA vaccine. The mRNA vaccines are a way where we can have proteins generated that the immune system can recognize as foreign and those proteins that are generated by those mRNA vaccines are proteins that are similar to, for example, the COVID virus. And in the case where you have cancer, similar to the proteins that are expressed in your cancer. 

And therefore providing that support for the immune system to kind of kickstart your immune system. Your immune system can then start off and roll forward with attacking the cancer. It's also a more minimally invasive way of treating patients. They don't have to get treated so often they can come in, usually monthly or more and more sporadically to come in. So I think it's definitely a way that we can innovate in the future and we'll continue to, 

Dr. Blue: Well, you heard it here, guys. It's a lot of different ways that we have to kill cancer. What a time to be alive.

You know, one of the focuses of this podcast is really talking about the black and African-American community. So is there any information that we need to get to, you know, the Black and African American community to say, hey, lung cancer is a problem in this group. Or like, what, what can we tell them and say, Hey, you really need to know this because in your group, this is a problem.

Dr. Gray: So I, think it is multifold within the Black and African-American community, especially when it comes to cancer. I think for lung cancer, one is that we know that Black men have worse outcomes when it comes to lung cancer and taking deeper dives to understand that. We also know that in the Black community, even though they may have less of a history of smoking, they still get diagnosed with lung cancer at a similar or even higher rate. So there are some other environmental and genetic factors that are going into that. 

And so being particularly hypervigilant, I think in those communities is very, very important. The other thing that I think is important to note, and I don't think this is unique to lung cancer is that there is under-representation when it comes to clinical trials and developing innovative therapies and those populations.

And it is something that we all need to work toward with patients, providers, as well as regulatory agencies, to make sure that we're offering, again, these cutting-edge therapies to patients of all populations that we're studying them across different populations. Exactly, that's what I was pointing to before about those environmental and genetic factors that do differ.

If we don't study medications and certain agents in these populations, how do we know they really work? How do we know their full side effect profile? I think it's okay to make assumptions for the short term, but we really need to prove the data. I think there's data out there in multiple other arenas, such as in cardiology and nephrology, where, when you actually study medications in particular in Black and African-American populations you can see different outcomes, you can see different side effects. And if you don't look, you won't find it. 

Dr. Blue: One thing that I think is a little bit unclear to me, maybe even unclear to the listeners is lung cancer something that is passed down? Like if my mother, my father has lung cancer, should I be worried as their child? 

Dr. Gray: Yeah. So for right now, we have done studies looking at, heritability of lung cancer and we actually participated in this study. And for right now there's nothing that we can find that can say, okay, if mom, dad, grandma, grandpa had lung cancer. Would you be at risk? The main thread that I do see commonalities when you, again, take in that deep history and really understand what that family lineage is, is really that smoking status. And so I think if there's anything we can educate people about, again, is don't start smoking if you're smoking stop smoking. 

Dr. Blue: So, I see from all the many things that you do, that you're really a superwoman. You do a lot of different things, you know, not only are you a doctor, you're a researcher, you're on the chair of a lot of different committees. You're a board member on certain organizations, you know, what is it about, you know, kind of doing this type of work that's important to you? Like, why is it that you say, you know what, I can't just see patients. Or I can't just answer research questions, you know, what is it about doing, you know, a lot of different things to really benefit people that really kind of motivates you.

Dr. Gray: I think there are a couple of things. I think first, I think there's something inherent in me that I want to help individuals. I think as a physician also, it's really, to me about impacting as many lives as possible, whether you're sitting right in front of me or not, how can we do that on a broader scale? Also, how can we train the next generation? Right?

What, has been imparted to me to allow me to get to where I am and how can I help support that next generation? Almost like a pay it forward. So that's, that's definitely something that, that motivates me. I think just being a good, helpful person and setting a good, example for my kids, in particular my daughter.

And making sure that just doing everything to show that you can do it, you can balance things. You just need to have the right kind of support around you in order to accomplish that. 

Dr. Blue: What's in the news right now and all over Twitter and Instagram are the hearings for Judge Ketanji Brown (Jackson). So we're really trying to find a new Supreme Court Justice. 

Dr. Gray: Yes. 

Dr. Blue: She would be the first African-American woman elected to some position of that nature. You have had your own kind of milestones of really kind of being ground-shaking and really kind of setting new boundaries, especially for a minority woman.

Can you talk about like how that journey was for you? Like, we don't have many minority women in leadership and so how. Do that, like how, how did you break that ground, that glass ceiling that was there. How did you shatter that to really become as successful as you are? 

Dr. Gray: Well, I don't know if I've broken it just yet.

I think it's multifold. I think that there are a lot of phenomenal women and men who have paved the way and I have had outstanding mentorship. I have never. I shouldn't say never cause that's a really strong word. I think there are certain things that come across your desk that you have to recognize what's an opportunity for you to potentially grow and be challenged, versus what is opportunistic. And you know, making sure that you're making those right decisions is very, very important. I think sometimes, honestly, just boots to the ground and keep your head down and do your work. And I think someday it will, it will show itself and speak for itself.

I do recognize this honor and privilege of being able to also represent, others in whether you're in the medical field, whether you're in, the business arena, whatever professional venue that you are in and representing other underrepresented minorities and continuing to pave the way for them.

And that's something that means a lot. 

I cannot say that it has been easy, every single turn, but I think the key message here is that it's doable. One of the things I would recommend to anyone who's trying to do something along these lines is to have a good support system, have a good support system at home within your family and also have a good support system in a community network of other individuals who are going through things that, may not be in the similar field as you, but can kind of help you through that, through that journey. And so I have a group of female physicians, Black female physicians, and Hispanic female physicians that I'm friends with from medical school. And, and we have all supported each other. And I can tell you that by the way, I am the least accomplished out of all of them. So really kudos to them for paving the way and letting you know that you can do it. You can do it. 

Dr. Blue: Well, I'm just so happy to be in your presence and you taking the time to really talk to us today.

You know, you've really given us a lot of information about lung cancer and things that I didn't know. And hopefully, our listeners learn something today. But before we say goodbye, given all the things that we've talked about, sometimes we really kind of need what we call the meat and potatoes. Could you leave us with a couple, like take-home points, something that, you know, if, if they get nothing else from all this information, what would be a couple of things that they should know about all the things you said today? 

Dr. Gray: Oh gosh. That's, that's a packed question. I think one thing I didn't touch on is that, and I would like to say this as a mom, right? Is that family is first and I want to thank my assistant. I send her my kids' schedule for everything. The kids' schedule goes on for everything and then everything works around it. And that's one thing we did not touch on. And if it doesn't work for my family schedule, then it just doesn't work. And that's okay, I've learned along this journey. 

Some things that come across your desk. Again, they may be an opportunity, but maybe they're not an opportunity at the right time. And if it doesn't work, then don't worry something else is going to come up along the way. And I was taught that by one of my mentors, many years ago, you can't do everything. But if it doesn't work for that, then, then it just, it's not going to work out. 

From a lung cancer standpoint. I think, you know again, don't start smoking. If any young kids are listening to this, middle-school is actually where people are getting most approached to start smoking. Don't start. Quit smoking if you are, and let's get you, let's get you ready and set up for screening. And if you do get diagnosed with lung cancer, we're here. We're here to be your partner and to help you along that journey and make sure that you're getting the best treatment possible, the right drug for the right patient at the right time to have the biggest impact.

Dr. Blue: All right. Well, thank you all today. We really appreciate everyone for listening. We thank you for your time today. This has been Dr. Jhanelle Gray from Moffitt Cancer Center. Thank you. 

Dr. Gray: Thank you.