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Hillyer GC, Milano N, Bulman WA. Pulmonary nodules and the psychological harm they can cause: A scoping review. Respir Med Res 2024; 86:101121. [PMID: 38964266 DOI: 10.1016/j.resmer.2024.101121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/21/2024] [Accepted: 06/13/2024] [Indexed: 07/06/2024]
Abstract
More than 1.6 million pulmonary nodules are diagnosed in the United States each year. Although the majority of nodules are found to be benign, nodule detection and the process of ruling out malignancy can cause patients psychological harm to varying degrees. The present study undertakes a scoping review of the literature investigating pulmonary nodule-related psychological harm as a primary or secondary outcome. Online databases were systematically searched to identify papers published through June 30, 2023, from which 19 publications were reviewed. We examined prevalence by type, measurement, associated factors, and behavioral or clinical consequences. Of the 19 studies reviewed, 11 studies investigated distress, anxiety (n = 6), and anxiety and depression (n = 4). Prevalence of distress was 24.0 %-56.7 %; anxiety 9.9 %-42.1 %, and 14.6 %-27.0 % for depression. A wide range of demographic and social characteristics and clinical factors were associated with nodule-related psychological harm. Outcomes of nodule-related harms included experiencing conflict when deciding about treatment or surveillance, decreased adherence to surveillance, adoption of more aggressive treatment, and lower health-related quality of life. Our scoping review demonstrates that nodule-related psychological harm is common. Findings provide evidence that nodule-related psychological harm can influence clinical decisions and adherence to treatment recommendations. Future research should focus on discerning between nodule-related distress and anxiety; identifying patients at risk; ascertaining the extent of psychological harm on patient behavior and clinical decisions; and developing interventions to assist patients in managing psychological harm for better health-related quality of life and treatment outcomes.
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Affiliation(s)
- Grace C Hillyer
- Mailman School of Public Health at Columbia University, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY USA.
| | - Nicole Milano
- School of Social Work, Rutgers University, New Brunswick, NJ, USA
| | - William A Bulman
- Veracyte Inc., South San Francisco, CA, USA; Columbia University Irving Medical Center, New York, NY, USA
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2
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Lange AV, Mehta AB, Ramos KJ, Campbell EG, Gray AL, Tietbohl C, Garcia-Hernandez S, Bekelman DB. Uncertainty and Communication Preferences Among Patients Undergoing Lung Transplant Evaluation: A Mixed-Methods Study. Clin Transplant 2024; 38:e15406. [PMID: 39023106 DOI: 10.1111/ctr.15406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/07/2024] [Accepted: 06/27/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE Higher uncertainty is associated with poorer quality of life and may be impacted by clinician communication about the future. We determined how patients undergoing lung transplant evaluation experience uncertainty and communication about the future from clinicians. METHODS We performed a convergent parallel mixed-methods study using a cross-sectional survey and semistructured interviews. Patients undergoing lung transplant evaluation at the University of Colorado and the University of Washington answered questions about future communication and completed the Mishel Uncertainty in Illness Scale-Adult (MUIS-A; range 33-165, higher scores indicate more uncertainty). Interviews were analyzed using content analysis. Integration of survey and interview results occurred during data interpretation. RESULTS A total of 101 patients completed the survey (response rate: 47%). Twelve survey participants completed interviews. In the survey, most patients identified changing family roles as important (76%), which was infrequently discussed with clinicians (31%). Most patients (86%) worried about the quality of their life in the future, and 74% said that not knowing what to expect in the future prevented them from making plans. The mean MUIS-A score was 85.5 (standard deviation 15.3). Interviews revealed three themes: (1) uncertainty of the future distresses participants; (2) participants want practical information from clinicians; and (3) communication preferences vary among participants. CONCLUSION Participants experienced distressing uncertainty and wanted information about the future. Communication topics that were important to participants were not always addressed by physicians. Clinicians should address how chronic lung disease and lung transplant can directly impact patients' lives and support patients to cope with uncertainty.
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Affiliation(s)
- Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Colorado, USA
| | - Anuj B Mehta
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Colorado, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Kathleen J Ramos
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington, USA
| | - Eric G Campbell
- Center of Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Alice L Gray
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Colorado, USA
| | - Caroline Tietbohl
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sandra Garcia-Hernandez
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - David B Bekelman
- Department of Medicine and Denver-Seattle Center of Innovation, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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3
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Núñez ER, Ito Fukunaga M, Stevens GA, Yang JK, Reid SE, Spiegel JL, Ingemi MR, Wiener RS. Review of Interventions That Improve Uptake of Lung Cancer Screening: A Cataloging of Strategies That Have Been Shown to Work (or Not). Chest 2024:S0012-3692(24)00654-8. [PMID: 38797278 DOI: 10.1016/j.chest.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/08/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024] Open
Abstract
TOPIC IMPORTANCE Lung cancer screening (LCS) has the potential to decrease mortality from lung cancer by 20%. Yet, more than a decade since LCS was established as an evidence-based practice, < 20% of the eligible population in the United States has been screened. This review focuses on critically appraising interventions that have been designed to increase the initial uptake of LCS, including how they address known barriers to LCS and their effectiveness in overcoming these barriers. REVIEW FINDINGS Studies were categorized based on the primary barriers that they addressed: (1) identifying eligible patients (including enhancing awareness through smoking history collection, outreach, and education), (2) shared decision-making-related interventions, and (3) patient navigation interventions. Four of the studies included multicomponent interventions, which often included patient navigation as one of the components. Overall, the effectiveness of the studies reviewed at improving LCS uptake generally was modest and was limited by the multilevel barriers that need to be overcome. Multicomponent interventions generally were more effective at improving LCS uptake, but most studies still had relatively low completion of screening. SUMMARY Improving uptake of LCS requires learning from prior interventions to design multilevel interventions that address barriers to LCS at key steps and identifying which components of these interventions are effective and generalizable.
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Affiliation(s)
- Eduardo R Núñez
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | | | - Gregg A Stevens
- University of Massachusetts Chan Medical School Worcester, MA
| | - James K Yang
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Sarah E Reid
- University of Massachusetts Chan Medical School Worcester, MA
| | - Jennifer L Spiegel
- University of Massachusetts Chan Medical School Worcester, MA; School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Molly R Ingemi
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA; The Pulmonary Center, Boston University School of Medicine, Boston, MA; National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
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4
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Polanco D, González J, Gracia-Lavedan E, Pinilla L, Plana R, Molina M, Pardina M, Barbé F. Multidisciplinary virtual management of pulmonary nodules. Pulmonology 2024; 30:239-246. [PMID: 35115280 DOI: 10.1016/j.pulmoe.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Multidisciplinary nodule clinics provide high-quality care and favor adherence to guidelines. Virtual care has shown savings benefits along with patient satisfaction. Our aim is to describe the first year of operation of a multidisciplinary virtual lung nodule clinic, the population evaluated and issued decisions. Secondarily, among discharged patients, we aimed to analyze their follow-up prior to the existence of our consultation, evaluating its adherence to guidelines. MATERIALS AND METHODS Observational study including all patients evaluated at the Virtual Lung Nodule Clinic (VLNC) (March 2018- March 2019). Clinical and radiological data were recorded. Recommendations, based on 2017 Fleischner Society guidelines, were categorized into follow-up, discharge or referral to lung cancer consultation. Discharged patients were classified according to adherence to guidelines of their previous management, into adequate, prolonged and non-indicated follow-up. RESULTS A total of 365 patients (58.9% men; median age 64.0 years) were included. Sixty-four percent had smoking history and 23% had chronic obstructive pulmonary disease (COPD). Most nodules were solid (87.4%) and multiple (57.5%). The median diameter was 6.00 mm. 43.8% of patients were discharged following first VLNC evaluation. Among them, 27.5% had received appropriate follow-up, but 66.9% had received poor management. Patients with prolonged follow-up (33.1%) were older (67.0 vs 60.5 years) and had larger nodules (6.00 mm vs 5.00). Non-indicated follow-up patients (33.8%) were more non-smokers (77.8% vs 31.8%) and presented smaller nodules (4.00 vs 5.00 mm). CONCLUSIONS During its first year of operation, the VLNC has evaluated a population with a relevant risk profile for lung cancer development, management of which should be cautious and adhere to guidelines. After the first VLNC assessment, approximately one-half of this population was discharged. It was noticeable that previous follow-up of discharged patients was found poorly adherent to guidelines, with a marked tendency to overmanagement.
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Affiliation(s)
- D Polanco
- Respiratory Department, University Hospital Arnau de Vilanova. Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain; Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, IRBLleida, Spain
| | - J González
- Respiratory Department, University Hospital Arnau de Vilanova. Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain; Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, IRBLleida, Spain
| | - E Gracia-Lavedan
- Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, IRBLleida, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - L Pinilla
- Group of Precision Medicine in Chronic Diseases, University Hospital Arnau de Vilanova and Santa Maria, IRBLleida, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - R Plana
- Respiratory Department, University Hospital Arnau de Vilanova. Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain; Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, IRBLleida, Spain
| | - M Molina
- Respiratory Department, University Hospital Arnau de Vilanova. Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain
| | - M Pardina
- Department of Radiology, Arnau de Vilanova University Hospital, IRBLleida
| | - F Barbé
- Respiratory Department, University Hospital Arnau de Vilanova. Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain; Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, IRBLleida, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain.
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Núñez ER, Bolton RE, Boudreau JH, Sliwinski SK, Herbst AN, Kearney LE, Caverly TJ, Wiener RS. "It Can't Hurt!": Why Many Patients With Limited Life Expectancy Decide to Accept Lung Cancer Screening. Ann Fam Med 2024; 22:95-102. [PMID: 38527813 PMCID: PMC11237214 DOI: 10.1370/afm.3081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 03/27/2024] Open
Abstract
PURPOSE Lung cancer screening (LCS) has less benefit and greater potential for iatrogenic harm among people with multiple comorbidities and limited life expectancy. Yet, such individuals are more likely to undergo screening than healthier LCS-eligible people. We sought to understand how patients with marginal LCS benefit conceptualize their health and make decisions regarding LCS. METHODS We interviewed 40 people with multimorbidity and limited life expectancy, as determined by high Care Assessment Need scores, which predict 1-year risk of hospitalization or death. Patients were recruited from 6 Veterans Health Administration facilities after discussing LCS with their clinician. We conducted a thematic analysis using constant comparison to explore factors that influence LCS decision making. RESULTS Patients commonly held positive beliefs about screening and perceived LCS to be noninvasive. When posed with hypothetical scenarios of limited benefit, patients emphasized the nonlongevity benefits of LCS (eg, peace of mind, planning for the future) and generally did not consider their health status or life expectancy when making decisions regarding LCS. Most patients were unaware of possible additional evaluations or treatment of screen-detected findings, but when probed further, many expressed concerns about the potential need for multiple evaluations, referrals, or invasive procedures. CONCLUSIONS Patients in this study with multimorbidity and limited life expectancy were unaware of their greater risk of potential harm when accepting LCS. Given patient trust in clinician recommendations, it is important that clinicians engage patients with marginal LCS benefit in shared decision making, ensuring that their values of desiring more information about their health are weighed against potential harms from further evaluations.
