Cost-Effectiveness of Initial Diagnostic Strategies for Pulmonary Nodules Presenting to Thoracic Surgeons

Deppen, Stephen A.; Davis, William T.; Green, Elizabeth A.; Rickman, Otis B.; Aldrich, Melinda C.; Fletcher, Sarah; Putnam, Joe B.; Grogan, Eric L.

doi:10.1016/j.athoracsur.2014.05.025

Cited by 28 publications

(61 citation statements)

References 26 publications

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“…erefore, it is expected that 18 F-FDG PET/CT is reported in the list of approved procedures for the investigation of SPNs in several countries [24]. On the other hand, it is expected that 18 F-FDG PET/CT may not be cost-effective for early diagnosis of LC in regions or countries where the specificity of this method is low (i.e., in countries where infectious lung diseases are endemic) Contrast Media & Molecular Imaging [25]. In summary, in countries with a low incidence of pulmonary inflammatory or infectious diseases and a high incidence of LC, the diagnostic workup of SPNs should include 18 F-FDG PET/CT as a main pillar.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic Performance of PET or PET/CT with Different Radiotracers in Patients with Suspicious Lung Cancer or Pleural Tumours according to Published Meta-Analyses

Lococo

Muoio

Chiappetta

et al. 2020

Contrast Media & Molecular Imaging

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Purpose. Several meta-analyses have reported data about the diagnostic performance of positron emission tomography or positron emission tomography/computed tomography (PET or PET/CT) with different radiotracers in patients with suspicious lung cancer (LC) or pleural tumours (PT). This review article aims at providing an overview on the recent evidence-based data in this setting. Methods. A comprehensive literature search of meta-analyses published in PubMed/MEDLINE and Cochrane Library database from January 2010 through March 2020 about the diagnostic performance of PET or PET/CT with different radiotracers in patients with suspicious LC or PT was performed. This combination of keywords was used: (A) “PET” OR “positron emission tomography” AND (B) “lung” OR “pulmonary” OR “pleur∗” AND (C) meta-analysis. Only meta-analyses on PET or PET/CT in patients with suspicious LC or PT were selected. Results. We have summarized the diagnostic performance of PET or PET/CT with fluorine-18 fluorodeoxyglucose (18F-FDG) and other radiotracers taking into account 17 meta-analyses. Evidence-based data demonstrated a good diagnostic performance of 18F-FDG PET or PET/CT for the characterization of solitary pulmonary nodules (SPNs) or pleural lesions with overall higher sensitivity than specificity. Evidence-based data do not support the routine use of dual time point (DTP) 18F-FDG PET/CT or fluorine-18 fluorothymidine (18F-FLT) PET/CT in the differential diagnosis of SPNs. Even if 18F-FDG PET/CT has high sensitivity and specificity as a selective screening modality for LC, its role in this setting remains unknown. Conclusions. Evidence-based data about the diagnostic performance of PET/CT with different radiotracers for suspicious LC or PT are increasing, with good diagnostic performance of 18F-FDG PET/CT. More prospective multicenter studies and cost-effectiveness analyses are warranted.

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Section: Discussionmentioning

confidence: 99%

Diagnostic Performance of PET or PET/CT with Different Radiotracers in Patients with Suspicious Lung Cancer or Pleural Tumours according to Published Meta-Analyses

Lococo

Muoio

Chiappetta

et al. 2020

Contrast Media & Molecular Imaging

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“…However, our work has questioned the use of FDG-PET/CT for the diagnosis of suspicious IPNs where fungal lung diseases are endemic. 6,8,20,21 Limitations of this study include our reliance on data from areas, with endemic fungal infections as well as the lack of prospective data collection with multiple cohorts specifically designed to represent a range of cancer prevalence, exposure to fungal lung disease, and other variables. Positron emission tomography specificity was highest in the Massachusetts cohort, a population with minimal fungal lung diseases and whose measured endemic rate is far lower than that of the other states’ cohorts (1.1%).…”

Section: Discussionmentioning

confidence: 99%

“…2,3 In a cost-effectiveness study comparing diagnostic FDG-PET/CT scan with aggressive tissue acquisition, we have previously reported that clinicians should pursue diagnosis by pathological tissue procedures instead of a diagnostic FDG-PET/CT scan when the specificity of FDG-PET/CT is less than 72%. 21 Frequent use of preoperative tissue acquisition strategies has been shown to result in lower rates of nontherapeutic lung resections. 23 …”

Section: Discussionmentioning

confidence: 99%

Assessment of Fluorodeoxyglucose F18–Labeled Positron Emission Tomography for Diagnosis of High-Risk Lung Nodules

