Prevalence and consequences of non-adherence to an evidence-based approach for incidental pulmonary nodules

Abstract

Importance Distinguishing benign from malignant pulmonary nodules is challenging. Evidence-based guidelines exist, but their impact on patient-centered outcomes is unknown. Objective To understand if the evaluation of incidental pulmonary nodules that follows an evidence-based management strategy is associated with fewer invasive procedures for benign lesions and/or fewer delays in cancer diagnosis. Design Retrospective cohort study. Setting Large academic medical center. Participants Adults (≥18 years age) with an incidental pulmonary nodule discovered between January 2012 and December 2014. Patients with calcified nodules, prior nodules, prior diagnosis of cancer, high suspicion for pulmonary metastasis, or limited life expectancy were excluded. Exposure Nodule management strategy (pre-specified based on evidence-based practices). Outcome Composite of any invasive procedure for a benign nodule or delay in diagnosis in patients with cancer (>3 month delay once probability of cancer was >15%). Results Of 314 patients that met inclusion criteria, median age was 61, 46.5% were men, and 66.5% had current or former tobacco use. The mean nodule size was 10.3 mm, mean probability of cancer was 11.8%, and 14.3% of nodules were malignant. Evaluation followed an evidence-based strategy in 245 patients (78.0%), and deviated in 69 patients (22%). The composite outcome occurred in 26 (8.3%) patients. Among patients whose nodule evaluation was concordant with an evidence-based evaluation, 6.1% (15/245) experienced the composite outcome versus 15.9% (11/69) of patients with an evaluation that deviated from evidence-based recommendations (P<0.01). Conclusions and relevance At a large academic medical center, more than 1 in 5 patients with an incidental pulmonary nodule underwent evaluation that deviated from evidence-based practice recommendations. Nodule evaluation that deviated from an evidence-based strategy was associated with biopsy of benign lesions and delays in cancer diagnosis, suggesting a need to improve guideline uptake.

Assessing a biomarker’s ability to reduce invasive procedures in patients with benign lung nodules: Results from the ORACLE study

“…Of greater concern, 35% percent of patients referred for surgical resection had benign disease and the rate of surgical resection was similar among those with low, intermediate, or high-risk nodules, suggesting clinicians did not always follow guideline directed care. These observations have been reinforced in a report from a large academic center, which showed that 1 in 5 incidentally identified PNs did not receive guideline concordant care [ 18 ]. The recent CHEST guidelines on lung cancer screening confirmed these findings in a compilation of prospective lung cancer screening studies [ 19 ].…”

“…It is remarkable that the invasive procedures on patients with benign nodules in this study are lower compared to prior reports. For example, the rates of procedures in the Tanner study were 41% and the current rates are only 19% and 5% for the control and IC tested groups respectively [ 18 ]. Similarly, the rates of malignant nodules routed to CT surveillance are also lower in this study.…”