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Affiliation(s)
- Eduardo R Núñez
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts and VA Bedford Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Rendelle E Bolton
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts and VA Bedford Healthcare System, Bedford, Massachusetts
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Jacqueline H Boudreau
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts and VA Bedford Healthcare System, Bedford, Massachusetts
| | - Samantha K Sliwinski
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts and VA Bedford Healthcare System, Bedford, Massachusetts
| | - Abigail N Herbst
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts and VA Bedford Healthcare System, Bedford, Massachusetts
| | - Lauren E Kearney
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts and VA Bedford Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Tanner J Caverly
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts and VA Bedford Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
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6
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Núñez ER, Zhang S, Glickman ME, Qian SX, Boudreau JH, Lindenauer PK, Slatore CG, Miller DR, Caverly TJ, Wiener RS. What Goes into Patient Selection for Lung Cancer Screening? Factors Associated with Clinician Judgments of Suitability for Screening. Am J Respir Crit Care Med 2024; 209:197-205. [PMID: 37819144 PMCID: PMC10806423 DOI: 10.1164/rccm.202301-0155oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 10/11/2023] [Indexed: 10/13/2023] Open
Abstract
Rationale: Achieving the net benefit of lung cancer screening (LCS) depends on optimizing patient selection. Objective: To identify factors associated with clinician assessments that a patient was unlikely to benefit from LCS ("LCS-inappropriate") because of comorbidities or limited life expectancy. Methods: Retrospective analysis of patients assessed for LCS at 30 Veterans Health Administration facilities from January 1, 2015 to February 1, 2021. We conducted hierarchical mixed-effects logistic regression analyses to determine factors associated with clinicians' designations of LCS inappropriateness (primary outcome), accounting for 3-year predicted probability (i.e., competing risk) of non-lung cancer death. Measurements and Main Results: Among 38,487 LCS-eligible patients, 1,671 (4.3%) were deemed LCS-inappropriate by clinicians, whereas 4,383 (11.4%) had an estimated 3-year competing risk of non-lung cancer death greater than 20%. Patients with higher competing risks of non-lung cancer death were more likely to be deemed LCS-inappropriate (odds ratio [OR], 2.66; 95% confidence interval [CI], 2.32-3.05). Older patients (ages 75-80; OR, 1.45; 95% CI, 1.18-1.78) and those with interstitial lung disease (OR, 1.98; 95% CI, 1.51-2.59) were more likely to be deemed LCS-inappropriate than would be explained by competing risk of non-lung cancer death, whereas patients currently smoking (OR, 0.65; 95% CI, 0.58-0.73) were less likely to be deemed LCS-inappropriate, suggesting that clinicians over- or underweighted these factors. The probability of being deemed LCS-inappropriate varied from 0.4% to 74%, depending on the clinician making the assessment (median OR, 3.07; 95% CI, 2.89-3.25). Conclusion: Concerningly, the likelihood that a patient is deemed LCS-inappropriate is more strongly associated with the clinician making the assessment than with patient characteristics. Patient selection may be optimized by providing decision support to help clinicians assess net LCS benefit.
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Affiliation(s)
- Eduardo R. Núñez
- Center for Healthcare Organization and Implementation Research, VA Boston and Bedford Healthcare Systems, Boston, Massachusetts
- VA Bedford Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, School of Medicine, Boston University, Boston, Massachusetts
- Department of Healthcare Delivery and Population Sciences, Chan Medical School-Baystate, University of Massachusetts, Springfield, Massachusetts
| | - Sanqian Zhang
- Center for Healthcare Organization and Implementation Research, VA Boston and Bedford Healthcare Systems, Boston, Massachusetts
- VA Bedford Healthcare System, Bedford, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Mark E. Glickman
- Center for Healthcare Organization and Implementation Research, VA Boston and Bedford Healthcare Systems, Boston, Massachusetts
- VA Bedford Healthcare System, Bedford, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Shirley X. Qian
- Center for Healthcare Organization and Implementation Research, VA Boston and Bedford Healthcare Systems, Boston, Massachusetts
- VA Bedford Healthcare System, Bedford, Massachusetts
| | - Jacqueline H. Boudreau
- Center for Healthcare Organization and Implementation Research, VA Boston and Bedford Healthcare Systems, Boston, Massachusetts
- VA Bedford Healthcare System, Bedford, Massachusetts
| | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences, Chan Medical School-Baystate, University of Massachusetts, Springfield, Massachusetts
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland Oregon
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research, VA Boston and Bedford Healthcare Systems, Boston, Massachusetts
- VA Bedford Healthcare System, Bedford, Massachusetts
- Zuckerberg College of Health Sciences, University of Massachusetts, Lowell, Massachusetts
| | - Tanner J. Caverly
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan; and
- School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research, VA Boston and Bedford Healthcare Systems, Boston, Massachusetts
- VA Bedford Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, School of Medicine, Boston University, Boston, Massachusetts
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
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Qiu H, Lou Y, Wang Z, Xue F, Chen Z, Xu C, Witharana P, Chen D, Zhu K, Li J, Chen B, Fumimoto S, Lachkar S, Efird JT, Zhu C, Shen J. Factors influencing surgical choice and anxiety in patients with pulmonary nodules smaller than 8 mm. J Thorac Dis 2023; 15:6889-6897. [PMID: 38249895 PMCID: PMC10797356 DOI: 10.21037/jtd-23-1701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024]
Abstract
Background The detection of pulmonary nodules significantly impacts the lives and mental health of patients. Although the 2020 National Comprehensive Cancer Network (NCCN) guidelines recommend scheduled surveillance for nodules ≤8 mm, patients often opt to have their nodules surgically removed. Methods A cross-sectional questionnaire was administered to patients with small pulmonary nodules who presented to a local grade 3 hospital with small pulmonary nodules and decided to receive surgery versus prescribed monitoring. The questionnaire included four aspects: (I) patient characteristics; (II) nodule-specific knowledge; (III) doctor-patient communication; and (IV) nodular-specific distress. Nodular-specific distress was measured by the Impact of Event Scale-Revised (IES-R). Results A total of 234 (69%) patients responded to the survey and were included in the final analysis. Poor performance in activities of daily living (ADLs), the presence of solid nodules, multifocal disease, and a family history of lung cancer were significantly associated with reported anxiety. Most notably, facilitating patient choice for surgery was the computed tomography (CT) scan results, with reference to lung nodule size and number of nodules, where concerns related to lung nodule, cancer risk, and fear of surgery or death had a significant psychological impact on patients. Conclusions In this cohort of patients who elected to have their small pulmonary nodules surgically removed, we identified key factors underlying their anxiety toward guideline recommended surveillance. Our findings will be useful for clinicians when discussing treatment options with their patients.
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Affiliation(s)
- Hongbin Qiu
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Yingqiao Lou
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Zimin Wang
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Fenglai Xue
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Zhongxiao Chen
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Congcong Xu
- Department of Cardiothoracic Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou University, Taizhou, China
| | - Pasan Witharana
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Dong Chen
- Department of Thoracic Surgery, Jinhua Hospital of Zhejiang University, Jinhua, China
| | - Kanghao Zhu
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Jiawei Li
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Baofu Chen
- Department of Cardiothoracic Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou University, Taizhou, China
| | - Satoshi Fumimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Samy Lachkar
- Department of Pneumology, CHU Rouen, Rouen, France
| | - Jimmy T. Efird
- VA Cooperative Studies Program Coordinating Center, Boston, MA, USA
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chengchu Zhu
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Jianfei Shen
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
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8
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Gould MK, Creekmur B, Qi L, Golden SE, Kaplan CP, Walter E, Mularski RA, Vaszar LT, Fennig K, Steiner J, de Bie E, Musigdilok VV, Altman DA, Dyer DS, Kelly K, Miglioretti DL, Wiener RS, Slatore CG, Smith-Bindman R. Emotional Distress, Anxiety, and General Health Status in Patients With Newly Identified Small Pulmonary Nodules: Results From the Watch the Spot Trial. Chest 2023; 164:1560-1571. [PMID: 37356710 DOI: 10.1016/j.chest.2023.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Anxiety and emotional distress have not been studied in large, diverse samples of patients with pulmonary nodules. RESEARCH QUESTION How common are anxiety and distress in patients with newly identified pulmonary nodules, and what factors are associated with these outcomes? STUDY DESIGN AND METHODS This study surveyed participants in the Watch the Spot Trial, a large, pragmatic clinical trial of more vs less intensive strategies for radiographic surveillance of patients with small pulmonary nodules. The survey included validated instruments to measure patient-centered outcomes such as nodule-related emotional distress (Impact of Event Scale-Revised) and anxiety (Six-Item State Anxiety Inventory) 6 to 8 weeks following nodule identification. Mixed-effects models were used to compare outcomes between study arms following adjustment for potential confounders and clustering within enrollment site, while also examining a limited number of prespecified explanatory factors, including nodule size, mode of detection, type of ordering clinician, and lack of timely notification prior to contact by the study team. RESULTS The trial enrolled 34,699 patients; 2,049 individuals completed the baseline survey (5.9%). Respondents and nonrespondents had similar demographic and nodule characteristics, although more respondents were non-Hispanic and White. Impact of Event Scale-Revised scores indicated mild, moderate, or severe distress in 32.2%, 9.4%, and 7.2% of respondents, respectively, with no difference in scores between study arms. Following adjustment, greater emotional distress was associated with larger nodule size and lack of timely notification by a clinician; distress was also associated with younger age, female sex, ever smoking, Black race, and Hispanic ethnicity. Anxiety was associated with lack of timely notification, ever smoking, and female sex. INTERPRETATION Almost one-half of respondents experienced emotional distress 6 to 8 weeks following pulmonary nodule identification. Strategies are needed to mitigate the burden of distress, especially in younger, female, ever smoking, and minoritized patients, and those with larger nodules. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT02623712; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Michael K Gould
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
| | - Beth Creekmur
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Lihong Qi
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA
| | | | - Celia P Kaplan
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Eric Walter
- Northwest Permanente Medical Group, Portland, OR; Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Richard A Mularski
- Northwest Permanente Medical Group, Portland, OR; Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - Kathleen Fennig
- Department of Research Affairs, Wright State University School of Medicine, Dayton, OH
| | - Julie Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Evan de Bie
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA
| | - Visanee V Musigdilok
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Debra S Dyer
- Department of Radiology, National Jewish Health, Denver, CO
| | - Karen Kelly
- Department of Medicine, School of Medicine, University of California, Davis, Davis, CA
| | - Diana L Miglioretti
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA; Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA; The Pulmonary Center, Boston University School of Medicine, Boston, MA; National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
| | - Christopher G Slatore
- VA Portland Healthcare System, Portland, OR; National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
| | - Rebecca Smith-Bindman
- Department of Epidemiology and Biostatistics, and the Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA
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9
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Pinsky PF, Osarogiagbon R. Diagnostic follow-up of indeterminate pulmonary nodules in the Medicare population. Cancer 2023; 129:2808-2816. [PMID: 37208803 DOI: 10.1002/cncr.34846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/24/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Management of indeterminate pulmonary nodules (IPNs) is associated with redistribution of lung cancer to earlier stages, but most subjects with IPNs do not have lung cancer. The burden of IPN management in Medicare recipients was assessed. METHODS Surveillance, Epidemiology, and End Results-Medicare data were analyzed for IPNs, diagnostic procedures, and lung cancer status. IPNs were defined as chest computed tomography (CT) scans with accompanying International Classification of Diseases (ICD) codes of 793.11 (ICD-9) or R91.1 (ICD-10). Two cohorts were defined: persons with IPNs during 2014-2017 comprised the IPN cohort, whereas those with chest CT scans without IPNs during 2014-2017 comprised the control cohort. Excess rates of various procedures due to reported IPNs over 2 years of follow-up (chest CT, positron emission tomography [PET]/PET-CT, bronchoscopy, needle biopsy, and surgical procedures) were estimated using multivariable Poisson regression models comparing the cohorts adjusted for covariates. Prior data on stage redistribution associated with IPN management were then used to define a metric of excess procedures per late-stage case avoided. RESULTS Totals of 19,009 and 60,985 subjects were included in the IPN and control cohorts, respectively; 3.6% and 0.8% had lung cancer during follow-up. Excess procedures per 100 persons with IPNs over a 2-year follow-up were 63, 8.2, 1.4, 1.9, and 0.9 for chest CT, PET/PET-CT, bronchoscopy, needle biopsy, and surgery, respectively. Corresponding excess procedures per late-stage case avoided were 48, 6.3, 1.1, 1.5, and 0.7 based on an estimated 1.3 late-stage cases avoided per 100 IPN cohort subjects. CONCLUSIONS The metric of excess procedures per late-stage case avoided can be used to measure the benefits-to-harms tradeoff of IPN management.
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Affiliation(s)
- Paul F Pinsky
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Raymond Osarogiagbon
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee, USA
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10
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Yu DH, Shafiq M, Batra H, Johnson M, Griscom B, Chamberlin J, Lofaro LR, Huang J, Bulman WA, Kennedy GC, Yarmus LB, Lee HJ, Feller-Kopman D. Comparing modalities for risk assessment in patients with pulmonary lesions and nondiagnostic bronchoscopy for suspected lung cancer. BMC Pulm Med 2022; 22:442. [PMID: 36434574 PMCID: PMC9700899 DOI: 10.1186/s12890-022-02181-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 09/09/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Bronchoscopy is commonly utilized for non-surgical sampling of indeterminant pulmonary lesions, but nondiagnostic procedures are common. Accurate assessment of the risk of malignancy is essential for decision making in these patients, yet we lack tools that perform well across this heterogeneous group of patients. We sought to evaluate the accuracy of three previously validated risk models and physician-assessed risk (PAR) in patients with a newly identified lung lesion undergoing bronchoscopy for suspected lung cancer where the result is nondiagnostic. METHODS We performed an analysis of prospective data collected for the Percepta Bronchial Genomic Classifier Multicenter Registry. PAR and three previously validated risk models (Mayo Clinic, Veteran's Affairs, and Brock) were used to determine the probability of lung cancer (low, intermediate, or high) in 375 patients with pulmonary lesions who underwent bronchoscopy for possible lung cancer with nondiagnostic pathology. Results were compared to the actual adjudicated prevalence of malignancy in each pre-test risk group, determined with a minimum of 12 months follow up after bronchoscopy. RESULTS PAR and the risk models performed poorly overall in the assessment of risk in this patient population. PAR most closely matched the observed prevalence of malignancy in patients at 12 months after bronchoscopy, but all modalities had a low area under the curve, and in all clinical models more than half of all the lesions labeled as high risk were truly or likely benign. The studied risk model calculators overestimate the risk of malignancy compared to PAR, particularly in the subset in older patients, irregularly bordered nodules, and masses > 3 cm. Overall, the risk models perform only slightly better when confined to lung nodules < 3 cm in this population. CONCLUSION The currently available tools for the assessment of risk of malignancy perform suboptimally in patients with nondiagnostic findings following a bronchoscopic evaluation for lung cancer. More accurate and objective tools for risk assessment are needed. TRIAL REGISTRATION not applicable.
