Podcast: It Looked Like the Flu

A man walks into his doctor’s office with flu-like symptoms—and walks out with a lung cancer diagnosis. What happens next opens up a broader conversation about early detection, access to screening, and the clinical nuances of treating non-small cell lung cancer.

In this special episode of DDx, which is hosted by Raj Bhardwaj, MD, and produced by Figure 1, we bring you a candid discussion between oncologists Sanjay Juneja, MD, and Eric Singhi, MD. They unpack a real patient case and explore the practical, diagnostic, and systemic challenges that shape lung cancer care today.

RAJ: This is DDx, a podcast from Figure 1 about how doctors think.

I’m Dr. Raj Bhardwaj.

Today we’re exploring the clinical decision-making that defines great medicine—how doctors recognize patterns, challenge assumptions, and refine their judgment in real time.

One of the biggest challenges in oncology—and medicine in general—is distinguishing between the routine and the urgent.

Some cancers present with symptoms so vague they can be mistaken for something benign.

Others seem straightforward at first, only to take an unexpected turn.

How do we sharpen our instincts to catch cancer early, without over-investigating every case?

That’s the question at the heart of today’s episode.

Our story is about a 67-year-old Black man who quit smoking nearly two decades ago—after more than two decades of consuming a pack a day.

His lung cancer was discovered when he saw a doctor for what seemed like the flu.

It’s a case that raises big questions—not just about early diagnosis, but about access to lung cancer screening, missed opportunities, and how collaboration across specialties makes a difference.

And today we’re offering something a bit unique.

Instead of our usual format, we’re bringing you a candid conversation between two oncologists.

It’s a chance to hear the kind of insight that comes not from textbooks, but from the real-time discussions between colleagues—the cases that make them pause, rethink, and adjust how they practice.

Joining us is Dr. Sanjay Juneja, a community oncologist and hematologist in Baton Rouge, Louisiana, who treated this patient, and Dr. Eric Singhi, a thoracic oncologist and Assistant Professor at the University of Texas MD Anderson Cancer Center.

Together, they’ll walk us through what happens when a seemingly routine case reveals something far more serious—and what comes next.

Let’s dive in.

Dr. Juneja: Hi, my name is Dr. Sanjay Juneja. I’m a hematologist and medical oncologist, and also Vice President of Clinical AI Innovations at Tempus AI.

Dr. Singhi: Hi, my name is Dr. Eric Singhi. I’m a thoracic medical oncologist. I specialize in the care of patients with lung cancer.

Dr. Juneja: So the case I wanted to discuss was actually a 67-year-old gentleman, and he had a smoking history, mind you, but it was probably 19 years ago that he had last smoked, and it was a pack a day for 25, 26 odd years, but that is actually not at all the context of what brought him to me.

He basically went into his doctor’s office and had flu-like symptoms, right? And they weren’t really responding to that general management you do as an outpatient. So they ordered some imaging to see if his lungs looked okay. What ended up happening was that the chest x-ray revealed something more serious.

And his symptoms didn’t really raise any red flags at first because they were what we call acute or subacute, right?

So I’m wondering, what kind of symptoms either tend to get overlooked for one, or what symptoms aren’t really obvious when it may relate to something like early-stage lung cancer?

Dr. Singhi: Yeah, you don’t necessarily have  symptoms if you have lung cancer, especially if it’s early stage. That’s why screening is so important. This case is all too familiar, unfortunately, where you do have a patient presenting maybe with some vague symptoms.

They can have fever, they can have cough, they can have worsening shortness of breath, they just don’t feel well, or they’re losing weight without intention. And then you think it’s not cancer, you think it’s something else, like infection or maybe there’s another reason. And then, unfortunately, you do more workup and you uncover that it is, right? Whether it’s early stage or whether, unfortunately, after delays, it ends up being a later stage of disease like stage four.

Dr. Juneja: We are recognizing that people get lung cancer without a smoking history. And no age is spared, so to speak. But to that point, when there is a smoker, there is a very approved survival benefit related screening process.

And when a lot of the things that we do for screening, like colonoscopy and pap smears and mammograms, are all hitting 70, 80, upwards of 90 percent, there’s about a 10 percent or 15 percent compliance of capturing those patients that have smoked to do some screening. So can you tell us, please, why is it just not ordered because I believe the survival benefit is better than all of the other ones.

Dr. Singhi: Yeah, this is a really good point, Sanjay. Less than 20 percent of eligible Americans are going for lung cancer screening routinely. And those rates vary so much by state. So some states are 1 percent or less, particularly in the South. And you’re right, the number needed to screen to save a life for lung cancer actually is less than breast cancer, less than colon cancer. That’s not to say that this is more important, but it should be of value just as much as looking for breast cancer, just as much as looking for colon cancer.

