Three years after a diagnosis of lung cancer, Rita Appel is cancer-free and enjoying life to the fullest.


Breathing Easier

Rita Appel, 68, of Westport never expected that an annual checkup with her primary care physician would lead to a visit with a pulmonologist and a diagnosis of lung cancer – nearly 40 years after quitting smoking.

It all began in 2016 when Appel had a chest X-ray as part of her physical. Her doctor prescribed antibiotics for pneumonia after noticing a spot on her right lung. But the spot was still there after a follow-up X-ray and a more precise CT scan. As a precaution, Appel was referred to a pulmonologist, who ordered a PET scan, which ultimately led to a diagnosis of non-small cell lung cancer.

A few weeks later, Paul Waters, MD, chief of thoracic surgery at Greenwich Hospital, confirmed the diagnosis and performed a lobectomy to remove the upper portion, or lobe, of her right lung. Today, Appel is cancer-free and enjoying an active lifestyle that includes Pilates, yoga and hiking.

“The entire experience at Greenwich Hospital – with Dr. Waters, the nursing staff and the physical therapist – was terrific,” Appel said. “I’m totally off medications now, and my health is otherwise good. In fact, I went snowshoeing in February and did really well.”



Paul Waters, MD, chief of thoracic surgery, offers patients the latest advances in the diagnosis and treatment of lung cancer.


Lung cancer is the second most common type of cancer in men and women, accounting for an estimated 25 percent of all cancer deaths in the U.S. each year. The two most common types are non-small cell and small cell lung cancer. Although lung cancer rates among men have declined in recent years, the number of women diagnosed with the disease is on the rise, reports the American Cancer Society.

Considering those ominous facts, Appel’s case is encouraging because it reveals the latest advances in the diagnosis and treatment of lung cancer at Greenwich Hospital, which is affiliated with Yale New Haven Health’s renowned Smilow Cancer Hospital.

First, Appel had none of the symptoms of lung cancer, such as a persistent cough, hoarseness or wheezing, shortness of breath, bloody spit or phlegm, recurring bronchitis or pneumonia, weight loss or loss of appetite, and chest pain. Second, although non-small cell lung cancer is often associated with smoking, Appel quit her “social smoker” habit nearly 40 years before her diagnosis. Dr. Waters suggested that exposure to secondhand smoke, another prominent risk factor, might have contributed to her disease. She grew up when nearly half of American adults smoked cigarettes – compared to less than 16 percent today.

Recognizing that lung cancer can occur among non-smokers and develop for years without causing symptoms, Greenwich Hospital offers screening to improve early diagnosis of the disease. “We encourage adults who are at high risk for the disease to get a low-dose CT scan of their lungs,” said Dickerman Hollister, MD, director of medical oncology at Greenwich Hospital. Clinical trials have shown these screenings to be more effective than chest X-rays in detecting early-stage lung cancer.

Greenwich Hospital provides several other tests to diagnose lung cancer and identify the extent of the disease to develop an individualized treatment plan. “We determine which test to use depending on the patient’s symptoms, risk factors, previous cancers and related factors,” Dr. Waters said, “but we start with some type of imaging.” The tests typically include a biopsy to remove tissue samples and examination under a microscope for possible cancer.

During a bronchoscopy, for example, a flexible tube with a tiny camera, called a bronchoscope, is passed through the mouth, the windpipe, and then into the lung to look for tumors or suspicious cells. A more sophisticated electromagnetic navigation bronchoscopy creates a virtual map of the windpipe to the outer edge of the lungs, allowing precise guidance to the lung shadow. A percutaneous needle biopsy involves passing a tiny needle through the skin and into the lung to remove tissue.

“We use the least invasive method possible,” Dr. Waters explained. “But if the diagnosis is still elusive and we’re concerned it is a cancer, we may move to a more invasive test.

”If the biopsy confirms a lung cancer diagnosis, a multidisciplinary team meets to determine a treatment plan for the patient. The team includes pulmonologists, medical oncologists, thoracic surgeons, radiation oncologists, radiologists, pathologists, nurses, and other supportive staff, such as psychologists, social workers, geneticists, physical and speech therapists, and dietitians.

“We discuss whether to treat the lung cancer with surgery, chemotherapy, radiation therapy or a combination of those methods,” said Dr. Hollister. “With so many options now, we decide which is most appropriate for a given patient, because each one is different.”

Dickerman Hollister, MD, director of medical oncology, is part of a multidisciplinary team that offers patients personalized treatment options.



Surgery is generally the first treatment choice. Besides lobectomy, two other common procedures are wedge resection (segmentectomy) to remove a small section of the lung and pneumonectomy to remove an entire lung.

Some lung cancer patients, such as Madeline Gaglione of Harrison, NY, are candidates for minimally invasive surgery using the da Vinci robot-assisted system. The da Vinci technology features a magnified, 3D vision system and special instruments that bend and rotate farther than the human hand. This enables surgeons to operate with enhanced vision, precision and control through a small incision. Patients typically experience less pain and a quicker recovery.

Gaglione, 74, had been experiencing intermittent pain on her left side, but wondered if it was associated with Crohn’s disease, a chronic inflammatory condition of the gastrointestinal tract that she has tackled most of her life. A series of tests, though, diagnosed non-small cell cancer in her left lung. “It was a shock to me,” she said, adding, “I had quit smoking 42 years ago.” Gaglione opted for a lobectomy. “Dr. Waters did a great job of explaining the entire procedure, including the robotics. The whole experience went wonderfully well,” she said.

Although neither Gaglione nor Appel required chemotherapy or radiation to treat the lung cancer, that’s not always the situation. Chemotherapy remains the standard for patients who require treatment after surgery. For patients who do not have surgery, newer, non-chemotherapy agents known as immunotherapy can be very effective, using the body’s own immune system to fight cancer. Immunotherapy can be administered either with chemotherapy, or by itself after chemotherapy and radiation. “We have many more treatment options than we did just a few years ago,” said Dr. Hollister.

Much of the chemotherapy research and drugs to treat lung cancer and other cancers at Greenwich Hospital are provided in coordination with colleagues at Smilow, noted Dr. Hollister. “We offer some patients clinical trials to test even newer treatments,” he said.

“We’re hopeful and excited that while lung cancer remains a very serious disease,” said Dr. Hollister, “today’s options create an outlook for patients that’s better than ever.”

Madeline Gaglione underwent minimally invasive surgery with the use of robot-assisted technology.