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Affiliation(s)
- Diana H. Yu
- grid.266102.10000 0001 2297 6811Department of Medicine, Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco, USA CA ,grid.413077.60000 0004 0434 9023UCSF Medical Center, 505 Parnassus Ave, 9414 San Francisco, CA USA
| | - Majid Shafiq
- grid.62560.370000 0004 0378 8294Brigham and Women’s Hospital, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Boston, MA USA
| | - Hitesh Batra
- grid.265892.20000000106344187Department of Medicine, Division of Pulmonary and Critical Care Medicine Birmingham, University of Alabama at Birmingham, Birmingham, AL USA
| | - Marla Johnson
- grid.503590.a0000 0004 5345 9448Veracyte, Inc., South San Francisco, CA USA
| | - Bailey Griscom
- grid.503590.a0000 0004 5345 9448Veracyte, Inc., South San Francisco, CA USA
| | - Janna Chamberlin
- grid.503590.a0000 0004 5345 9448Veracyte, Inc., South San Francisco, CA USA
| | - Lori R. Lofaro
- grid.503590.a0000 0004 5345 9448Veracyte, Inc., South San Francisco, CA USA
| | - Jing Huang
- grid.503590.a0000 0004 5345 9448Veracyte, Inc., South San Francisco, CA USA
| | - William A. Bulman
- grid.503590.a0000 0004 5345 9448Veracyte, Inc., South San Francisco, CA USA
| | - Giulia C. Kennedy
- grid.503590.a0000 0004 5345 9448Veracyte, Inc., South San Francisco, CA USA
| | - Lonny B. Yarmus
- grid.21107.350000 0001 2171 9311Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Hans J. Lee
- grid.21107.350000 0001 2171 9311Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - David Feller-Kopman
- grid.254880.30000 0001 2179 2404Department of Medicine, Division of Pulmonary and Critical Care Medicine, Dartmouth College, Hanover, NH USA
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Ingle MP, Carroll AM, Matlock DD, Gama KD, Valle JA, Allen LA, Knoepke CE. Decision Support Needs for Patients with Severe Symptomatic Aortic Stenosis. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2022; 65:589-603. [PMID: 34809525 DOI: 10.1080/01634372.2021.1995095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 06/13/2023]
Abstract
Social workers in healthcare settings often support patient decision-making processes for complex medical decisions. The objective of this study was to examine decision support needs for patients considering aortic valve replacement (AVR) for aortic stenosis. Seventeen qualitative interviews were conducted to explore treatment decision experiences of patients who accepted AVR. Analysis was conducted using a mixed inductive-deductive approach. Fear was a prevalent response for most participants in the face of AVR. Two general paths of decision making emerged: an "active" information seeking approach, or a "passive" simplicity seeking approach. Patients with unique clinical presentations felt alienated by the decision-making process. Acknowledging fear while understanding different decision-making styles provide opportunities for social workers and other members of multidisciplinary teams to support complex patient decisions.
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Affiliation(s)
- M Pilar Ingle
- Graduate School of Social Work, University of Denver, Denver, Colorado, USA
| | - Adam M Carroll
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Daniel D Matlock
- Adult & Child Consortium for Outcomes Research & Delivery Science (Accords), University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Eastern Colorado, Denver, Colorado, USA
| | - Kristy D Gama
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Javier A Valle
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Interventional Cardiology, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Larry A Allen
- Graduate School of Social Work, University of Denver, Denver, Colorado, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Christopher E Knoepke
- Graduate School of Social Work, University of Denver, Denver, Colorado, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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12
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Singh H, Koster M, Jani C, Rupal A, Walker A, Khoory J, Tewari A, Casasola M, Ranker LR, Thomson C. Nodule net: A centralized prospective lung nodule tracking and safety-net program. Respir Med 2022; 192:106737. [PMID: 35051877 DOI: 10.1016/j.rmed.2022.106737] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/28/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Inadequate follow-up of suspicious lung nodules can result in diagnostic delays and potential progression to advanced lung cancer. In 2015, a multidisciplinary lung nodule management program, Nodule Net, was implemented to increase the timely follow-up rate. In this study, we sought to evaluate the effectiveness of the program. METHODS 2398 chest CT reports were reviewed for the presence of a lung nodule. Baseline demographics, nodule characteristics, and follow-up recommendations were collected. For reports that did not include structured recommendations, Fleischner Society guidelines were applied if appropriate. The rate of follow-up imaging was recorded and compared with historical rates. RESULTS Lung nodules were reported on 1367 (57%) of scans. Of the 632 participants with recommendations for follow-up, the Nodule Net nurse navigator was notified on 523 (83%). Of these, 408 (78%) completed follow-up, compared to 57/109 (52%) in those who were not reported to Nodule Net tracking system (risk ratio: 1.49, 95% CI: 1.24-1.79, p-value < 0.05). Out of these 408, nodule net outreach was required to prompt the follow-up in 116 (28%). Of these, a lung malignancy was diagnosed in 4 (4%). CONCLUSIONS Management of lung nodules is a complex process. Implementation of a lung nodule tracking program led to a significant increase in the completion of recommended follow-up imaging compared with usual care. Developing a comprehensive lung nodule program using an automated software system rather than manual processes to refer and track incidental findings may further reduce barriers to completion of follow-up.
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Affiliation(s)
- Harpreet Singh
- Department of Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Megan Koster
- Department of Pulmonary and Critical Care, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Chinmay Jani
- Department of Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Arashdeep Rupal
- Department of Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Alexander Walker
- Department of Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Joseph Khoory
- Department of Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Arti Tewari
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Marcel Casasola
- Department of Pulmonary and Critical Care, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | | | - Carey Thomson
- Department of Pulmonary and Critical Care, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA; Department of Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA
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13
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The Utility of Chest Imaging for Surveillance of Atypical Lipomatous Tumors. Sarcoma 2021; 2021:4740924. [PMID: 34671190 PMCID: PMC8523289 DOI: 10.1155/2021/4740924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background Unlike other soft tissue sarcomas, atypical lipomatous tumors (ALTs) are thought to have a low propensity for metastasis. Despite this, a standard of care for pulmonary metastasis (PM) surveillance has not been established. This study aimed to evaluate the utility of chest imaging for PM surveillance following ALT excision. Methods This was a multi-institution, retrospective review of all patients with primary ALTs of the extremities or superficial torso who underwent excision between 2006 and 2018. Minimum follow-up was two years. Long-term survival was evaluated using the Kaplan-Meier method. Results 190 patients with ALT were included. Average age was 61.7 years and average follow-up was 58.6 months (24 to 180 months). MDM2 testing was positive in 88 patients (46.3%), and 102 (53.7%) did not receive MDM2 testing. 188 patients (98.9%) had marginal excision, and 127 (66.8%) had marginal or positive margins. Patients received an average of 0.9 CT scans and 1.3 chest radiographs over the surveillance period. 10-year metastasis-free survival was 100%, with no documented deaths from disease. Conclusions This study suggests that chest imaging does not have a significant role in PM surveillance following ALT excision, but advanced local imaging and chest surveillance may be considered in cases of local recurrence or concern for dedifferentiation.
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14
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Xiao R, Huang Y, Meng S, Liu X, Zhao X, Wang J, Li X. A cross-sectional study of psychological burden in Chinese patients with pulmonary nodules: Prevalence and impact on the management of nodules. Thorac Cancer 2021; 12:3150-3156. [PMID: 34651451 PMCID: PMC8636209 DOI: 10.1111/1759-7714.14165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/26/2022] Open
Abstract
Background Uncertainty after the detection of pulmonary nodules (PNs) can cause psychological burden. We designed this study to quantitatively evaluate the prevalence, severity and possible impact of this burden on the preference of patients for management of nodules. Methods The Hospital Anxiety and Depression Scale (HADS) was used to evaluate psychological burden in patients. An independent t‐test and a Mann–Whitney U test were used to determine the significance of differences between groups in continuous variables. A chi‐square test was used to determine the significance of difference between groups in categorical variables. Results A total of 334 inpatients diagnosed with PNs were included in the study. A total of 17.96% of the participates screened positive for anxiety and 14.67% for depression. Female patients had significantly higher positive rates of both anxiety and depression screenings than male patients (21.57% vs. 12.31%, p = 0.032 and 18.05% vs. 9.30%, p = 0.028, respectively). Among patients screened positive for anxiety, the proportion of those who chose more aggressive management was significantly higher (34/60 vs. 113/274, p = 0.029). The rate of benign or precursor disease resected was significantly higher in patients with more aggressive management (46.94% vs. 9.63%, p < 0.01). Conclusions Anxiety and depression are common in Chinese patients with PNs. Patients with positive HADS anxiety screening results are more likely to adopt more aggressive management that leads to a higher rate of benign or precursor disease resected/biopsied. This study alerts clinicians to the need to assess and possibly treat emotional responses.
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Affiliation(s)
- Rongxin Xiao
- Department of Thoracic Surgery, Centre of Thoracic Minimally Invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Yuqing Huang
- Department of Thoracic Surgery, Beijing Haidian Hospital, Haidian Section of Peking University Third Hospital, Beijing, China
| | - Shushi Meng
- Department of Thoracic Surgery, Beijing Haidian Hospital, Haidian Section of Peking University Third Hospital, Beijing, China
| | - Xianping Liu
- Department of Thoracic Surgery, Centre of Thoracic Minimally Invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Xiaoyi Zhao
- Department of Thoracic Surgery, Centre of Thoracic Minimally Invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Jun Wang
- Department of Thoracic Surgery, Centre of Thoracic Minimally Invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Xiao Li
- Department of Thoracic Surgery, Centre of Thoracic Minimally Invasive Surgery, Peking University People's Hospital, Beijing, China
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15
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Wang YW, Wang JW, Yang SX, Qi LL, Lin HL, Zhou Z, Yu YZ. Proposing a deep learning-based method for improving the diagnostic certainty of pulmonary nodules in CT scan of chest. Eur Radiol 2021; 31:8160-8167. [PMID: 33956178 DOI: 10.1007/s00330-021-07919-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 03/01/2021] [Accepted: 03/19/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To compare the performance of a deep learning (DL)-based method for diagnosing pulmonary nodules compared with radiologists' diagnostic approach in computed tomography (CT) of the chest. MATERIALS AND METHODS A total of 150 pathologically confirmed pulmonary nodules (60% malignant) assessed and reported by radiologists were included. CT images were processed by the proposed DL-based method to generate the probability of malignancy (0-100%), and the nodules were divided into the groups of benign (0-39.9%), indeterminate (40.0-59.9%), and malignant (60.0-100%). Taking the pathological results as the gold standard, we compared the diagnostic performance of the proposed DL-based method with the radiologists' diagnostic approach using the McNemar-Bowker test. RESULTS There was a statistically significant difference between the diagnosis results of the proposed DL-based method and the radiologists' diagnostic approach (p < 0.001). Moreover, there was no statistically significant difference in the composition of the diagnosis results between the proposed DL-based method and the radiologists' diagnostic approach (all p > 0.05). The difference in diagnostic accuracy between the proposed DL-based method (70%) and radiologists' diagnostic performance (64%) was not statistically significant (p = 0.243). CONCLUSIONS The proposed DL-based method achieved an accuracy comparable with the radiologists' diagnostic approach in clinical practice. Furthermore, its advantage in improving diagnostic certainty may raise the radiologists' confidence in diagnosing pulmonary nodules and may help clinical management. Therefore, the proposed DL-based method showed great potential in a certain clinical application. KEY POINTS • Deep learning-based method for diagnosing the pulmonary nodules in computed tomography provides a higher diagnostic certainty.
