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Kearney L, Bolton RE, Núñez ER, Boudreau JH, Sliwinski S, Herbst AN, Caverly TJ, Wiener RS. Tackling Guideline Non-concordance: Primary Care Barriers to Incorporating Life Expectancy into Lung Cancer Screening Decision-Making-A Qualitative Study. J Gen Intern Med 2024:10.1007/s11606-024-08705-x. [PMID: 38459413 DOI: 10.1007/s11606-024-08705-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/27/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Primary care providers (PCPs) are often the first point of contact for discussing lung cancer screening (LCS) with patients. While guidelines recommend against screening people with limited life expectancy (LLE) who are less likely to benefit, these patients are regularly referred for LCS. OBJECTIVE We sought to understand barriers PCPs face to incorporating life expectancy into LCS decision-making for patients who otherwise meet eligibility criteria, and how a hypothetical point-of-care tool could support patient selection. DESIGN Qualitative study based on semi-structured telephone interviews. PARTICIPANTS Thirty-one PCPs who refer patients for LCS, from six Veterans Health Administration facilities. APPROACH We thematically analyzed interviews to understand how PCPs incorporated life expectancy into LCS decision-making and PCPs' receptivity to a point-of-care tool to support patient selection. Final themes were organized according to the Cabana et al. framework Why Don't Physicians Follow Clinical Practice Guidelines, capturing the influence of clinician knowledge, attitudes, and behavior on LCS appropriateness determinations. KEY RESULTS PCP referrals to LCS for patients with LLE were influenced by limited knowledge of the life expectancy threshold at which patients are less likely to benefit from LCS, discomfort estimating life expectancy, fear of missing cancer at the point of early detection, and prioritization of factors such as quality of life, patient values, clinician-patient relationship, and family support. PCPs were receptive to a decision support tool to inform and communicate LCS appropriateness decisions if easy to use and integrated into clinical workflows. CONCLUSIONS Our study suggests knowledge gaps and attitudes may drive decisions to offer screening despite LLE, a behavior counter to guideline recommendations. Integrating a LCS decision support tool that incorporates life expectancy within the electronic medical record and existing clinical workflows may be one acceptable solution to improve guideline concordance and increase confidence in selecting high benefit patients for LCS.
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Affiliation(s)
- Lauren Kearney
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA and VA Bedford Healthcare System, Bedford, MA, USA.
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.
| | - Rendelle E Bolton
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA and VA Bedford Healthcare System, Bedford, MA, USA
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Eduardo R Núñez
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA and VA Bedford Healthcare System, Bedford, MA, USA
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA
| | - Jacqueline H Boudreau
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA and VA Bedford Healthcare System, Bedford, MA, USA
| | - Samantha Sliwinski
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA and VA Bedford Healthcare System, Bedford, MA, USA
| | - Abigail N Herbst
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA and VA Bedford Healthcare System, Bedford, MA, USA
| | - Tanner J Caverly
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC, USA
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA and VA Bedford Healthcare System, Bedford, MA, USA
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC, USA
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Young RP, Scott RJ. Should we be screening for COPD? - looking through the lens of lung cancer screening. Expert Rev Respir Med 2023; 17:753-771. [PMID: 37728077 DOI: 10.1080/17476348.2023.2259800] [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: 04/30/2023] [Accepted: 09/13/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION In May 2022, the US Preventive Services Task Force published their recommendation against screening for chronic obstructive pulmonary disease (COPD) in asymptomatic adults. However, we argue the routine use of spirometry in both asymptomatic and symptomatic high-risk smokers has utility. AREAS COVERED We provide published and unpublished observations from a secondary analyses of the American College of Radiology Imaging Network (ACRIN), arm of the National Lung Screening Trial, including 18,463 high-risk current or former smokers who underwent pre-bronchodilator spirometry at baseline. According to history alone, 20% reported a prior diagnosis of 'COPD,' although only 11% (about one half), actually had airflow limitation (Diagnosed COPD) and 9% had Global Initiative for Obstructive Pulmonary Disease GOLD 0 Pre-COPD. Of the remaining 80% of 'asymptomatic' screening participants, 23% had airflow limitation (Screen-detected COPD) and 13% had preserved ratio impaired spirometry (PRISm). This means 45% of this high-risk cohort were reclassified by spirometry, and together with comorbid disease, identified subgroups where lung cancer screening efficacy could be optimized by between 2-6 fold. EXPERT OPINION Our preliminary findings suggest lung cancer screening outcomes vary according to 'new' COPD-related spirometric-defined subgroups and that screening spirometry, together with comorbid disease, identifies those for whom lung cancer screening is mostly beneficial or potentially harmful.
