Kremens is a critical care and pulmonary medicine doctor at Essentia Health in Fargo. And while he approaches each procedure with the same careful attention to detail he has always practiced, the Monarch has enhanced the results.

The Monarch is a boon to lung cancer patients, he said, in part because it allows for earlier detection and more accurate diagnosis of small and hard-to-reach nodules in the periphery of the lung. With its farther reach the scope can, in essence, go where no scope has gone before to biopsy a lung.

Essentia Health started using the Monarch on Oct. 18. It is the first hospital in North Dakota to introduce the platform that was recently approved by the U.S. Food and Drug Administration. Sanford Health in Sioux Falls, S.D., adopted the Monarch in August 2020 and started using it the following month.

Kremens said he and another doctor at Essentia had been trying to get the technology there for about a year, after it was first introduced in 2020. He said he is excited for what it will bring his patients.

Doctor Robot

Produced by Auris Health, the Monarch integrates the latest advancements in robotics, software, data science and endoscopy – the use of small cameras and tools to enter the body through its natural openings.

Kremens told Prairie Business that while there are other diagnostic options for lung cancer and other diseases, their limitations can lead to false positives, false negatives and, in some cases, cause side effects such as a collapsed lung or hemorrhage. In turn, these scenarios increase health care costs and extend hospital stays.

Also, more than 90% of people diagnosed with lung cancer do not survive the disease, according to information provided by Essentia, in part because it often is found at an advanced stage.

Modern ways to detect lung cancer have been by X-ray and CT scan, but Kremens said there remain challenges with these methods. By the time an X-ray can detect lung cancer, for instance, the patient usually is in Stage 3 or 4, diminishing the survival rate.

The CT scan can detect potential cancer earlier, which shows up as nodules in the lung, but the challenge has been to get to the nodule for a biopsy in a safe and reliable way. Usually that has been done with a bronchoscope – a thin, lighted tube with a camera at its end to look at the airways.

But the traditional bronchoscopes are larger than the Monarch, the scopes not as long, and often a needle is used between the ribs and lining of the lung to get to the nodule. The lung has few nerve receptors, but there’s a chance of puncturing the lung, causing it to lose air or to collapse.

Marlena Zeis, a registered nurse at Essentia Health in Fargo, N.D., uses a controller and computer visualization to demonstrate what the Monarch provides for doctors who use the platform during procedures to detect cancer and other diseases in the lung.Image: Andrew Weeks/Prairie Business

Biopsies can be obtained, Kremens said, but at a cost to the patient. Many of those risks have been eliminated with the Monarch.

For one thing, “the cameras are getting smaller and smaller,” Kremens said of advancements in medical technology. “We can go farther and farther (with the Monarch) without having to worry that we’re going to get stuck before we get to the nodule. And so this accessory improves the biopsy.”

Kremens may look as if he’s playing a video game when he watches a computer monitor while using the handheld controller that resembles one from an Xbox game console, but he’s not. He’s maneuvering the flexible robotic endoscope inside a patient’s airway and lung.

He receives help from the Monarch’s computer-assisted navigation and based on 3D models of the patient’s own lung anatomy. The computer will let him know if he is off course. Kremens said the system allows him continuous bronchoscope vision throughout the entire procedure.

As such, peripheral nodules can be diagnosed earlier — and via a minimally invasive procedure — allowing for more successful outcomes in the treatment of lung cancer. Kremens said it is an outpatient procedure and patients, if cancer is diagnosed, do not have to wait until Stage 3 or 4 to begin treatment.

There are a few weeks of training before physicians use the Monarch on a patient, but Kremens and his team went through the training with flying colors.

Not just for cancer patients

Dr. Paul Berger, who provides pulmonary, critical and neurocritical care at Sanford Health in Sioux Falls, was the first doctor to offer the Monarch service to patients in South Dakota. He said patients have come from near and far, sometimes from out of state, to visit with him for the outpatient procedure.

Berger was looking to upgrade the technology at his practice when he learned of the Monarch last year. He decided to invest in it, and the robot arrived in August 2020. A month later, after training, he started using it.

Since then, he’s seen the results time and time again: It is a much safer, more effective way at diagnosing potential lung cancer and other diseases, and, because the risk of collapsing a lung is lessened, it is not as invasive as previous methods.

“The Monarch platform is incredibly unique in the fact that it allows for enhanced reach to deal with lesions within the lung or within the airways, as opposed to a conventional bronchoscopy where you can really only see the first third of the primary airways,” he said. “You’d have to get ‘creative’ to be able to do more diagnostic procedures in the areas that you cannot visualize.

“The robotic bronchoscopy, however, allows for direct visualization of wherever I’m at in an airway, even near the visceral pleura, which is the outer lining of the lung. There are not very many areas within the lung I cannot get to for a diagnostic procedure.”

The scope itself is about 4.4 millimeters in width, he said. It is attached to two robotic arms, which feed the scope into the airways, maneuvered and controlled by the doctor.

“With a bronchoscope, that’s small,” he said. “It’s very easy to maneuver through even smaller airways. … That maneuverability within the airways is fairly straightforward, very safe, and incredibly easy.”

Berger said the Monarch is the only platform that allows him direct visualization during the entire procedure and allows him to get the scope to the target area “within a reasonable period of time” and safely do the biopsy.

The end result for patients: “We can give them a more expedient diagnosis so they can get premium therapies,” he said.

Cigarette smoking is the number one risk factor for lung cancer, according to the Center for Disease Control and Prevention, with smoking linked to between 80% and 90% of lung cancer deaths. Second-hand smoking also is a high-risk factor. Besides detecting cancer in patients at earlier stages, Berger said the Monarch can be used to detect other lung diseases. The best news, of course, is when a biopsy comes back negative.

“You don’t have to be a smoker to have lung cancer,” Berger said. “And cancer is not the only thing that I’m potentially looking at when I go through a diagnostic procedure.”

He said a patient may have infections, an autoimmune disease, or inflamed lung tissue that’s not cancerous.

“That’s what the task is – to go in trying to provide the patient with an appropriate diagnosis,” he said. In some cases proper diagnosis may bring the patient peace of mind, improve quality of life, and reduce health care costs.

They are Berger’s end goals, and with the Monarch those goals are better achieved “so we’re not inadvertently treating something that has not been appropriately diagnosed,” he said.

Andrew Weeks may be reached at aweeks@prairiebusinessmagazine.com.