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Affiliation(s)
- Ya-Wen Wang
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Wei Wang
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Shou-Xin Yang
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin-Lin Qi
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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16
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Fernandes S, Williams G, Williams E, Ehrlich K, Stone J, Finlayson N, Bradley M, Thomson RR, Akram AR, Dhaliwal K. Solitary pulmonary nodule imaging approaches and the role of optical fibre-based technologies. Eur Respir J 2021; 57:2002537. [PMID: 33060152 PMCID: PMC8174723 DOI: 10.1183/13993003.02537-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 09/29/2020] [Indexed: 12/18/2022]
Abstract
Solitary pulmonary nodules (SPNs) are a clinical challenge, given there is no single clinical sign or radiological feature that definitively identifies a benign from a malignant SPN. The early detection of lung cancer has a huge impact on survival outcome. Consequently, there is great interest in the prompt diagnosis, and treatment of malignant SPNs. Current diagnostic pathways involve endobronchial/transthoracic tissue biopsies or radiological surveillance, which can be associated with suboptimal diagnostic yield, healthcare costs and patient anxiety. Cutting-edge technologies are needed to disrupt and improve, existing care pathways. Optical fibre-based techniques, which can be delivered via the working channel of a bronchoscope or via transthoracic needle, may deliver advanced diagnostic capabilities in patients with SPNs. Optical endomicroscopy, an autofluorescence-based imaging technique, demonstrates abnormal alveolar structure in SPNs in vivo Alternative optical fingerprinting approaches, such as time-resolved fluorescence spectroscopy and fluorescence-lifetime imaging microscopy, have shown promise in discriminating lung cancer from surrounding healthy tissue. Whilst fibre-based Raman spectroscopy has enabled real-time characterisation of SPNs in vivo Fibre-based technologies have the potential to enable in situ characterisation and real-time microscopic imaging of SPNs, which could aid immediate treatment decisions in patients with SPNs. This review discusses advances in current imaging modalities for evaluating SPNs, including computed tomography (CT) and positron emission tomography-CT. It explores the emergence of optical fibre-based technologies, and discusses their potential role in patients with SPNs and suspected lung cancer.
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Affiliation(s)
- Susan Fernandes
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Gareth Williams
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Elvira Williams
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Katjana Ehrlich
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - James Stone
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- Centre for Photonics and Photonic Materials, Dept of Physics, The University of Bath, Bath, UK
| | - Neil Finlayson
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- Institute for Integrated Micro and Nano Systems, School of Engineering, The University of Edinburgh, Edinburgh, UK
| | - Mark Bradley
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- EaStCHEM, School of Chemistry, The University of Edinburgh, Edinburgh, UK
| | - Robert R. Thomson
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- Institute of Photonics and Quantum Sciences, School of Engineering and Physical Sciences, Heriot-Watt University, Edinburgh, UK
| | - Ahsan R. Akram
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Kevin Dhaliwal
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
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17
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Differences in the clinical management of women and men after detection of a solitary pulmonary nodule in clinical practice. Eur Radiol 2020; 30:4390-4397. [PMID: 32193639 DOI: 10.1007/s00330-020-06791-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/25/2020] [Accepted: 03/04/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To explore differences in the clinical management of men and women in the 5 years after detecting a solitary pulmonary nodule (SPN) by chest radiograph or CT in routine clinical practice. METHODS We followed up 545 men and 347 women with an SPN detected by chest radiograph or CT in a retrospective cohort of 25,422 individuals undergoing routine thoracic imaging in 2010-2011. We compared the frequency of each management strategy (no further test, immediate intervention or follow up) according to sex by means of chi-squared. We estimated the relative risk of women versus men of having been followed up instead of an immediate intervention using multivariate logistic regression. We compared by sex the time between detection of the nodule and lung cancer diagnosis, the time between diagnosis and death by means of Mann-Whitney U test and the cumulative effective dose of radiation in each management strategy by means of t test. RESULTS Women were more likely than men to have follow-up rather than immediate intervention (aRR = 1.8, CI 1.3-2.7, p = 0.002), particularly in those who underwent CT (aRR = 4.2, CI 1.9-9.3, p < 0.001). The median time between SPN detection and lung cancer diagnosis was higher in women (4.2 months, interquartile range (IQR) 5.1) than in men (1.5 months, IQR 16.2). The mean cumulative effective dose was 21.3 mSv, 19.4 mSv in men and 23.9mv in women (p = 0.023). CONCLUSIONS Our results could reflect decisions based on a greater suspicion of lung cancer in men. The incidental detection of SPNs is increasing, and it is necessary to establish clear strategies aimed to reduce variability in their management according to patient's sex. KEY POINTS • After incidental finding of SPN, women were less likely to receive an immediate intervention. • Accumulative radiation was higher in women than in men. • Our results could reflect decisions based on a greater suspicion of lung cancer in men.
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18
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Wiener DC, Wiener RS. Patient-Centered, Guideline-Concordant Discussion and Management of Pulmonary Nodules. Chest 2020; 158:416-422. [PMID: 32081651 DOI: 10.1016/j.chest.2020.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/01/2020] [Indexed: 12/17/2022] Open
Abstract
Providing guideline-concordant management of pulmonary nodules can present challenges when a patient's anxiety about cancer or fear of invasive procedures colors judgment. The way in which providers discuss and make decisions about how to evaluate a pulmonary nodule can affect patient satisfaction, distress, and adherence to evaluation. This article discusses the complexity of tailoring patient-provider communication, decision-making, and implementation of guidelines for pulmonary nodule evaluation to the individual patient, emphasizing the importance of how information is conveyed and the value of listening to and addressing patients' concerns. We summarize the relevant guideline recommendations and literature, and provide two case scenarios to illustrate a patient-centered approach to discussing and managing pulmonary nodules from our perspectives as a pulmonologist and thoracic surgeon.
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Affiliation(s)
- Daniel C Wiener
- VA Boston Healthcare System, Boston, MA; Division of Thoracic Surgery, Brigham & Women's Hospital, Boston, MA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA; The Pulmonary Center, Boston University School of Medicine, Boston, MA.
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19
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Kanellakis NI, Lamote K. Management of incidental nodules in lung cancer screening: ready for prime-time? Breathe (Sheff) 2019; 15:346-349. [PMID: 31803272 PMCID: PMC6885334 DOI: 10.1183/20734735.0247-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Current clinical management of lung nodule patients is inefficient and therefore causes patient misclassification, which increases healthcare expenses. A precise and robust lung nodule classifier could minimise healthcare costs and discomfort for patients. http://bit.ly/2oMIEwQ.
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Affiliation(s)
- Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Kevin Lamote
- Laboratory Experimental Medicine and Pediatrics, Dept of Translational Research in Immunology and Inflammation, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Dept of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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A Secondary Analysis to Identify Patient-Centered Outcomes in the ACR’s Appropriateness Criteria. J Am Coll Radiol 2019; 16:1645-1655. [DOI: 10.1016/j.jacr.2019.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 11/20/2022]
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Ruparel M, Quaife S, Baldwin D, Waller J, Janes S. Defining the information needs of lung cancer screening participants: a qualitative study. BMJ Open Respir Res 2019; 6:e000448. [PMID: 31803474 PMCID: PMC6890387 DOI: 10.1136/bmjresp-2019-000448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 10/09/2019] [Accepted: 11/06/2019] [Indexed: 01/10/2023] Open
Abstract
Introduction Lung cancer screening (LCS) by low-dose CT has been shown to improve mortality, but individuals must consider the potential benefits and harms before making an informed decision about taking part. Shared decision-making is required for LCS in USA, though screening-eligible individuals' specific views of these harms, and their preferences for accessing this information, are not well described. Methods In this qualitative study, we aimed to explore knowledge and perceptions around lung cancer and LCS with a focus on harms. We carried out seven focus groups with screening-eligible individuals, which were divided into current versus former smokers and lower versus higher educational backgrounds; and 16 interviews with health professionals including general practitioners, respiratory physicians, lung cancer nurse specialists and public health consultants. Interviews and focus groups were audio-recorded and transcribed. Data were coded inductively and analysed using the framework method. Results Fatalistic views about lung cancer as an incurable disease dominated, particularly among current smokers, and participants were often unaware of curative treatment options. Despite this, beliefs that screening is sensible and worthwhile were expressed. Generally participants felt they had the 'right' to an informed decision, though some cautioned against information overload. The potential harms of LCS were poorly understood, particularly overdiagnosis and radiation exposure, but participants were unlikely to be deterred by them. Strong concerns about false-negative results were expressed, while false-positive results and indeterminate nodules were also reported as concerning. Conclusions These findings demonstrate the need for LCS information materials to highlight information on the benefits of early detection and options for curative treatment, while accurately presenting the possible harms. Information needs are likely to vary between individuals and we recommend simple information materials to be made available to all individuals considering participating in LCS, with signposting to more detailed information for those who require it.
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Affiliation(s)
- Mamta Ruparel
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - Samantha Quaife
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - David Baldwin
- Respiratory Medicine Unit, David Evans Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jo Waller
- Research Department of Behavioural Science and Health, University College London, London, UK
- Cancer Prevention Group, King's College London, London, UK
| | - Samuel Janes
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
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Iaccarino JM, Silvestri GA, Wiener RS. Patient-Level Trajectories and Outcomes After Low-Dose CT Screening in the National Lung Screening Trial. Chest 2019; 156:965-971. [PMID: 31283920 DOI: 10.1016/j.chest.2019.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/22/2019] [Accepted: 06/10/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Shared decision-making is an essential element of low-dose CT (LDCT) screening for lung cancer. Understanding patient-level outcomes from the National Lung Screening Trial (NLST) is critical to effectively communicate risks and benefits of screening to patients. METHODS We performed a secondary analysis of data collected in the NLST. We determined outcomes of each LDCT scan performed in the NLST (downstream evaluation, complications, lung cancer diagnoses), and compared outcomes at the test level with outcomes calculated at the patient level for those randomized to LDCT screening. To assess the impact of COPD on patient outcomes, we compared outcomes among patients with and without COPD. RESULTS Of 75,138 LDCT scans, 14.2% led to a diagnostic study and 1.5% to an invasive procedure, with 0.3% of LDCT scans resulting in a procedure-related complication and 0.1% in a serious complication. Among 24,453 patients who underwent LDCT screening, 30.5% underwent a diagnostic study and 4.2% an invasive procedure, with 0.9% of screened patients experiencing a procedure-related complication and 0.3% a serious complication. Patients with COPD (defined by self-report) were more likely to need a diagnostic study (adjusted OR [aOR], 1.29; P < .01) and an invasive procedure (aOR, 1.41; P < .01) and more likely to experience a complication (aOR, 1.83; P < .01) and a serious complication (aOR, 1.78; P = .01). Patients with COPD also were more likely to be diagnosed with lung cancer (aOR, 1.43; P < .01). CONCLUSIONS We provide important patient-level data from the NLST that can be used to guide shared decision-making. The risk-to-benefit ratio of screening may vary significantly in some patients, such as those with COPD, in whom both risks and benefits of screening may be increased.
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Affiliation(s)
| | - Gerard A Silvestri
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Renda Soylemez Wiener
- Pulmonary Center, Boston University School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
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Nemesure B, Clouston S, Albano D, Kuperberg S, Bilfinger TV. Will That Pulmonary Nodule Become Cancerous? A Risk Prediction Model for Incident Lung Cancer. Cancer Prev Res (Phila) 2019; 12:463-470. [PMID: 31248853 DOI: 10.1158/1940-6207.capr-18-0500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/14/2019] [Accepted: 05/13/2019] [Indexed: 11/16/2022]
Abstract
This prospective investigation derived a prediction model for identifying risk of incident lung cancer among patients with visible lung nodules identified on computed tomography (CT). Among 2,924 eligible patients referred for evaluation of a pulmonary nodule to the Stony Brook Lung Cancer Evaluation Center between January 1, 2002 and December 31, 2015, 171 developed incident lung cancer during the observation period. Cox proportional hazard models were used to model time until disease onset. The sample was randomly divided into discovery (n = 1,469) and replication (n = 1,455) samples. In the replication sample, concordance was computed to indicate predictive accuracy and risk scores were calculated using the linear predictions. Youden index was used to identify high-risk versus low-risk patients and cumulative lung cancer incidence was examined for high-risk and low-risk groups. Multivariable analyses identified a combination of clinical and radiologic predictors for incident lung cancer including ln-age, ln-pack-years smoking, a history of cancer, chronic obstructive pulmonary disease, and several radiologic markers including spiculation, ground glass opacity, and nodule size. The final model reliably detected patients who developed lung cancer in the replication sample (C = 0.86, sensitivity/specificity = 0.73/0.81). Cumulative incidence of lung cancer was elevated in high-risk versus low-risk groups [HR = 14.34; 95% confidence interval (CI), 8.17-25.18]. Quantification of reliable risk scores has high clinical utility, enabling physicians to better stratify treatment protocols to manage patient care. The final model is among the first tools developed to predict incident lung cancer in patients presenting with a concerning pulmonary nodule.
