1
|
Roberts TJ, Lennes IT, Hawari S, Sequist LV, Park ER, Willers H, Frank A, Gaissert H, Shepard JA, Ryan D. Integrated, Multidisciplinary Management of Pulmonary Nodules Can Streamline Care and Improve Adherence to Recommendations. Oncologist 2019; 25:431-437. [PMID: 31876321 DOI: 10.1634/theoncologist.2019-0519] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/13/2019] [Indexed: 01/03/2023] Open
Abstract
Every year millions of pulmonary nodules are discovered incidentally and through lung cancer screening programs. Management of these nodules is often suboptimal, with low follow-up rates and poor provider understanding of management approaches. There is an emerging body of literature about how to optimize management of pulmonary nodules. The Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) at Massachusetts General Hospital was founded in 2012 to manage pulmonary nodules via a multidisciplinary approach with optimized support staff. Recommendations from clinic providers and treatment details were recorded for all patients seen at the PNLCSC. Adherence to recommendations and outcomes were also tracked and reviewed. From October 2012 to September 2019, 1,136 patients were seen at the PNLCSC, each for a mean of 1.8 appointments (range, 1-10). A total of 356 procedures were recommended by the clinic and 271 patients were referred for surgery and/or radiation. The majority of interventions (74%) were recommended at the initial PNLCSC appointment. In total, 211 patients (19%) evaluated at the PNLCSC had pathologically confirmed pulmonary malignancies or were treated empirically with radiation. Among patients followed by the clinic, the adherence rate to clinic recommendations was 95%. This study shows how a multidisciplinary approach to pulmonary nodule management can streamline care and optimize follow-up. The PNLCSC provides a template that can be replicated in other health systems. It also provides an example of how multidisciplinary approaches can be applied to other complex conditions. IMPLICATIONS FOR PRACTICE: This work demonstrates how an integrated, multidisciplinary approach to management of pulmonary nodules can streamline patient care and improve adherence to provider recommendations. This approach has the potential to improve patient outcomes and reduce health care costs.
Collapse
Affiliation(s)
- Thomas J Roberts
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Inga T Lennes
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Saif Hawari
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lecia V Sequist
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Elyse R Park
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Health Policy Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Henning Willers
- Thoracic Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Frank
- Department of Pulmonary & Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Henning Gaissert
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jo-Anne Shepard
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David Ryan
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Madariaga ML, Lennes IT, Best T, Shepard JAO, Fintelmann FJ, Mathisen DJ, Gaissert HA. Multidisciplinary selection of pulmonary nodules for surgical resection: Diagnostic results and long-term outcomes. J Thorac Cardiovasc Surg 2019; 159:1558-1566.e3. [PMID: 31669016 DOI: 10.1016/j.jtcvs.2019.09.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 08/22/2019] [Accepted: 09/07/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Pulmonary nodules found incidentally or by lung cancer screening differ in prevalence, risk profile, and diagnostic intervention. The results of surgical intervention for incidental versus screening lung nodules during multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) follow-up have not been reported. METHODS All patients evaluated at a PNLCSC from 2012 to 2018 following referral by primary care physicians, specialist physicians, or self-referral after computed tomography (CT) identified nodules on routine diagnostic CT (incidental group) or lung cancer screening CT (screening group) were included. Follow-up interval, invasive intervention, histology, postoperative events, survival, and recurrence were compared. RESULTS Of 747 patients evaluated in the PNLCSC, 129 (17.2%) underwent surgical intervention. The surgical cohort consisted of 104 (80.6%) incidental and 25 (19.3%) screening patients followed over a mean of 122 and 70 days, respectively. More benign lesions were excised in the incidental group (20.2%, 21/104)-representing 3.3% (21/632) of all incidental nodules evaluated-than in the screening group (4%, 1/25) (P = .038). Operative mortality was zero. Among 99 patients with primary lung cancer, 87% (screening) and 86.8% (incidental) were pathologic stage Ia. Complete follow-up was available in 725 of 747 (97%), and no patient developed progressive disease. Disease-free survival at 5 years was 74.9% (incidental) and 89.3% (screening) (P = .48). CONCLUSIONS A unique multidisciplinary PNLCSC for incidental and lung cancer screening-detected nodules with individualized risk assessment reliably identifies primary and metastatic tumors while exposing few patients to diagnostic excision for benign disease. Longer-term outcomes, strategies to limit radiation exposure, and cost control need further study.
