‘Too Much and Too Little Care’ in Pulmonary Nodule Evaluation
Pulmonary nodules are common and many more will be found with implementation of lung cancer screening. In a retrospective cohort study reported in JAMA Internal Medicine, Wiener et al found that patients with pulmonary nodules were at high risk of both underevaluation and overevaluation for cancer, with the latter including unneeded procedures with potential for harm.
Study Details
The study involved 300 adults with “typical” indeterminate pulmonary nodules to which nodule evaluation guidelines would apply. Nodules were detected by computed tomography (CT) or radiography between January 2003 and December 2006 at 15 Veterans Affairs hospitals. A detailed review of medical records was performed from time of nodule detection through evaluation completion, cancer diagnosis, or study end on December 31, 2012. The primary outcome measures were resources used for nodule evaluation and the proportion of patients who received evaluation consistent with Fleischner Society guidelines.
Nodule sizes were ≤ 4 mm in 57 patients, 5 to 8 mm in 134, and > 8 mm in 109. Among all patients, mean age was 66 years, 94% were male, 86% were current or former smokers, 54% had chronic obstructive pulmonary disease, 57% had the nodule detected on radiograph, and nodule characteristics were ground glass in 13%, spiculated in 11%, and upper lobe location in 36%.
The reason for initial imaging was symptoms suggestive of lung cancer in 13%, symptoms not likely related to the nodule in 42%, and no symptoms (eg, preoperative film) in 45%. Patients with larger nodules were significantly more likely to have the nodule detected by radiograph (23%, 59%, and 72% for smaller to larger size categories, P < .001) and to have spiculated nodules (0%, 4%, and 26%, P < .001).
Cancer Rate
Overall, 27 patients (9.0%) ultimately received a diagnosis of lung cancer, including 1 (1.8%) with a nodule ≤ 4 mm, 4 (3.0%) with a nodule of 5 to 8 mm, and 22 (20.2%) with a nodule > 8 mm. Patients with larger nodules were also more likely to have other cancers diagnosed (0%, 3.7%, and 2.7% by size category).
Procedures and Complications
Nodule evaluation included 1,044 imaging studies, 147 consultations, 76 biopsies, 13 resections, and 21 hospitalizations. The median number of tests for nodule evaluation was 2 (range, 1–32) among patients with benign nodules and 8 (range, 2–24) among patients with lung cancer (P < .001). Radiographic surveillance (n = 277) lasted a median of 13 months but ranged from < 0.5 months to 8.5 years.
Invasive procedures were performed in 46 patients (15%); of these, 19 (41%) did not have cancer and 8 (17%) experienced complications, including pneumothorax in 7 (5 requiring hospitalization), hemorrhage in 2 (1 requiring hospitalization), pneumonia in 2 (both requiring hospitalization), and death in 1 (due to pneumonia). Among the 46 patients who underwent biopsy, the median number of biopsies was 1 (range, 1–4), but 9 (20%) underwent at least three biopsy procedures before a diagnosis was established. Of the 13 patients undergoing surgical resection, 4 (31%) had benign nodules. Among 19 patients who underwent invasive procedures for a benign nodule, 4 (21%) experienced complications. A total of 15 patients (5.0%) received no purposeful evaluation and had no obvious reason for deferral.
Factors Associated With Underevaluation and Overevaluation
Among 197 patients with a nodule detected after release of the Fleischner Society guidelines in 2005, 45% received care inconsistent with guidelines, including overevaluation in 18% and underevaluation in 27%. Overevaluation was inversely associated with baseline nodule size (44% for nodules ≤ 4mm, 15% for nodules 5–8 mm, and 11.4% for nodules > 8 mm, P = .001). Radiologist recommendations were usually consistent with guidelines (81%); otherwise, they were more likely to recommend more intensive (16%) vs less intensive (2%) evaluation.
On multivariate analysis including multiple factors associated with more or less intensive care compared with guidelines on bivariate analysis, the strongest predictor of guideline-inconsistent care was inappropriate radiologist recommendations (relative risk [RR] for overevaluation = 4.6, P < .001; RR for underevaluation = 4.3, P < .001). Nodule detection on CT scan vs radiograph was also associated with increased risk of overevaluation (RR = 1.7, P = .02) and receiving care at more than one facility (RR = 2.0, P < .001) and nodule detection during an inpatient or preoperative visit (RR = 1.6, P = .03) were also associated with increased risk of underevaluation.
The investigators concluded, “Pulmonary nodule evaluation is often inconsistent with guidelines, including cases with no workup and others with prolonged surveillance or unneeded procedures that may cause harm. Systems to improve quality (eg, aligning radiologist recommendations with guidelines and facilitating communication across providers) are needed before lung cancer screening is widely implemented.”
Renda Soylemez Wiener, MD, MPH, of the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, is the corresponding author for the JAMA Internal Medicine article.
The study was supported by Veterans Affairs (VA) Health Services Research and Development and with resources from White River Junction VA Medical Center, Edith Nourse Rogers Memorial Veterans Hospital, and Portland VA Medical Center.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