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Affiliation(s)
- Barbara Nemesure
- Department of Family, Population and Preventive Medicine, Stony Brook Medicine, Stony Brook, New York.
| | - Sean Clouston
- Department of Family, Population and Preventive Medicine, Stony Brook Medicine, Stony Brook, New York.,Program in Public Health, Stony Brook Medicine, Stony Brook, New York
| | - Denise Albano
- Department of Surgery, Stony Brook Medicine, Stony Brook, New York
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Byrne MM, Lillie SE, Studts JL. Lung cancer screening in a community setting: Characteristics, motivations, and attitudes of individuals being screened. Health Psychol Open 2019; 6:2055102918819163. [PMID: 30643640 PMCID: PMC6322099 DOI: 10.1177/2055102918819163] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We describe the characteristics of individuals being screened in community settings including factors influencing screening decisions and the level of information sought prior to screening. Individuals from two community-based radiology clinics (N = 27) were surveyed after screening. Screening efficacy and salience were the most important factors in screening decisions, whereas healthcare provider recommendations were rated not important. Half of participants reported no or little conversation about screening with their primary care provider, and 61.5 percent had not sought any information on screening. Individuals being screened in a community setting are unlikely to have sufficient information for an informed decision about screening.
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Abstract
Overdiagnosis, is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm a patient during his or her lifetime, and it is increasingly acknowledged as a consequence of screening for cancer and other conditions. Because preventive care is a crucial component of primary care, which is delivered to the broad population, overdiagnosis in primary care is an important problem from a public health perspective and has far reaching implications. The scope of overdiagnosis as a result of services delivered in primary care is unclear, though overdiagnosis of indolent breast, prostate, thyroid, and lung cancers is well described and overdiagnosis of chronic kidney disease, depression, and attention-deficit/hyperactivity disorder is also recognized. However, overdiagnosis is a known consequence of all screening and can be assumed to occur in many more clinical contexts. Overdiagnosis can harm patients by leading to overtreatment (with associated potential toxicities), diagnosis related anxiety or depression, and labeling, or through financial burden. Many entrenched factors facilitate overdiagnosis, including the growing use of advanced diagnostic technology, financial incentives, a medical culture that encourages greater use of tests and treatments, limitations in the evidence that obscure the understanding of diagnostic utility, use of non-beneficial screening tests, and the broadening of disease definitions. Efforts to reduce overdiagnosis are hindered by physicians' and patients' lack of awareness of the problem and by confusion about terminology, with overdiagnosis often conflated with related concepts. Clarity of terminology would facilitate physicians' understanding of the problem and the growth in evidence regarding its prevalence and downstream consequences in primary care. It is hoped that international coordination regarding diagnostic standards for disease definitions will also help minimize overdiagnosis in the future.
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Affiliation(s)
- Minal S Kale
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Deborah Korenstein
- Department of Medicine and Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
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Opening the Black Box of Communication and Decision-Making for Lung Cancer Screening and Nodule Evaluation. Implications for Policy and Practice. Ann Am Thorac Soc 2018; 13:1887-1889. [PMID: 27831805 DOI: 10.1513/annalsats.201609-695ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Clark ME, Bedford LE, Young B, Robertson JFR, das Nair R, Vedhara K, Littleford R, Sullivan FM, Mair FS, Schembri S, Rauchhaus P, Kendrick D. Lung cancer CT screening: Psychological responses in the presence and absence of pulmonary nodules. Lung Cancer 2018; 124:160-167. [PMID: 30268456 DOI: 10.1016/j.lungcan.2018.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/30/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To determine the psychological response (thoughts, perceptions and affect) to a diagnosis of pulmonary nodules following a novel antibody blood test and computed tomography (CT) scans within a UK population. MATERIALS AND METHODS This study was nested within a randomised controlled trial of a blood test (Early CDT®-Lung test), followed by a chest x-ray and serial CT-scanning of those with a positive blood test for early detection of lung cancer (ECLS Study). Trial participants with a positive Early CDT®-Lung test were invited to participate (n = 338) and those agreeing completed questionnaires assessing psychological outcomes at 1, 3 and 6 months following trial recruitment. Responses of individuals with pulmonary nodules on their first CT scan were compared to those without (classified as normal CT) at 3 and 6 months follow-up using random effects regression models to account for multiple observations per participant, with loge transformation of data where modelling assumptions were not met. RESULTS There were no statistically significant differences between the nodule and normal CT groups in affect, lung cancer worry, health anxiety, illness perceptions, lung cancer risk perception or intrusive thoughts at 3 or 6 months post-recruitment. The nodule group had statistically significantly fewer avoidance symptoms compared to the normal CT group at 3 months (impact of events scale avoidance (IES-A) difference between means -1.99, 95%CI -4.18, 0.21) than at 6 months (IES-A difference between means 0.88, 95%CI -1.32, 3.08; p-value for change over time = 0.003) with similar findings using loge transformed data. CONCLUSION A diagnosis of pulmonary nodules following an Early CDT®-Lung test and CT scan did not appear to result in adverse psychological responses compared to those with a normal CT scan.
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Affiliation(s)
- Marcia E Clark
- University of Nottingham, Division of Primary Care, United Kingdom
| | - Laura E Bedford
- University of Nottingham, Division of Primary Care, United Kingdom
| | - Ben Young
- University of Nottingham, Division of Primary Care, United Kingdom
| | - John F R Robertson
- University of Nottingham, Division of Medical Sciences and Graduate Entry Medicine, United Kingdom
| | - Roshan das Nair
- University of Nottingham, Institute of Mental Health, United Kingdom
| | - Kavita Vedhara
- University of Nottingham, Division of Primary Care, United Kingdom
| | | | | | - Frances S Mair
- University of Glasgow, General Practice and Primary Care, United Kingdom
| | - Stuart Schembri
- University of Dundee, Scottish Centre for Respiratory Research, United Kingdom
| | - Petra Rauchhaus
- University of Dundee, Tayside Clinical Trials Unit, United Kingdom
| | - Denise Kendrick
- University of Nottingham, Division of Primary Care, United Kingdom.
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28
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Selby PJ, Banks RE, Gregory W, Hewison J, Rosenberg W, Altman DG, Deeks JJ, McCabe C, Parkes J, Sturgeon C, Thompson D, Twiddy M, Bestall J, Bedlington J, Hale T, Dinnes J, Jones M, Lewington A, Messenger MP, Napp V, Sitch A, Tanwar S, Vasudev NS, Baxter P, Bell S, Cairns DA, Calder N, Corrigan N, Del Galdo F, Heudtlass P, Hornigold N, Hulme C, Hutchinson M, Lippiatt C, Livingstone T, Longo R, Potton M, Roberts S, Sim S, Trainor S, Welberry Smith M, Neuberger J, Thorburn D, Richardson P, Christie J, Sheerin N, McKane W, Gibbs P, Edwards A, Soomro N, Adeyoju A, Stewart GD, Hrouda D. Methods for the evaluation of biomarkers in patients with kidney and liver diseases: multicentre research programme including ELUCIDATE RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2018. [DOI: 10.3310/pgfar06030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BackgroundProtein biomarkers with associations with the activity and outcomes of diseases are being identified by modern proteomic technologies. They may be simple, accessible, cheap and safe tests that can inform diagnosis, prognosis, treatment selection, monitoring of disease activity and therapy and may substitute for complex, invasive and expensive tests. However, their potential is not yet being realised.Design and methodsThe study consisted of three workstreams to create a framework for research: workstream 1, methodology – to define current practice and explore methodology innovations for biomarkers for monitoring disease; workstream 2, clinical translation – to create a framework of research practice, high-quality samples and related clinical data to evaluate the validity and clinical utility of protein biomarkers; and workstream 3, the ELF to Uncover Cirrhosis as an Indication for Diagnosis and Action for Treatable Event (ELUCIDATE) randomised controlled trial (RCT) – an exemplar RCT of an established test, the ADVIA Centaur® Enhanced Liver Fibrosis (ELF) test (Siemens Healthcare Diagnostics Ltd, Camberley, UK) [consisting of a panel of three markers – (1) serum hyaluronic acid, (2) amino-terminal propeptide of type III procollagen and (3) tissue inhibitor of metalloproteinase 1], for liver cirrhosis to determine its impact on diagnostic timing and the management of cirrhosis and the process of care and improving outcomes.ResultsThe methodology workstream evaluated the quality of recommendations for using prostate-specific antigen to monitor patients, systematically reviewed RCTs of monitoring strategies and reviewed the monitoring biomarker literature and how monitoring can have an impact on outcomes. Simulation studies were conducted to evaluate monitoring and improve the merits of health care. The monitoring biomarker literature is modest and robust conclusions are infrequent. We recommend improvements in research practice. Patients strongly endorsed the need for robust and conclusive research in this area. The clinical translation workstream focused on analytical and clinical validity. Cohorts were established for renal cell carcinoma (RCC) and renal transplantation (RT), with samples and patient data from multiple centres, as a rapid-access resource to evaluate the validity of biomarkers. Candidate biomarkers for RCC and RT were identified from the literature and their quality was evaluated and selected biomarkers were prioritised. The duration of follow-up was a limitation but biomarkers were identified that may be taken forward for clinical utility. In the third workstream, the ELUCIDATE trial registered 1303 patients and randomised 878 patients out of a target of 1000. The trial started late and recruited slowly initially but ultimately recruited with good statistical power to answer the key questions. ELF monitoring altered the patient process of care and may show benefits from the early introduction of interventions with further follow-up. The ELUCIDATE trial was an ‘exemplar’ trial that has demonstrated the challenges of evaluating biomarker strategies in ‘end-to-end’ RCTs and will inform future study designs.ConclusionsThe limitations in the programme were principally that, during the collection and curation of the cohorts of patients with RCC and RT, the pace of discovery of new biomarkers in commercial and non-commercial research was slower than anticipated and so conclusive evaluations using the cohorts are few; however, access to the cohorts will be sustained for future new biomarkers. The ELUCIDATE trial was slow to start and recruit to, with a late surge of recruitment, and so final conclusions about the impact of the ELF test on long-term outcomes await further follow-up. The findings from the three workstreams were used to synthesise a strategy and framework for future biomarker evaluations incorporating innovations in study design, health economics and health informatics.Trial registrationCurrent Controlled Trials ISRCTN74815110, UKCRN ID 9954 and UKCRN ID 11930.FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Peter J Selby
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rosamonde E Banks
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Walter Gregory
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - William Rosenberg
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Christopher McCabe
- Department of Emergency Medicine, University of Alberta Hospital, Edmonton, AB, Canada
| | - Julie Parkes
- Primary Care and Population Sciences Academic Unit, University of Southampton, Southampton, UK
| | | | | | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Janine Bestall
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Tilly Hale
- LIVErNORTH Liver Patient Support, Newcastle upon Tyne, UK
| | - Jacqueline Dinnes
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Marc Jones
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | | | - Vicky Napp
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Alice Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sudeep Tanwar
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Naveen S Vasudev
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Baxter
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sue Bell
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David A Cairns
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | | | - Neil Corrigan
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Peter Heudtlass
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nick Hornigold
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michelle Hutchinson
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Carys Lippiatt
- Department of Specialist Laboratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Roberta Longo
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Matthew Potton
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Stephanie Roberts
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Sheryl Sim
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Sebastian Trainor
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Matthew Welberry Smith
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James Neuberger
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Paul Richardson
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - John Christie
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Neil Sheerin
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - William McKane
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul Gibbs
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Naeem Soomro
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Grant D Stewart
- NHS Lothian, Edinburgh, UK
- Academic Urology Group, University of Cambridge, Cambridge, UK
| | - David Hrouda
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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Raz DJ, Nelson RA, Kim JY, Sun V. Pilot study of a video intervention to reduce anxiety and promote preparedness for lung cancer screening. Cancer Treat Res Commun 2018; 16:1-8. [PMID: 31298996 DOI: 10.1016/j.ctarc.2018.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 03/22/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Lung cancer screening (LCS) with low dose computed tomography (LDCT) is associated with a 20% reduction in lung cancer mortality. Psychological burden is a potential harm associated with LCS, and is a major barrier to utilization. We aimed to examine the feasibility and acceptability of a video intervention designed to reduce anxiety and promote psychological preparedness of LCS. PATIENTS AND METHODS This is a two group, sequential enrollment pilot study of a video intervention that integrates information on screen criteria, procedures, benefits and harms, and follow-up plan. Participants were enrolled 1-2 weeks prior to baseline LDCT, and the intervention was administered in one in-person session on the day of LDCT. Outcomes were assessed at baseline (pre-screen), immediately after LDCT, and at 1 week, 3 months, and 7 months post-screen. Outcome measures included the SF-12 (HRQOL), STAI (anxiety), psychosocial consequences of LCS (COS-LC), risk perceptions for lung cancer, and a satisfaction tool. The student's t-test was used for exploratory evaluations on change from baseline scores both within and between groups. RESULTS Sixteen participants (8 intervention, 8 controls) enrolled and completed the study (61.5% retention). Participants in the control group reported a significantly increased sense of dejection at 1-month and 7-months post-screen as measured by the COS-LC (p = 0.01). Participants were highly satisfied with the intervention. CONCLUSION A video intervention that promoted psychological preparedness for LCS was feasible to implement as part of an LCS program and highly accepted by participants.