et al. 2018

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IMPORTANCE Clinicians rely heavily on fluorodeoxyglucose F18–labeled positron emission tomography (FDG-PET) imaging to evaluate lung nodules suspicious for cancer. We evaluated the performance of FDG-PET for the diagnosis of malignancy in differing populations with varying cancer prevalence. OBJECTIVE To determine the performance of FDG-PET/computed tomography (CT) in diagnosing lung malignancy across different populations with varying cancer prevalence. DESIGN, SETTING, AND PARTICIPANTS Multicenter retrospective cohort study at 6 academic medical centers and 1 Veterans Affairs facility that comprised a total of 1188 patients with known or suspected lung cancer from 7 different cohorts from 2005 to 2015. EXPOSURES 18F fluorodeoxyglucose PET/CT imaging. MAIN OUTCOME AND MEASURES Final diagnosis of cancer or benign disease was determined by pathological tissue diagnosis or at least 18 months of stable radiographic follow-up. RESULTS Most patients were male smokers older than 60 years. Overall cancer prevalence was 81% (range by cohort, 50%–95%). The median nodule size was 22 mm (interquartile range, 15–33 mm). Positron emission tomography/CT sensitivity and specificity were 90.1% (95%CI, 88.1%–91.9%) and 39.8% (95%CI, 33.4%–46.5%), respectively. False-positive PET scans occurred in 136 of 1188 patients. Positive predictive value and negative predictive value were 86.4% (95%CI, 84.2%–88.5%) and 48.7% (95%CI, 41.3%–56.1%), respectively. On logistic regression, larger nodule size and higher population cancer prevalence were both significantly associated with PET accuracy (odds ratio, 1.027; 95%CI, 1.015–1.040 and odds ratio, 1.030; 95%CI, 1.021–1.040, respectively). As the Mayo Clinic model–predicted probability of cancer increased, the sensitivity and positive predictive value of PET/CT imaging increased, whereas the specificity and negative predictive value dropped. CONCLUSIONS AND RELEVANCE High false-positive rates were observed across a range of cancer prevalence. Normal PET/CT scans were not found to be reliable indicators of the absence of disease in patients with a high probability of lung cancer. In this population, aggressive tissue acquisition should be prioritized using a comprehensive lung nodule program that emphasizes advanced tissue acquisition techniques such as CT-guided fine-needle aspiration, navigational bronchoscopy, and endobronchial ultrasonography.

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“…The cutoff points are based on cost-effectiveness studies and clinical guidelines for the management of IPNs. 6,22 …”

Section: Discussionmentioning

confidence: 99%

Communication About the Probability of Cancer in Indeterminate Pulmonary Nodules

et al. 2018

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IMPORTANCE Clinical guidelines recommend that clinicians estimate the probability of malignancy for patients with indeterminate pulmonary nodules (IPNs) larger than 8 mm. Adherence to these guidelines is unknown. OBJECTIVES To determine whether clinicians document the probability of malignancy in high-risk IPNs and to compare these quantitative or qualitative predictions with the validated Mayo Clinic Model. DESIGN, SETTING, AND PARTICIPANTS Single-institution, retrospective cohort study of patients from a tertiary care Department of Veterans Affairs hospital from January 1, 2003, through December 31, 2015. Cohort 1 included 291 veterans undergoing surgical resection of known or suspected lung cancer from January 1, 2003, through December 31, 2015. Cohort 2 included a random sample of 239 veterans undergoing inpatient or outpatient pulmonary evaluation of IPNs at the hospital from January 1, 2003, through December 31, 2012. EXPOSURES Clinician documentation of the quantitative or qualitative probability of malignancy. MAIN OUTCOMES AND MEASURES Documentation from pulmonary and/or thoracic surgery clinicians as well as information from multidisciplinary tumor board presentations was reviewed. Any documented quantitative or qualitative predictions of malignancy were extracted and summarized using descriptive statistics. Clinicians’ predictions were compared with risk estimates from the Mayo Clinic Model. RESULTS Of 291 patients in cohort 1, 282 (96.9%) were men; mean (SD) age was 64.6 (9.0) years. Of 239 patients in cohort 2, 233 (97.5%) were men; mean (SD) age was 65.5 (10.8) years. Cancer prevalence was 258 of 291 cases (88.7%) in cohort 1 and 110 of 225 patients with a definitive diagnosis (48.9%) in cohort 2. Only 13 patients (4.5%) in cohort 1 and 3 (1.3%) in cohort 2 had a documented quantitative prediction of malignancy prior to tissue diagnosis. Of the remaining patients, 217 of 278 (78.1%) in cohort 1 and 149 of 236 (63.1%) in cohort 2 had qualitative statements of cancer risk. In cohort 2, 23 of 79 patients (29.1%) without any documented malignancy risk statements had a final diagnosis of cancer. Qualitative risk statements were distributed among 32 broad categories. The most frequently used statements aligned well with Mayo Clinic Model predictions for cohort 1 compared with cohort 2. The median Mayo Clinic Model–predicted probability of cancer was 68.7% (range, 2.4%–100.0%). Qualitative risk statements roughly aligned with Mayo predictions. CONCLUSIONS AND RELEVANCE Clinicians rarely provide quantitative documentation of cancer probability for high-risk IPNs, even among patients drawn from a broad range of cancer probabilities. Qualitative statements of cancer risk in current practice are imprecise and highly variable. A standard scale that correlates with predicted cancer risk for IPNs should be used to communicate with patients and other clinicians.

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Cost-Effectiveness of Initial Diagnostic Strategies for Pulmonary Nodules Presenting to Thoracic Surgeons

Cited by 28 publications

References 26 publications

Diagnostic Performance of PET or PET/CT with Different Radiotracers in Patients with Suspicious Lung Cancer or Pleural Tumours according to Published Meta-Analyses

Diagnostic Performance of PET or PET/CT with Different Radiotracers in Patients with Suspicious Lung Cancer or Pleural Tumours according to Published Meta-Analyses

Assessment of Fluorodeoxyglucose F18–Labeled Positron Emission Tomography for Diagnosis of High-Risk Lung Nodules

Communication About the Probability of Cancer in Indeterminate Pulmonary Nodules

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