Collapse
Affiliation(s)
- Maria Lucia Madariaga
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Inga T Lennes
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Till Best
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, Mass
| | - Jo-Anne O Shepard
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, Mass
| | - Florian J Fintelmann
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, Mass
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Henning A Gaissert
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
| | | |
Collapse
|
3
|
Elia S, Loprete S, De Stefano A, Hardavella G. Does aggressive management of solitary pulmonary nodules pay off? Breathe (Sheff) 2019; 15:15-23. [PMID: 30838056 PMCID: PMC6395991 DOI: 10.1183/20734735.0275-2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Indeterminate solitary pulmonary nodules (SPNs), measuring up to 3 cm in diameter, are incidental radiological findings. The ever-growing use of modern imaging has increased their detection. The majority of those nodules are benign; however, the possibility of diagnosing early-stage lung cancer still stands. Guidelines for the management of SPNs have never been validated in prospective comparative studies. Positron emission tomography (PET) is a useful tool to provide functional information on SPNs. However, overall sensitivity and specificity of PET in detecting malignant SPNs of at least 10 mm in diameter are about 90% and false-negative results are reported. The development of video-assisted thoracic surgery has provided minimally invasive diagnosis and treatment of SPNs. In our series, 105 patients underwent surgery based on combined increased 18F-labelled 2-fluoro-2-deoxy-d-glucose (FDG) uptake on PET computed tomography and radiological features (morphology and density) without prior histological confirmation. We detected 26 false negatives (24.8%) and only nine false positives (8.57%). Therefore, our minimally invasive surgical approach prevented 25% of patients with lung cancer from a delayed treatment versus only 9% undergoing “overtreatment”. In our monocentric cohort, patients with SPNs with large diameter, irregular outline, no calcifications, central location, increased FDG uptake and/or subsolid aspect benefited from a primary surgical resection. There is much debate on the best management of solitary pulmonary nodules. Even if they are mostly benign, they may represent an early-stage lung cancer. Minimally invasive surgical removal is probably the best approach to this insidious disease.http://ow.ly/wMKz30nemjR
Collapse
Affiliation(s)
- Stefano Elia
- Dept of Surgical Sciences, Thoracic Surgery Unit, Tor Vergata University, Rome, Italy
| | - Serafina Loprete
- Dept of Biomedicine and prevention, Tor Vergata University, Rome, Italy
| | | | - Georgia Hardavella
- Dept of Respiratory Medicine and Allergy, Medical School, King's College London, London, UK.,10th Dept of Respiratory Medicine, Athens' Chest Diseases Hospital "Sotiria", Athens, Greece
| |
Collapse
|
4
|
Wang GX, Baggett TP, Pandharipande PV, Park ER, Percac-Lima S, Shepard JAO, Fintelmann FJ, Flores EJ. Barriers to Lung Cancer Screening Engagement from the Patient and Provider Perspective. Radiology 2019; 290:278-287. [PMID: 30620258 DOI: 10.1148/radiol.2018180212] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Lung cancer remains the leading cause of cancer mortality in the United States. Lung cancer screening (LCS) with low-dose CT reduces mortality among high-risk current and former smokers and has been covered by public and private insurers without cost sharing since 2015. Patients and referring providers confront numerous barriers to participation in screening. To best serve in multidisciplinary efforts to expand LCS nationwide, radiologists must be knowledgeable of these challenges. A better understanding of the difficulties confronted by other stakeholders will help radiologists continue to collaboratively guide the growth of LCS programs in their communities. This article reviews barriers to participation in LCS for patients and referring providers, as well as possible solutions and interventions currently underway.