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Affiliation(s)
- Dan J Raz
- Division of Thoracic Surgery, Department of Surgery, USA.
| | | | - Jae Y Kim
- Division of Thoracic Surgery, Department of Surgery, USA.
| | - Virginia Sun
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA, USA.
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Slatore CG, Wiener RS. Pulmonary Nodules: A Small Problem for Many, Severe Distress for Some, and How to Communicate About It. Chest 2018; 153:1004-1015. [PMID: 29066390 PMCID: PMC5989642 DOI: 10.1016/j.chest.2017.10.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/26/2017] [Accepted: 10/09/2017] [Indexed: 12/21/2022] Open
Abstract
Every year, millions of patients are diagnosed with pulmonary nodules, and as increasing numbers of people undergo lung cancer screening, even more patients will be found to have a nodule. The vast majority of patients cannot benefit from the detection of a pulmonary nodule because most are benign. Accordingly, it is important to develop strategies to minimize harm, in particular the distress of a "near-cancer" diagnosis. In other settings, communication strategies are critical mediators of patient-centered outcomes for those with cancer and those at-risk of cancer. We conducted multiple studies to characterize the experience of patients with the diagnosis and evaluation of incidental pulmonary nodules, measure patient-centered outcomes for patients with pulmonary nodules, and determine the association of patient-clinician communication practices with those outcomes. We learned that a substantial proportion of patients experience distress and inadequate communication about pulmonary nodules and their evaluation, and yet many clinicians are unaware of the degree to which some patients are affected by the finding of a pulmonary nodule. The present review provides a comprehensive summary of our results and offers suggestions for how clinicians can best provide high-quality communication for their patients.
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Affiliation(s)
- Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR; Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System, Portland, OR; Division of Pulmonary & Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR.
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA; The Pulmonary Center, Boston University School of Medicine, Boston, MA
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How Patients View Lung Cancer Screening. The Role of Uncertainty in Medical Decision Making. Ann Am Thorac Soc 2017; 13:1969-1976. [PMID: 27676595 DOI: 10.1513/annalsats.201604-290oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Radiographic lung cancer screening guidelines and coverage requirements warrant a shared decision-making process. Guidance is needed regarding how to conduct shared decision making effectively. A useful organizing theme should include consideration of a patient's response to and tolerance of uncertainty associated with lung cancer screening. OBJECTIVES The objectives of this study are to: (1) describe how patients respond to specific categories of uncertainty in the context of lung cancer screening, and (2) inform strategies for addressing concerns about uncertainty as part of the shared decision making. METHODS We performed two series of structured interviews on participants in a convenience sample of current or former cigarette smokers recruited from primary care and pulmonary practices in Philadelphia. An interview guide included prompts related to benefits, harms, and responses to general and specific types of uncertainty (stochastic, statistical, and evidentiary) associated with lung cancer screening. Interviews were audio-recorded, transcribed, and independently coded by two investigators. An inductive analysis was conducted, and major themes were identified. MEASUREMENTS AND MAIN RESULTS Twenty-two adults participated in the study. Sixty-eight percent were men, 72% were black or African American, and 50% met U.S. Preventive Services Task Force criteria for lung cancer screening. The primary themes to emerge from our study were: (1) the desire to decrease uncertainty may motivate lung cancer screening decisions; (2) uncertainty is an attribute of health states that impacts how patients weigh benefits and harms of lung cancer screening; (3) patient understanding and tolerance of uncertainty varies across stochastic, statistical, and evidentiary uncertainty; and (4) provider-patient communication may mitigate intolerance of uncertainty in the context of lung cancer screening. CONCLUSIONS A systematic approach to understanding and addressing patients' concerns about uncertainty in the context of lung cancer screening can guide a patient-centered approach to shared decision making. The results of this study can inform provider-patient communication strategies regarding the decision to perform radiographic lung cancer screening.
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Abstract
RATIONALE Millions of patients are diagnosed with pulmonary nodules every year. Increased distress may be a common harm, but methods of mitigating this distress are unclear. OBJECTIVES We aimed to determine whether high-quality communication regarding the discovery of a pulmonary nodule is associated with a lower level of patient distress. METHODS We conducted a prospective, repeated-measures cohort study of 121 patients with newly reported, incidentally detected pulmonary nodules. The primary exposure was participant-reported quality of communication regarding the nodule. Secondary exposures included communication measures regarding participants' values, preferences, and decision making. The main outcome was nodule-related distress measured using the Impact of Event Scale. We used adjusted generalized estimating equations to measure the association between nodule communication quality and at least mild distress. MEASUREMENTS AND MAIN RESULTS Most participants (57%) reported at least mild distress at least once. While average distress scores decreased over time, one-fourth still had elevated distress after 2 years of surveillance for a nodule. The average calculated risk of cancer at baseline was 10% (SD, 13%), but 52.4% believed they had a greater than 30% risk of lung cancer at baseline, and this percentage remained fairly constant at all visits. High-quality nodule communication was associated with decreased odds of distress (adjusted odds ratio, 0.42; 95% confidence interval, 0.24-0.73). Lower-quality communication processes regarding participants' values and preferences were also associated with increased odds of distress, but concordance between the actual and preferred decision-making roles was not. CONCLUSIONS Among patients with incidentally discovered pulmonary nodules, distress is common and persistent for about 25%. Many participants substantially overestimate their risk of lung cancer. Incorporating patients' values and preferences into communication about a pulmonary nodule and its evaluation may mitigate distress.
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Kathuria H, Detterbeck FC, Fathi JT, Fennig K, Gould MK, Jolicoeur DG, Land SR, Massetti GM, Mazzone PJ, Silvestri GA, Slatore CG, Smith RA, Vachani A, Zeliadt SB, Wiener RS. Stakeholder Research Priorities for Smoking Cessation Interventions within Lung Cancer Screening Programs. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2017; 196:1202-1212. [PMID: 29090963 DOI: 10.1164/rccm.201709-1858st] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
RATIONALE Smoking cessation counseling in conjunction with low-dose computed tomography (LDCT) lung cancer screening is recommended in multiple clinical practice guidelines. The best approach for integrating effective smoking cessation interventions within this setting is unknown. OBJECTIVES To summarize evidence, identify research gaps, prioritize topics for future research, and propose standardized tools for use in conducting research on smoking cessation interventions within the LDCT lung cancer screening setting. METHODS The American Thoracic Society convened a multistakeholder committee with expertise in tobacco dependence treatment and/or LDCT screening. During an in-person meeting, evidence was reviewed, research gaps were identified, and key questions were generated for each of three research domains: (1) target population to study; (2) adaptation, development, and testing of interventions; and (3) implementation of interventions with demonstrated efficacy. We also identified standardized measures for use in conducting this research. A larger stakeholder panel then ranked research questions by perceived importance in an online survey. Final prioritization was generated hierarchically on the basis of average rank assigned. RESULTS There was little consensus on which questions within the population domain were of highest priority. Within the intervention domain, research to evaluate the effectiveness in the lung cancer screening setting of evidence-based smoking cessation interventions shown to be effective in other contexts was ranked highest. In the implementation domain, stakeholders prioritized understanding strategies to identify and overcome barriers to integrating smoking cessation in lung cancer screening settings. CONCLUSIONS This statement offers an agenda to stimulate research surrounding the integration and implementation of smoking cessation interventions with LDCT lung cancer screening.
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Rationale and Design of the Lung Cancer Screening Implementation. Evaluation of Patient-Centered Care Study. Ann Am Thorac Soc 2017. [DOI: 10.1513/annalsats.201705-378sd] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Iaccarino JM, Simmons J, Gould MK, Slatore CG, Woloshin S, Schwartz LM, Wiener RS. Clinical Equipoise and Shared Decision-making in Pulmonary Nodule Management. A Survey of American Thoracic Society Clinicians. Ann Am Thorac Soc 2017; 14:968-975. [PMID: 28278389 PMCID: PMC5566306 DOI: 10.1513/annalsats.201609-727oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 02/14/2017] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Guidelines for pulmonary nodule evaluation suggest a variety of strategies, reflecting the lack of high-quality evidence demonstrating the superiority of any one approach. It is unclear whether clinicians agree that multiple management options are appropriate at different levels of risk and whether this impacts their decision-making approaches with patients. OBJECTIVES To assess clinicians' perceptions of the appropriateness of various diagnostic strategies, approach to decision-making, and perceived clinical equipoise in pulmonary nodule evaluation. METHODS We developed and administered a web-based survey in March and April, 2014 to clinician members of the American Thoracic Society. The primary outcome was perceived appropriateness of pulmonary nodule evaluation strategies in three clinical vignettes with different malignancy risk. We compared responses to guideline recommendations and analyzed clinician characteristics associated with a reported shared decision-making approach. We also assessed clinicians' likelihood to enroll patients in hypothetical randomized trials comparing nodule evaluation strategies. RESULTS Of 5,872 American Thoracic Society members e-mailed, 1,444 opened the e-mail and 428 eligible clinicians participated in the survey (response rate, 30.0% among those who opened the invitation; 7% overall). The mean number of options considered appropriate increased with pretest probability of cancer, ranging from 1.8 (SD, 1.2) for the low-risk case to 3.5 (1.1) for the high-risk case (P < 0.0001). As recommended by guidelines, the proportion that deemed surgical resection as an appropriate option also increased with cancer risk (P < 0.0001). One-half of clinicians (50.4%) reported engaging in shared decision-making with patients for pulmonary nodule management; this was more commonly reported by clinicians with more years of experience (P = 0.01) and those who reported greater comfort in managing pulmonary nodules (P = 0.005). Although one-half (49.9%) deemed the evidence for pulmonary nodule evaluation to be strong, most clinicians were willing to enroll patients in randomized trials to compare nodule management strategies in all risk categories (low risk, 87.6%; moderate risk, 89.7%; high risk, 63.0%). CONCLUSIONS Consistent with guideline recommendations, clinicians embrace multiple options for pulmonary nodule evaluation and many are open to shared decision-making. Clinicians support the need for randomized clinical trials to strengthen the evidence for nodule evaluation, which will further improve decision-making.
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Affiliation(s)
| | - James Simmons
- Division of Pulmonary, Critical Care, and Sleep Medicine, Brown University, Providence, Rhode Island
| | - Michael K. Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon
| | - Steven Woloshin
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Lisa M. Schwartz
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Renda Soylemez Wiener
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
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Abstract
Indeterminate pulmonary nodules are commonly encountered and often result in costly and invasive procedures that eventually turn out to be unnecessary. Current prediction models can help to estimate the pretest probability of cancer and assist in determining a strategy of observation with serial imaging for a low pretest probability of cancer, and a more aggressive approach for those patients with a high pretest probability. However, the majority of patients will have an intermediate pretest probability which becomes complex. Decisions for further management are often based on preference by the clinician with the majority of physicians not following current guidelines in the management of pulmonary nodules. Poor adherence to pulmonary nodule guidelines is multifactorial with a variety of factors coming into play. These include inappropriate advice given by the radiologist, patient age, comorbidities, patient preference, and physician's technical skill all influencing the decision making.
