[Interview] Paul Berger III, DO, on the Monarch Robotic Navigational Bronchoscopy Platform

Recognizing that early diagnosis is the key to lung cancer survival, Sanford Health recently began using the most advanced lung cancer diagnostic technology yet, the Monarch Platform robot assisted navigational bronchoscopy. MED asked lung cancer specialist Paul Berger, III, DO, to tell us more about the new technology. 

MED: What was your first reaction to getting the Monarch Platform?

PB: I grew up a 'Trekkie', a big fan of Star Trek, and I played my share of early video games like Atari. For a guy like me, any time you can throw a robot into the equation, how cool is that? Everything those science fiction shows predicted, we are slowly moving into. 

MED: How does it help with lung cancer diagnosis?

PB: Compared to our traditional manual bronchoscopy that we have been doing for decades, or more invasive procedures such as CT-guided biopsy through the chest wall, Monarch allows us to reach the smallest and hardest-to-reach lung nodules without an incision in the chest wall.

MED: What makes the Monarch system so precise?

PB: Not only is it robotic, but you perform the procedure after taking CT images and creating a 3D image. That image is used to guide the robotics. I have continuous vision throughout the procedure thanks to a fantastically innovative telescoping endoscope and I can see what the lung tissue actually looks like. 

MED: How does this compare to prior robotic technology?

PB: With some other non-robotic platforms, you are still basing your bronchoscopy ability on a CT, but you have no visualization and very limited control during the procedure. When I was using a different navigational bronchoscopy platform, my diagnostic yield was about 47 percent. That is for lung nodules greater than 1 cm. With Monarch, I'm able to go out into the periphery of the lung for a nodule 6 mm or greater in size and have near 100 percent diagnostic accuracy. This is an absolute game changer for patients with lung diseases that require culture or tissue for diagnosis.

MED: How do you expect Monarch to improve lung cancer survival rates?

PG: In the past, the majority of lung cancers were more extensive or late stage. Because of that, their ability to have a surgery with curative intent or chemoradiation for enhanced survivability was somewhat limited. With the Monarch platform, we are going to be able to provide them with earlier diagnosis and enhanced ability to improve their quality of life and their survival. If we can get to Stage I non-small cell lung cancer, up to 90 percent of patients can expect to live at least five years.

MED: Who is the typical lung cancer patient and is there anyone who would not be a good candidate for diagnosis with the Monarch system?

PG: Most lung cancer patients are over 65 and the majority have been smokers. We do see a small number of patients in the 40 to 50 range, but the average age is around 70. There are certain situations that are more difficult, such as nodules less than 6 mm or if there is not an airway with 2 cm of the nodule. But there is no patient profile that we would exclude. 

MED: Are there certain patients who are likely to do better with the Monarch system than they would have with transthoracic needle biopsy?

PG: Transthoracic needle biopsy is invasive and there are limitations in accuracy and safety. Some patients with chronic obstructive pulmonary disease, for instance, may not handle a transthoracic biopsy well. There is a heightened risk for collapsed lung. There is also a greater risk for false positives, false negatives, post biopsy hemorrhage. 

In contrast, if I am doing an endobronchial biopsy, I am right there in the lung to treat any potential hemorrhage. I'm also directly visualizing anything I do so I am aware of and can take care of complications. It provides a safer avenue for patients who already have some degree or lung disease. 

MED: I understand you are one of the most active users of this platform in the country?

PG: We received the Monarch system at the end of August and have been doing cases with it since September. I did 30 cases in my first quarter of use and the Auris Health/Johnson & Johnson rep let me know that this put me in the top 3 among practitioners starting out with the Monarch platform. One of them was the physician involved in the original design. We recently completed our 40th case here at Sanford and we are full steam ahead, developing quite the service line for navigational bronchoscopy with Monarch. As a practitioner, I can't thank Sanford enough for giving us the opportunity to use this truly awesome technology.