The guidelines that we have right now are based on the United States Preventative Services Task Force, which is a mouthful, but that stands for U-S-P-S-T-F. And what we have is criteria that is somewhat selective. You have to have a smoking history, not just a smoking history, but you have to have at least a 20 pack-year smoking history, right?

So it’s the number of packs per day times the number of years. And that gives you a pack-year history. So 20 pack years or more, you have to be between the ages of 50 to 80 and you have to currently still be smoking, or you had to have quit within the past 15 years. So it’s a very select group of patients, and that’s the criteria that we have right now.

Dr. Juneja: Yeah. And I think that’s what made this case something significant because even though he had quit smoking 19 years ago, mind you, when I saw him as his oncologist, it was not, again, from the screening that he clearly qualified for because he had 26 pack years, but because of a symptom and a symptom seemingly unrelated to the early cancer itself.

So you could imagine that when I did see him in my office to tell him that he had lung cancer; the flu symptoms could have actually saved his life because it actually clued into something that was otherwise being missed, which is to get a CT scan annually. The strange circumstances where he is, like well, I’m really glad that I had the symptoms, but on the flip side, I’m, how come I hadn’t gotten the screening before? Unfortunately, there is data that depending on your race alone, there is a discrepancy on either the timeliness to diagnosis or even the outcomes.

Dr. Singhi: One of the statistics that I look for, or sort of the information I look for, actually comes from the American Lung Association.They’re a fantastic organization and they put out the state of lung cancer report every year. And I remember unpacking that information and looking specifically at what are they reporting in lung cancer. So black individuals with lung cancer were 15% less likely to be diagnosed early.

Black individuals with lung cancer were 15 percent less likely to be diagnosed early, 19 percent less likely to receive surgery, 12 percent more likely to not get any type of treatment for their lung cancer. And as a result, 16 percent less likely to survive five years compared to white individuals.

Dr. Juneja: What does that tell you? Because I know what it tells me when I hear that.

Dr. Singhi: Yeah. I think we’ve really failed our Black Americans, to be honest, as a medical society. And it’s years of disservice, I think, to them. We’ve left them out of the conversation. We’ve taken advantage of their trust as well, and we’re not really putting in the focused efforts to repair that relationship.

I think that’s one thing from a historical context, from the other aspect, I’m worried about implicit bias, to be honest with you, that we’re not inviting the conversation. We’re not inviting them to take charge of their health. We’re not empowering them with the right way to inform them about making the right choices for their health.

We can’t just put it on them. It’s definitely us as a medical society. That’s why it’s important to do things like this, right? To have education that’s accessible to providers to say, hey, listen, this is an issue. These are the statistics. What are we gonna do about it? It’s a call to action.

And then we should also have dedicated education specifically to those communities. Where we go meet them in their environment. We rebuild that trust, we repair a lot of the damage that’s been done. We need to be proactive about it.

Dr. Juneja: Yeah. One quote I’ll never forget and people say, Black Americans need to learn to trust doctors. And instead the appropriate statement is doctors need to learn to earn Black Americans’ trust. And I loved it because there is very well-documented historical context on which maybe even seeking healthcare or seeking what’s recommended is met with a little bit of weariness.

And that’s because of literally what happened, like what is known. With that said, and I hope everyone that hears that conversation or has it thinks about those things and it’s not a one-off. The second is also just access, right? if there’s four different ways to get into a store versus one, the line is just gonna be a lot longer. And then how far that store is another factor. And how many people from different territories are needing to get there.

How do you see us addressing, or first let me say, how bad is it when as it relates to geographical regions or certain demographics on even being able to get the standard thing, so everyone knows what to do, the primary care doctor’s on it, the patient’s on it. Is there some component to where just even getting the screening or the workup is either limited or not as timely?

Dr. Singhi: The practical barriers are huge. We leave out our patients that are in rural communities, for example, that don’t live next to a cancer center or a hospital that offers these screenings. So I like your analogy of the store. Why can’t we bring the store to them? Why can’t we bring the screening to patients? And we’re starting to see these initiatives, which I love—mobile screening. Where they have the scanner, it’s easy to transport and you go to the patient, you go to the community.

Dr. Juneja: Can you tell me though, how that translates to actually a timely process, right? Because getting to the specialist in time, and if you’re lucky in the CT surgeon or pulmonologist, is just very on top of the guidelines and refers to you. This could end up being a prolonged process before actually nipping it in the bud, so to speak.