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Affiliation(s)
- Sonali Sethi
- Interventional Pulmonology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Parrish
- Interventional Pulmonary Division, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Hart JL, Pflug E, Madden V, Halpern SD. Thinking Forward: Future-oriented Thinking among Patients with Tobacco-associated Thoracic Diseases and Their Surrogates. Am J Respir Crit Care Med 2016; 193:321-9. [PMID: 26436758 DOI: 10.1164/rccm.201505-0882oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The goal of shared decision making is to match patient preferences, including evaluation of potential future outcomes, with available management options. Yet, it is unknown how patients with smoking-related thoracic diseases or their surrogates display future-oriented thinking. OBJECTIVES To document prevalent themes in patients' and potential surrogate decision makers' future-oriented thinking when facing preference-sensitive choices. METHODS We conducted 44 scenario-based semistructured interviews among a diverse group of outpatients with smoking-associated thoracic diseases and potential surrogates for whom one of three preference-sensitive decisions would be medically relevant. Using content analysis, we documented prevalent themes to understand how these individuals display future-oriented thinking. MEASUREMENTS AND MAIN RESULTS Patients and potential surrogates generally expressed expectations for future outcomes but also acknowledged their limitations in doing so. When thinking about potential outcomes, decision makers relied on past experiences, including those only loosely related; perceived familiarity with treatment options; and spirituality. The content of these expectations included effects on family, emotional predictions, and prognostication. For surrogates, a tension existed between hope-based and fact-based expectations. CONCLUSIONS Patients and surrogates may struggle to generate expectations, and these future-oriented thoughts may be based on loosely related past experiences or unrealistic optimism. These tendencies may lead to errors, preventing selection of treatments that promote true preferences. Clinicians should explore how decision makers engage in future-oriented thinking and what their expectations are as a component of the shared decision-making process. Future research should evaluate whether targeted guidance in future-oriented thinking may improve outcomes important to patients.
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Affiliation(s)
- Joanna L Hart
- 1 Division of Pulmonary, Allergy, and Critical Care Medicine.,2 Leonard Davis Institute of Health Economics.,3 Fostering Improvement in End-of-Life Decision Science Program
| | - Emily Pflug
- 4 Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Vanessa Madden
- 3 Fostering Improvement in End-of-Life Decision Science Program.,5 Center for Clinical Epidemiology and Biostatistics, and
| | - Scott D Halpern
- 1 Division of Pulmonary, Allergy, and Critical Care Medicine.,2 Leonard Davis Institute of Health Economics.,3 Fostering Improvement in End-of-Life Decision Science Program.,5 Center for Clinical Epidemiology and Biostatistics, and.,6 Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
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Freiman MR, Clark JA, Slatore CG, Gould MK, Woloshin S, Schwartz LM, Wiener RS. Patients' Knowledge, Beliefs, and Distress Associated with Detection and Evaluation of Incidental Pulmonary Nodules for Cancer: Results from a Multicenter Survey. J Thorac Oncol 2016; 11:700-708. [PMID: 26961390 DOI: 10.1016/j.jtho.2016.01.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/06/2016] [Accepted: 01/08/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Pulmonary nodules are detected in more than 1 million Americans each year. Prior qualitative work suggests that the detection of incidental pulmonary nodules can be burdensome for patients, but whether these findings generalize to a broader sample of patients is unknown. We categorized patients' knowledge, beliefs, and distress associated with detection and evaluation of a pulmonary nodule, as well as their impressions of clinician communication. METHODS We administered a cross-sectional survey to adults with an incidental pulmonary nodule who were recruited from a rural medical center, an urban safety net hospital, and a Veterans Affairs hospital. RESULTS Of the 490 individuals mailed surveys, 244 (50%) responded. Median nodule size was 7 mm, mean patient age was 67 years, 29% of respondents were female, and 86% were white. A quarter of the respondents (26%) reported clinically significant distress related to their nodule, our primary outcome, as measured by the Impact of Event Scale. Patients reported multiple concerns, including uncertainty about the nodule's cause (78%), the possibility of cancer (73%), and the possible need for surgery (64%). Only 25% of patients accurately estimated their lung cancer risk (within 15% of their actual risk); overall, there was no correlation between perceived and actual risk (r = -0.007, p = 0.93). The 23% of patients who did receive information on cancer risk from their provider were more likely to find this information reassuring (16%) than scary (7%). CONCLUSION A quarter of patients with incidental pulmonary nodules experienced clinically significant distress. Knowledge about cancer risk and evaluation was poor. Clinician communication may help bridge knowledge gaps and alleviate distress in some patients.
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Affiliation(s)
- Marc R Freiman
- Pulmonary Center, Boston University Medical Center, Boston, Massachusetts
| | - Jack A Clark
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Affairs Memorial Hospital, Bedford, Massachusetts; Boston University School of Public Health, Boston, Massachusetts
| | - Christopher G Slatore
- Center to Improve Veteran Involvement and Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon
| | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Steven Woloshin
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Lisa M Schwartz
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Renda Soylemez Wiener
- Pulmonary Center, Boston University Medical Center, Boston, Massachusetts; Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Affairs Memorial Hospital, Bedford, Massachusetts.
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Golden SE, Wiener RS, Sullivan D, Ganzini L, Slatore CG. Primary Care Providers and a System Problem: A Qualitative Study of Clinicians Caring for Patients With Incidental Pulmonary Nodules. Chest 2015; 148:1422-1429. [PMID: 25790082 PMCID: PMC4665737 DOI: 10.1378/chest.14-2938] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 02/26/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND As lung cancer screening with low-dose CT scanning is implemented, an increasing number of people will be diagnosed with pulmonary nodules. Primary care clinicians care for the vast majority of these patients, but their experiences with communication and managing distress in this population are not well understood. METHODS We conducted qualitative interviews of 15 primary care providers (PCPs) at two academic medical centers who care for patients with pulmonary nodules. We used qualitative description analysis, focusing on clinicians' information exchange and other communication behaviors. RESULTS Most PCPs believed they had inadequate information to counsel patients regarding lung nodules, although this information is desired. PCPs were concerned patients could "fall through the cracks" but did not have access to a reliable system to ensure follow-up adherence. They were limited by time, knowledge, and resources in providing the preferred level of care. Most PCPs did not discuss the specific risk a nodule was lung cancer, in part because they did not have ready access to this information. PCPs believed most patients did not have substantial distress as a result of nodule detection. Most PCPs did not include patients when making decisions about the follow-up plan. CONCLUSIONS PCPs often lack systemic resources to optimize patient-centered approaches when discussing incidental pulmonary nodules with patients. With the advent of lung cancer screening, pulmonologists can assist primary care colleagues by providing accurate information to counsel patients and assisting in managing conversations about the risk of cancer. Pulmonologists should support efforts to implement reliable systems to ensure adherence to follow-up.
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Affiliation(s)
- Sara E Golden
- From the Health Services Research and Development, Department of Medicine, Oregon Health and Science University, Portland, OR.
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA; The Pulmonary Center, Boston University School of Medicine, Boston, MA
| | - Donald Sullivan
- From the Health Services Research and Development, Department of Medicine, Oregon Health and Science University, Portland, OR; Division of Geriatric Medicine, Department of Psychiatry, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Linda Ganzini
- From the Health Services Research and Development, Department of Medicine, Oregon Health and Science University, Portland, OR; Division of Geriatric Medicine, Department of Psychiatry, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Christopher G Slatore
- From the Health Services Research and Development, Department of Medicine, Oregon Health and Science University, Portland, OR; Section of Pulmonary and Critical Care Medicine, VA Portland Health Care System, Portland, OR; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR
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Wiener RS, Slatore CG, Gillespie C, Clark JA. Pulmonologists' Reported Use of Guidelines and Shared Decision-making in Evaluation of Pulmonary Nodules: A Qualitative Study. Chest 2015; 148:1415-1421. [PMID: 25789979 PMCID: PMC4665736 DOI: 10.1378/chest.14-2941] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 02/25/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Selecting a strategy (surveillance, biopsy, resection) for pulmonary nodule evaluation can be complex given the absence of high-quality data comparing strategies and the important tradeoffs among strategies. Guidelines recommend a three-step approach: (1) assess the likelihood of malignancy, (2) evaluate whether the patient is a candidate for invasive intervention, and (3) elicit the patient's preferences and engage in shared decision-making. We sought to characterize how pulmonologists select a pulmonary nodule evaluation strategy and the extent to which they report following the guideline-recommended approach. METHODS We conducted semistructured qualitative interviews with 14 pulmonologists who manage patients with pulmonary nodules at four clinical sites. Transcripts of audiorecorded interviews were analyzed using the principles of grounded theory. RESULTS Pulmonologists reported consistently performing steps 1 and 2 but described diverse approaches to step 3 that ranged from always engaging the patient in decision-making to never doing so. Many described incorporating patients' preferences only in particular circumstances, such as when the patient appeared particularly anxious or was aggressive in questioning management options. Indeed, other factors, including convenience, physician preferences, physician anxiety, malpractice concerns, and physician experience, appeared to drive decision-making as much as, if not more than, patient preferences. CONCLUSIONS Although pulmonologists appear to routinely personalize pulmonary nodule evaluation strategies based on the individual patient's risk-benefit tradeoffs, they may not consistently take patient preferences into account during the decision-making process. In the absence of high-quality evidence regarding the optimal methods of pulmonary nodule evaluation, physicians should strive to ensure that management decisions are consistent with patients' values.
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Affiliation(s)
- Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA; Pulmonary Center, Department of Medicine, Oregon Health and Science University, Portland, OR.
| | - Christopher G Slatore
- Health Services Research and Development, Department of Medicine, Oregon Health and Science University, Portland, OR; Section of Pulmonary and Critical Care Medicine, VA Portland Health Care System, Portland, OR; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Chris Gillespie
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA
| | - Jack A Clark
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA; Department of Health Policy and Management, Boston University School of Public Health, Boston, MA
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Distress and patient-centered communication among veterans with incidental (not screen-detected) pulmonary nodules. A cohort study. Ann Am Thorac Soc 2015; 12:184-92. [PMID: 25521482 DOI: 10.1513/annalsats.201406-283oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Incidental pulmonary nodule detection is postulated to cause distress, but the frequency and magnitude of that distress have not been reported. The quality of patient-clinician communication and the perceived risk of lung cancer may influence distress Objectives: To evaluate the association of communication processes with distress and the perceived risk of lung cancer using validated instruments. METHODS We conducted a prospective cohort study of patients with incidentally detected nodules who received care at one Department of Veterans Affairs Medical Center. We measured distress with the Impact of Event Scale and patient-centered communication with the Consultation Care Measure, both validated instruments. Risk of lung cancer was self-reported by participants. We used multivariable adjusted logistic regression to measure the association of communication quality with distress. MEASUREMENTS AND MAIN RESULTS Among 122 Veterans with incidental nodules, 23%, 12%, and 4% reported experiencing mild, moderate, and severe distress, respectively, at the time they were informed of the pulmonary nodule. Participant-reported risk of lung cancer was not associated with distress. In the adjusted model, high-quality communication was associated with decreased distress (odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.08-1.00, P = 0.05). Among participants who reported a risk of malignancy of 30% or less, high-quality communication was associated with decreased distress (OR = 0.15, 95% CI = 0.02-0.92, P = 0.04), but was not associated with distress for those who reported a risk greater than 30% (OR = 0.12 (95% CI = 0.00-3.97, P = 0.24), although the P value for interaction was not significant. CONCLUSIONS Veterans with incidental pulmonary nodules frequently reported inadequate information exchange regarding their nodule. Many patients experience distress after they are informed that they have a pulmonary nodule, and high-quality patient-clinician communication is associated with decreased distress. Communication strategies that only target improved knowledge of the risk of malignancy may not be sufficient to reduce the distress associated with nodule detection.
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Slatore CG, Horeweg N, Jett JR, Midthun DE, Powell CA, Wiener RS, Wisnivesky JP, Gould MK. An Official American Thoracic Society Research Statement: A Research Framework for Pulmonary Nodule Evaluation and Management. Am J Respir Crit Care Med 2015; 192:500-14. [PMID: 26278796 DOI: 10.1164/rccm.201506-1082st] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pulmonary nodules are frequently detected during diagnostic chest imaging and as a result of lung cancer screening. Current guidelines for their evaluation are largely based on low-quality evidence, and patients and clinicians could benefit from more research in this area. METHODS In this research statement from the American Thoracic Society, a multidisciplinary group of clinicians, researchers, and patient advocates reviewed available evidence for pulmonary nodule evaluation, characterized six focus areas to direct future research efforts, and identified fundamental gaps in knowledge and strategies to address them. We did not use formal mechanisms to prioritize one research area over another or to achieve consensus. RESULTS There was widespread agreement that novel tests (including novel imaging tests and biopsy techniques, biomarkers, and prognostic models) may improve diagnostic accuracy for identifying cancerous nodules. Before they are used in clinical practice, however, better evidence is needed to show that they improve more distal outcomes of importance to patients. In addition, the pace of research and the quality of clinical care would be improved by the development of registries that link demographic and nodule characteristics with patient-level outcomes. Methods to share data from registries are also necessary. CONCLUSIONS This statement may help researchers to develop impactful and innovative research projects and enable funders to better judge research proposals. We hope that it will accelerate the pace and increase the efficiency of discovery to improve the quality of care for patients with pulmonary nodules.