Collapse
Affiliation(s)
- Gary X Wang
- From the Department of Radiology (G.X.W., P.V.P., J.O.S., F.J.F., E.J.F.), Division of General Internal Medicine (T.P.B., S.P.L.), and Department of Psychiatry (E.R.P.), Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Founders 202, Boston, MA 02114; and Institute for Technology Assessment (P.V.P.), Mongan Institute Health Policy Center (E.R.P.), and Tobacco Research and Treatment Center (E.R.P., T.P.B.), Massachusetts General Hospital, Boston, Mass
| | - Travis P Baggett
- From the Department of Radiology (G.X.W., P.V.P., J.O.S., F.J.F., E.J.F.), Division of General Internal Medicine (T.P.B., S.P.L.), and Department of Psychiatry (E.R.P.), Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Founders 202, Boston, MA 02114; and Institute for Technology Assessment (P.V.P.), Mongan Institute Health Policy Center (E.R.P.), and Tobacco Research and Treatment Center (E.R.P., T.P.B.), Massachusetts General Hospital, Boston, Mass
| | - Pari V Pandharipande
- From the Department of Radiology (G.X.W., P.V.P., J.O.S., F.J.F., E.J.F.), Division of General Internal Medicine (T.P.B., S.P.L.), and Department of Psychiatry (E.R.P.), Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Founders 202, Boston, MA 02114; and Institute for Technology Assessment (P.V.P.), Mongan Institute Health Policy Center (E.R.P.), and Tobacco Research and Treatment Center (E.R.P., T.P.B.), Massachusetts General Hospital, Boston, Mass
| | - Elyse R Park
- From the Department of Radiology (G.X.W., P.V.P., J.O.S., F.J.F., E.J.F.), Division of General Internal Medicine (T.P.B., S.P.L.), and Department of Psychiatry (E.R.P.), Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Founders 202, Boston, MA 02114; and Institute for Technology Assessment (P.V.P.), Mongan Institute Health Policy Center (E.R.P.), and Tobacco Research and Treatment Center (E.R.P., T.P.B.), Massachusetts General Hospital, Boston, Mass
| | - Sanja Percac-Lima
- From the Department of Radiology (G.X.W., P.V.P., J.O.S., F.J.F., E.J.F.), Division of General Internal Medicine (T.P.B., S.P.L.), and Department of Psychiatry (E.R.P.), Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Founders 202, Boston, MA 02114; and Institute for Technology Assessment (P.V.P.), Mongan Institute Health Policy Center (E.R.P.), and Tobacco Research and Treatment Center (E.R.P., T.P.B.), Massachusetts General Hospital, Boston, Mass
| | - Jo-Anne O Shepard
- From the Department of Radiology (G.X.W., P.V.P., J.O.S., F.J.F., E.J.F.), Division of General Internal Medicine (T.P.B., S.P.L.), and Department of Psychiatry (E.R.P.), Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Founders 202, Boston, MA 02114; and Institute for Technology Assessment (P.V.P.), Mongan Institute Health Policy Center (E.R.P.), and Tobacco Research and Treatment Center (E.R.P., T.P.B.), Massachusetts General Hospital, Boston, Mass
| | - Florian J Fintelmann
- From the Department of Radiology (G.X.W., P.V.P., J.O.S., F.J.F., E.J.F.), Division of General Internal Medicine (T.P.B., S.P.L.), and Department of Psychiatry (E.R.P.), Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Founders 202, Boston, MA 02114; and Institute for Technology Assessment (P.V.P.), Mongan Institute Health Policy Center (E.R.P.), and Tobacco Research and Treatment Center (E.R.P., T.P.B.), Massachusetts General Hospital, Boston, Mass
| | - Efren J Flores
- From the Department of Radiology (G.X.W., P.V.P., J.O.S., F.J.F., E.J.F.), Division of General Internal Medicine (T.P.B., S.P.L.), and Department of Psychiatry (E.R.P.), Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Founders 202, Boston, MA 02114; and Institute for Technology Assessment (P.V.P.), Mongan Institute Health Policy Center (E.R.P.), and Tobacco Research and Treatment Center (E.R.P., T.P.B.), Massachusetts General Hospital, Boston, Mass
| |
Collapse
|