Dr. Singhi: Multidisciplinary collaboration is so important. I tell my patients that cancer care takes a village. So the screening starts from having a longitudinal relationship with your primary care physician, having an advocate in your health, a one-stop shop, if you will, that they know you, they know your family, they know how to advocate for your health and your health needs.

I wonder if the patient that came to you had a longitudinal primary care physician, was able to pick up on maybe even subtle signs or symptoms that were developing, was able to educate the patient right about how to get screened for lung cancer, how to educate his family members even to do it. That’s so important.

Dr. Juneja:  Yeah. And I think  this case unpacks a lot of different issues and points that I know, you and I have both been vocal about over time.  This case, it was fortunate because it would seem to be early stage disease, which in other words means, the intention is cure, right? Because after you check everything else, if it hasn’t spread anywhere and it’s one of those stage two, stage threes or stage one, ideally, then you can have a curative approach.

So what I did was, I referred him to CT surgery. And the big thing though, that is I think a little challenging for a lot of you know, community or general oncologist, is really knowing when the guidelines are suggesting doing therapy before getting it taken out, and I know to a lot of people, this sounds crazy, they’re like, you’re telling me I have a cancer that hasn’t spread and you’re telling me you wanna wait three months, up to six months, depending on the tumor type to actually take it out and cure me.

But there’s a reason for that because you have data that shows that by trying to shrink this down and killing any disease, you cannot see, because it takes something like 200 million cells to be able to see it on an average CAT scan.

Dr. Singhi: You’re highlighting really great points and challenges, Sanjay. Time is everything right, but you also wanna have a very meaningful plan before you go in. So that’s what I tell my patients. If we’re aiming for cure, we want to do this right? We wanna do it safe, and we wanna be effective when we go in.

Dr. Juneja: Where should we be thinking about a referral to a medical oncologist? There’s so many tumor types now and all of ’em have their gray zones. Where, where are the black and white zones of when a medical oncologist should get involved to possibly give treatment before surgery?

Dr. Singhi: We have gold standard of what we should be doing, and then we have the real-world implementation of how things are done, whether it’s because of logistical barriers, whether it’s because of education or lack of that. From the provider perspective, from the patient perspective.

There’s a lot of things that go into this. Who really needs neoadjuvant therapy? Who needs therapy upfront? The answer I would say is patients with lymph node-positive disease, especially if they’ve got bulky lymph node-positive disease, they have several sites of lymph node disease.

You really want to try and shrink that tumor again before surgery to make it more effective, make it easier for the surgeon. Get rid of as much cancer as possible before the surgery. So definitely for patients with stage three disease I do think neoadjuvant therapy is really important.

For patients with stage two disease, I’m leaning towards that or even what we call a perioperative strategy where patients get a sandwich, if you will, of treatments. So they get some treatments before they go to surgery, they go to surgery. And then they get treatments after. That’s what we call perioperative.

Now that being said, there are patients that I’ve also seen where a surgeon has seen them and either lymph node staging wasn’t done beforehand, or they just went for an upfront surgical resection without getting the full picture of what was going on with their staging. And then they did find lymph nodes and then we considered what we call adjuvant therapy, which is treatment after surgery is done to reduce the risk of that cancer coming back. So I would say in an ideal world, I think having that multidisciplinary conversation upfront immediately at time of diagnosis is what should be done for everyone. But it doesn’t always happen. So it’s nice to have some of these parameters.

Historically, we used to think about just using traditional cytotoxic chemotherapy alone to see if we could get a response to shrink the tumor before somebody went for surgery and we really didn’t see great responses with that approach, to be honest with you.

So this pathologic complete response, that’s a really fancy term for looking at how well does a tumor truly respond to some type of medical treatment before surgery, like chemotherapy, for example, a patient gets some chemotherapy, then goes to surgery, then the tumor gets taken out and a pathologist looks at the tissue and they say, okay, how much of the tumor was actually killed? How much of the tumor is still alive?

And the ideal would be there’s zero percent tumor that was alive because the patient really benefited from some treatment upfront. And we call that pathologic complete response or PCR.So historically, with just chemotherapy, we only got rates of about 2 percent. That’s really bad, right? So 98 percent of patients on average were not really getting there.

What’s changed a lot in just the last four or five years are FDA approvals or we’re trying to do better than just giving chemotherapy upfront to patients, whether it’s immunotherapy, which is a whole different bucket of drugs that we use to teach your own immune system to recognize the lung cancer and to fight it, or even targeted therapy, which many of them are oral pills that really work to shut down a pathway that’s teaching the lung cancer to grow, to shrink that tumor even before surgery.