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Abstract
RATIONALE Pulmonologists frequently encounter indeterminate pulmonary nodules in practice, but it is unclear what clinical factors they rely on to guide the diagnostic evaluation. OBJECTIVES To assess the current approach to the management of indeterminate pulmonary nodules and to determine the extent to which the addition of a hypothetical diagnostic blood test will influence clinical decision making. METHODS Selected pulmonologists practicing in the United States were invited to participate in a conjoint exercise based on 20 randomly generated cases of varying age, smoking history, and nodule size. Some cases included the result of a hypothetical blood test. Each respondent chose from among three diagnostic options for a patient: noninvasive monitoring (i.e., serial CT or positron emission tomography scan), a minor procedure (i.e., biopsy or bronchoscopy), or a major procedure (i.e., video-assisted thorascopic surgery or thoracotomy). Multivariate logistic regression was used to assess the impact of the three risk factors and the diagnostic blood test on decision making. MEASUREMENTS AND MAIN RESULTS Four hundred nineteen physicians participated (response rate, 10%). One hundred fifty-three physician surveys met predetermined criteria and were analyzed (4% of all invitees). A diagnostic procedure was recommended for 23% of 6-mm nodules, versus 54, 66, 77, and 84% of nodules 10, 14, 18, and 22 mm, respectively (P < 0.001). Older age limited recommendations for invasive testing: 54% of 80-year-olds versus 61, 64, 63, and 61% of patients 71, 62, 53, and 44 years of age, respectively (P < 0.001). In multivariate analyses, nodule size, smoking history, age, and the blood test each influenced decision making (P < 0.001). CONCLUSIONS The pulmonologists who participated in this survey were more likely to proceed with invasive testing, instead of observation or additional imaging, as the size of the nodule increased. The use of a hypothetical blood test resulted in significant alterations in the decision to pursue invasive testing.
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Sullivan DR, Golden SE, Ganzini L, Hansen L, Slatore CG. 'I still don't know diddly': a longitudinal qualitative study of patients' knowledge and distress while undergoing evaluation of incidental pulmonary nodules. NPJ Prim Care Respir Med 2015; 25:15028. [PMID: 26028564 PMCID: PMC4532158 DOI: 10.1038/npjpcrm.2015.28] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/05/2015] [Accepted: 02/09/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hundreds of thousands of incidental pulmonary nodules are detected annually in the United States, and this number will increase with the implementation of lung cancer screening. The lengthy period for active pulmonary nodule surveillance, often several years, is unique among cancer regimens. The psychosocial impact of longitudinal incidental nodule follow-up, however, has not been described. AIMS We sought to evaluate the psychosocial impact of longitudinal follow-up of incidental nodule detection on patients. METHODS Veterans who participated in our previous study had yearly follow-up qualitative interviews coinciding with repeat chest imaging. We used conventional content analysis to explore their knowledge of nodules and the follow-up plan, and their distress. RESULTS Seventeen and six veterans completed the year one and year two interviews, respectively. Over time, most patients continued to have inadequate knowledge of pulmonary nodules and the nodule follow-up plan. They desired and appreciated more information directly from their primary care provider, particularly about their lung cancer risk. Distress diminished over time for most patients, but it increased around the time of follow-up imaging for some, and a small number reported severe distress. CONCLUSIONS In settings in which pulmonary nodules are commonly detected, including lung cancer screening programmes, resources to optimise patient-centred communication strategies that improve patients' knowledge and reduce distress should be developed.
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Affiliation(s)
- Donald R Sullivan
- 1] Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA [2] Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Sara E Golden
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA
| | - Linda Ganzini
- 1] Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA [2] Division of Geriatric Psychiatry, Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, OR, USA
| | - Christopher G Slatore
- 1] Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA [2] Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA [3] Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, OR, USA
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Vachani A, Pass HI, Rom WN, Midthun DE, Edell ES, Laviolette M, Li XJ, Fong PY, Hunsucker SW, Hayward C, Mazzone PJ, Madtes DK, Miller YE, Walker MG, Shi J, Kearney P, Fang KC, Massion PP. Validation of a multiprotein plasma classifier to identify benign lung nodules. J Thorac Oncol 2015; 10:629-37. [PMID: 25590604 PMCID: PMC4382127 DOI: 10.1097/jto.0000000000000447] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Indeterminate pulmonary nodules (IPNs) lack clinical or radiographic features of benign etiologies and often undergo invasive procedures unnecessarily, suggesting potential roles for diagnostic adjuncts using molecular biomarkers. The primary objective was to validate a multivariate classifier that identifies likely benign lung nodules by assaying plasma protein expression levels, yielding a range of probability estimates based on high negative predictive values (NPVs) for patients with 8 to 30 mm IPNs. METHODS A retrospective, multicenter, case-control study was performed using multiple reaction monitoring mass spectrometry, a classifier comprising five diagnostic and six normalization proteins, and blinded analysis of an independent validation set of plasma samples. RESULTS The classifier achieved validation on 141 lung nodule-associated plasma samples based on predefined statistical goals to optimize sensitivity. Using a population based nonsmall-cell lung cancer prevalence estimate of 23% for 8 to 30 mm IPNs, the classifier identified likely benign lung nodules with 90% negative predictive value and 26% positive predictive value, as shown in our prior work, at 92% sensitivity and 20% specificity, with the lower bound of the classifier's performance at 70% sensitivity and 48% specificity. Classifier scores for the overall cohort were statistically independent of patient age, tobacco use, nodule size, and chronic obstructive pulmonary disease diagnosis. The classifier also demonstrated incremental diagnostic performance in combination with a four-parameter clinical model. CONCLUSIONS This proteomic classifier provides a range of probability estimates for the likelihood of a benign etiology that may serve as a noninvasive, diagnostic adjunct for clinical assessments of patients with IPNs.
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Affiliation(s)
- Anil Vachani
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Harvey I. Pass
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - William N. Rom
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - David E. Midthun
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Eric S. Edell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Michel Laviolette
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Xiao-Jun Li
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Pui-Yee Fong
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Stephen W. Hunsucker
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Clive Hayward
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Peter J. Mazzone
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - David K. Madtes
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - York E. Miller
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Michael G. Walker
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Jing Shi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Paul Kearney
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Kenneth C. Fang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
| | - Pierre P. Massion
- Division of Pulmonary, Allergy, and Critical Care Medicine, Penn Lung Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York University Langone Medical Center, New York, New York; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Unité de Recherche en Pneumologie, Centre de Recherche de l’Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval; Québec, Canada; Integrated Diagnostics, Seattle, Washington; Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Healthcare System, University of Colorado Denver School of Medicine, Denver, Colorado; Statistics Consultant, Carlsbad, California; Thoracic Program, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus, Nashville, Tennessee
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Wiener RS, Gould MK, Slatore CG, Fincke BG, Schwartz LM, Woloshin S. Resource use and guideline concordance in evaluation of pulmonary nodules for cancer: too much and too little care. JAMA Intern Med 2014; 174:871-80. [PMID: 24710850 PMCID: PMC4266552 DOI: 10.1001/jamainternmed.2014.561] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Pulmonary nodules are common, and more will be found with implementation of lung cancer screening. How potentially malignant pulmonary nodules are evaluated may affect patient outcomes, health care costs, and effectiveness of lung cancer screening programs. Guidelines for evaluating pulmonary nodules for cancer exist, but little is known about how nodules are evaluated in the usual care setting. OBJECTIVE To characterize nodule evaluation and concordance with guidelines. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted including detailed review of medical records from pulmonary nodule detection through evaluation completion, cancer diagnosis, or study end (December 31, 2012). The participants included 300 adults with pulmonary nodules from 15 Veterans Affairs hospitals. MAIN OUTCOMES AND MEASURES Resources used for evaluation at any Veterans Affairs facility and guideline-concordant evaluation served as the main outcomes. RESULTS Twenty-seven of 300 patients (9.0%) with pulmonary nodules ultimately received a diagnosis of lung cancer: 1 of 57 (1.8%) with a nodule of 4 mm or less, 4 of 134 (3.0%) with a nodule of 5 to 8 mm, and 22 of 109 (20.2%) with a nodule larger than 8 mm. Nodule evaluation entailed 1044 imaging studies, 147 consultations, 76 biopsies, 13 resections, and 21 hospitalizations. Radiographic surveillance (n = 277) lasted a median of 13 months but ranged from less than 0.5 months to 8.5 years. Forty-six patients underwent invasive procedures (range per patient, 1-4): 41.3% (19 patients) did not have cancer and 17.4% (8) experienced complications, including 1 death. Notably, 15 of the 300 (5.0%) received no purposeful evaluation and had no obvious reason for deferral, seemingly "falling through the cracks." Among 197 patients with a nodule detected after release of the Fleischner Society guidelines, 44.7% received care inconsistent with guidelines (17.8% overevaluation, 26.9% underevaluation). In multivariable analyses, the strongest predictor of guideline-inconsistent care was inappropriate radiologist recommendations (overevaluation relative risk, 4.6 [95% CI, 2.3-9.2]; underevaluation, 4.3 [2.7-6.8]). Other systems factors associated with underevaluation included receiving care at more than 1 facility (2.0 [1.5-2.7]) and nodule detection during an inpatient or preoperative visit (1.6 [1.1-2.5]). CONCLUSIONS AND RELEVANCE 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.
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Affiliation(s)
- Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts2The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts3The Dartmouth Institute for Health Pol
| | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Christopher G Slatore
- Health Services Research and Development, Portland Veterans Affairs Medical Center, Portland, Oregon6Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland
| | - Benjamin G Fincke
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts7Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Lisa M Schwartz
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire8Veterans Affairs Outcomes Group, Department of Veterans Affairs, White River Junction, Vermont
| | - Steven Woloshin
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire8Veterans Affairs Outcomes Group, Department of Veterans Affairs, White River Junction, Vermont
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47
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Wiener RS, Ouellette DR, Diamond E, Fan VS, Maurer JR, Mularski RA, Peters JI, Halpern SD. An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine. Chest 2014; 145:1383-1391. [PMID: 24889436 PMCID: PMC4694177 DOI: 10.1378/chest.14-0670] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/19/2014] [Indexed: 12/11/2022] Open
Abstract
The American Board of Internal Medicine Foundation's Choosing Wisely campaign aims to curb health-care costs and improve patient care by soliciting lists from medical societies of the top five tests or treatments in their specialty that are used too frequently and inappropriately. The American Thoracic Society (ATS) and American College of Chest Physicians created a joint task force, which produced a top five list for adult pulmonary medicine. Our top five recommendations, which were approved by the executive committees of the ATS and American College of Chest Physicians and published by Choosing Wisely in October 2013, are as follows: (1) Do not perform CT scan surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines; (2) do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension); (3) for patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia; (4) do not perform chest CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay; (5) do not perform CT scan screening for lung cancer among patients at low risk for lung cancer. We hope pulmonologists will use these recommendations to stimulate frank discussions with patients about when these tests and treatments are indicated--and when they are not.
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Affiliation(s)
- Renda Soylemez Wiener
- Pulmonary Center, Boston University School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, NH.
| | - Daniel R Ouellette
- Pulmonary and Critical Care Medicine, Henry Ford Health System, Detroit, MI
| | | | - Vincent S Fan
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Janet R Maurer
- Department of Medicine, College of Medicine, The University of Arizona, Phoenix, AZ; Quality Improvement and Compliance, National Imaging Associates/Magellan Health Services, Inc, Phoenix, AZ
| | - Richard A Mularski
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR; Department of Pulmonary/Critical Care Medicine, Northwest Permanente PC, Portland, OR; Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Jay I Peters
- UT Health Science Center, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX
| | - Scott D Halpern
- Departments of Medicine, Biostatistics and Epidemiology, and Medical Ethics and Health Policy, and the Leonard Davis Institute Center for Health Incentives and Behavioral Economics, The University of Pennsylvania, Philadelphia, PA
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48
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Participation rate or informed choice? Rethinking the European key performance indicators for mammography screening. Health Policy 2014; 115:100-3. [DOI: 10.1016/j.healthpol.2013.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 10/07/2013] [Accepted: 11/23/2013] [Indexed: 12/13/2022]
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