Dr. Juneja: No doubt, and I think when we’re analyzing the tumor to see, hey, is there a candidate or a feature on this tumor that can give us some kind of, what we call an actionable mutation. So it has a characteristic that qualifies for therapy directed to that characteristic, rather than in a general sense like chemotherapy, which just acts on replicating cells and not necessarily targeted therapy. But my question is, when you say, hey, everyone needs biomarker testing in this setting, what are those kind of landmarks that you recommend?

Dr. Singhi: Yeah, so in my practice, anyone with non-small cell lung cancer, regardless of the stage, is getting molecular testing, is getting biomarker testing. And that’s looking at the DNA and RNA genetic changes that are specific to the tumor itself. Really trying to understand, okay, why is this tumor growing and how can we personalize a treatment to really shut down the pathways that are teaching it to grow?

So you really need to have that knowledge as power in this setting to make a decision. To also even think about clinical trials, right? So we have drugs that are already approved. We have drugs that are being studied, and so there’s a lot of opportunities to learn from understanding the biology of the tumor.

And so I am personally ordering molecular testing on all of my patients with non-small cell lung cancer, regardless of stage, also regardless of histology. So a lot of times we’re often so focused on non-squamous, non-small cell lung cancer, but I have had patients that have an actionable alteration and have a squamous histology. So I wouldn’t limit it there.

And then the other thing to talk about too is checking for what we call PD-L1 testing or PD-L1 expression. It’s a different type of test that we do, but it really helps us understand the value of potentially using immunotherapy for patients. So I’m ordering that routinely for all my patients.

Dr. Juneja: Yeah, and the more we actually get those cases and take a harder look and have that biomarker testing, like you said, we can really tease out what is your tumor type and what are your features. So in this patient’s case, we ended up actually doing the sandwich approach. He appropriately got neoadjuvant therapy before, had the definitive treatment, and got some treatment afterward. And I think it’s probably two years out now and doing well—no evidence of disease.

But I think in a more general sense, when we look back, what are some assumptions about lung cancer or lung cancer diagnosis that possibly led to either not getting screening or having this missed? Is it just simply that he hadn’t smoked for a long time?

Dr. Singhi: Yeah, this question really resonates with me a lot because the majority of my practice has actually become 50 and younger. So we call that young-onset lung cancer. And a lot of these patients actually don’t have a smoking history. And a lot of patients come to me very puzzled and confused. They say, “Oh my god, I thought you had to be actively smoking,” or, “I thought you had to have a very extensive history of smoking to get lung cancer.”

That’s not the case. One in five Americans currently are being diagnosed with lung cancer and they’ve never touched a cigarette. They’ve never smoked. So that’s 20 percent, which is really high. I think there’s a lot of this stigma around lung cancer. And so what I tell people is that anyone with lungs is at risk for lung cancer. But no one deserves to have lung cancer. And so that’s a message that needs to be very clear. That being said, if you meet the criteria for the USPSTF screening, I really strongly do believe in it.

I think that the problem with that—one, yes, is the stigma that’s surrounded, the blame that’s surrounded around lung cancer—but also just the education and uptake, not even from the patient standpoint, but from the provider standpoint. Stressing that this is an annual low-dose CT scan is important.

It’s not a one and done. You have to be longitudinally enrolled in this, longitudinally able to sign up for this. Stressing that it’s a non-invasive test. It takes on average about three minutes to get through a scan, right? A scan that could potentially reduce your mortality risk of lung cancer by 20 percent. We’ve seen it on trials. So I would stress the benefit.

And then the third thing I would say is there’s actually a paper that came out maybe a couple months ago now, and they called it the Boston Lung Cancer Study. So it was led by thoracic surgeons. It looked at about 7,000  patients with lung cancer in the Boston area.

And what they found was that less than half of those patients who were ultimately diagnosed with lung cancer—about 46 percent of the patients—were eligible to get screened under our current USPSTF screening guidelines. So that means we’re missing almost about half of the patients who do have lung cancer.

Whether it’s because of age, whether it’s because of, like you pointed out, Sanjay, that the smoking duration, right, having these pack years that are mandated, or even having to think about that 15 years since quitting smoking criteria.

So there’s a lot of work that needs to be done to identify some of the non-traditional risk factors to really make it more inclusive and expansive to screen patients for lung cancer. And it’s an active area of research that I want to promote and highlight.

Dr. Juneja: And to that point, what are some broader trends—maybe either in medicine and then even larger than that in society—that make these cases of what we call “incidental” more common?

One, it sounds like just simply people aren’t aware that it is very much a non-smoker’s cancer. But if one is lucky enough to have symptoms before it has spread—which are the more global symptoms: weight loss, no appetite, fatigue—before any of that stuff, what are some of those symptoms that are the most concerning for, like you said, under 50, never smoked, that primary cares could be more aware of or have a lower threshold for?

Dr. Singhi: Yeah. So if you have a cough that doesn’t go away. If you’re having shortness of breath that’s getting worse and you’re noticing it. The really scary one of coughing up blood— take that seriously. Chest pain that just isn’t making sense.

Unfortunately, in my personal practice, I see these patients. They’re unfortunately dismissed because they’re young, they’re supposed to be healthy, they’re busy with their social lives, they’re actively working. They don’t have time for a longitudinal primary care physician relationship, and they make these pit stops at urgent cares or other places once the symptoms really start to add up.

These symptoms can be so vague, and people still don’t know that you don’t have to be an old male with a heavy smoking history to get lung cancer. So any of these symptoms that we mentioned—or if something feels off with your health—you should advocate for it.

And you should have an advocate in healthcare to really know what your baseline is and to advocate and say, “Hey, that doesn’t seem right. That doesn’t seem like you. We need to investigate it further.”

Dr. Juneja: Absolutely. In an ideal world, if there was no risk of an image—I think this way about ovarian cancer—you would just image everyone. If there was no cost and nothing sustained in the way of radiation to the patient, you’d want to capture everyone. But that’s just not the reality.

 Changing gears a little bit, every single treatment that is recommended in today’s healthcare system—at least the traditional system—was studied on a trial. Every one of them. Because a trial is what demonstrates that this is better than the status quo. This is better than what we’re doing today.

What are some of the kind of misunderstandings of trials that you’ve seen, and what is your optimism on how we can learn and do better with targeted therapy and immune therapy and all these things that we’ve seen only in the last few years?

Dr. Singhi: Nationally, only about five to 10 percent of adults with cancer are actively participating in clinical trials, right? So there’s a lot of room to enhance that.

I work at an academic institution and I’m a big believer that clinical trials offer hope. They offer promise, and they offer a potential for impact on the way that a patient’s going to be treated and the outcomes they can get.

And so you’re exactly right. What you highlighted and said was, every FDA-approved drug that we have has gone through rigorous clinical trial enrollment and study.

And so that’s the way that we change the landscape, that we change the outcomes for patients with cancer—especially lung cancer. That being said, right now, the 5 to 10 percent of these adult patients with cancer that are enrolling in clinical trials, the diversity is not there. It’s mostly white, middle-class males that make up the majority of these patients that are on clinical trials.

And there’s barriers to clinical trial participation from a patient standpoint. There’s the access issue, there’s awareness, there’s the racism and lack of workforce diversity that we’ve highlighted as well. And so I think those are all real barriers that we have to rise up to and really think about when we’re designing a clinical trial.

I focus on patient education research, and there was a study that I saw in early 2020, I believe, by the NCI, the National Cancer Institute, and they published and showed that almost 40 plus percent of Americans have never even heard about what a clinical trial is.

And 87 percent, close to 90 percent of them, reported never being invited to participate in a clinical trial. Yet these same people were saying, if you needed to learn about a clinical trial or learn something about your healthcare, who’s the first person you’re going to go to? Where are you going to go?

And almost 60 plus percent of them said, “My healthcare provider.” So that shows you a call to action—that it’s got to be the healthcare providers that initiate this conversation, that say, “Hey, listen, let’s talk about what a clinical trial is. Let’s talk about what it could mean for you. And let’s talk about the impact it could potentially have on your case, but also the future of science.”

Dr. Juneja: That is such a beautiful point. And I would be remiss if I didn’t take a second to say, that’s why also participating with policy is so important. People are very receptive to patients with personal experiences and their family members that have those experiences—as well as medical professionals of any kind. So that’s the way that we get those screening considerations earlier, or things funded to justify screening earlier. So I just think it’s such an important point. Eric, it’s been an absolute pleasure to be able to get your insights and really hear the passion about an important subject.

Dr. Singhi: Likewise. Thanks, Sanjay. It’s always great to unpack some of these difficult conversations that we have with our patients in everyday practice, and to say, okay, this is what we learned from it and this is what we can do.

RAJ: A big thank you to both Dr. Juneja and Dr. Singhi for this discussion. You’ve been listening to a special episode of DDx.
I’m your host and story editor, Dr. Raj Bhardwaj.
Until next time, take care of each other—and stay safe.

This podcast episode originally appeared on DDx.