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Affiliation(s)
- Robert P Young
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Raewyn J Scott
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Weir-McCall JR, Debruyn E, Harris S, Qureshi NR, Rintoul RC, Gleeson FV, Gilbert FJ. Diagnostic Accuracy of a Convolutional Neural Network Assessment of Solitary Pulmonary Nodules Compared With PET With CT Imaging and Dynamic Contrast-Enhanced CT Imaging Using Unenhanced and Contrast-Enhanced CT Imaging. Chest 2023; 163:444-454. [PMID: 36087795 PMCID: PMC9899635 DOI: 10.1016/j.chest.2022.08.2227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 08/19/2022] [Accepted: 08/24/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Solitary pulmonary nodules (SPNs) measuring 8 to 30 mm in diameter require further workup to determine the likelihood of malignancy. RESEARCH QUESTION What is the diagnostic performance of a lung cancer prediction convolutional neural network (LCP-CNN) in SPNs using unenhanced and contrast-enhanced CT imaging compared with the current clinical workup? STUDY DESIGN AND METHODS This was a post hoc analysis of the Single Pulmonary Nodule Investigation: Accuracy and Cost-Effectiveness of Dynamic Contrast Enhanced Computed Tomography in the Characterisation of Solitary Pulmonary Nodules trial, a prospective multicenter study comparing the diagnostic accuracy of dynamic contrast-enhanced (DCE) CT imaging with PET imaging in SPNs. The LCP-CNN was designed and validated in an external cohort. LCP-CNN-generated risk scores were created from the noncontrast and contrast-enhanced CT scan images from the DCE CT imaging. The gold standard was histologic analysis or 2 years of follow-up. The area under the receiver operating characteristic curves (AUC) were calculated using LCP-CNN score, maximum standardized uptake value, and DCE CT scan maximum enhancement and were compared using the DeLong test. RESULTS Two hundred seventy participants (mean ± SD age, 68.3 ± 8.8 years; 49% women) underwent PET with CT scan imaging and DCE CT imaging with CT scan data available centrally for LCP-CNN analysis. The accuracy of the LCP-CNN on the noncontrast images (AUC, 0.83; 95% CI, 0.79-0.88) was superior to that of DCE CT imaging (AUC, 0.76; 95% CI, 0.69-0.82; P = .03) and equal to that of PET with CT scan imaging (AUC, 0.86; 95% CI, 0.81-0.90; P = .35). The presence of contrast resulted in a small reduction in diagnostic accuracy, with the AUC falling from 0.83 (95% CI, 0.79-0.88) on the noncontrast images to 0.80 to 0.83 after contrast (P < .05 for 240 s after contrast only). INTERPRETATION An LCP-CNN algorithm provides an AUC equivalent to PET with CT scan imaging in the diagnosis of solitary pulmonary nodules. TRIAL REGISTRATION ClinicalTrials.gov Identifier; No.: NCT02013063.
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Affiliation(s)
- Jonathan R Weir-McCall
- Department of Radiology, University of Cambridge School of Clinical Medicine, Biomedical Research Centre, University of Cambridge; Department of Radiology, Royal Papworth Hospital, Cambridge
| | - Elise Debruyn
- College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Scott Harris
- Faculty of Public Health Sciences and Medical Statistics, University of Southampton, Southampton
| | | | - Robert C Rintoul
- Department of Oncology, University of Cambridge; Department of Thoracic Oncology, Royal Papworth Hospital
| | - Fergus V Gleeson
- Department of Radiology, Churchill Hospital and University of Oxford, Oxford, England
| | - Fiona J Gilbert
- Department of Radiology, University of Cambridge School of Clinical Medicine, Biomedical Research Centre, University of Cambridge.
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Airflow limitation and mortality during cancer screening in the National Lung Screening Trial: why quantifying airflow limitation matters. Thorax 2022:thorax-2022-219334. [DOI: 10.1136/thorax-2022-219334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/06/2022] [Indexed: 12/03/2022]
Abstract
ImportanceCurrent eligibility criteria for lung cancer (LC) screening are derived from randomised controlled trials and primarily based on age and smoking history. However, the individual benefits of screening are highly variable and potentially attenuated by co-morbidities such as advanced airflow limitation (AL).ObjectiveTo examine the relationship between the presence and severity of AL and screening outcomes.MethodsThis was a secondary analysis of 18 463 high-risk smokers, a substudy from the National Lung Screening Trial, who underwent pre-bronchodilator spirometry at baseline and median follow-up of 6.1 years. We used descriptive statistics and a competing risk proportional hazards model to examine differences in screening outcomes by chronic obstructive pulmonary disease severity group.ResultsThe risk of developing LC increased with worsening AL (effect size=0.34, p<0.0001), as did the risk of dying of LC (effect size=0.35, p<0.0001). While those with severe AL (Global Initiative for Obstructive Lung Disease, GOLD grade 3–4) had the highest risk of LC and the highest LC mortality, they also had fewer adenocarcinomas (effect size=−0.20, p=0.008) and a lower surgery rate (effect size=−0.16, p=0.014) despite comparable staging, and greater non-LC mortality relative to LC mortality (effect size=0.30, p<0.0001). In participants with no AL, screening with CT was associated with a significant reduction in LC deaths relative to chest X-ray (30.3%, 95% CI 4.5% to 49.2%, p<0.05). The clinically relevant but attenuated reduction in those with AL (18.5%, 95% CI −8.4% to 38.7%, p>0.05) could be attributed to GOLD 3–4, where no appreciable mortality reduction was observed.ConclusionDespite a greater risk of LC, severe AL was not associated with any apparent reduction in LC mortality following screening.
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Silvestri GA, Goldman L, Burleson J, Gould M, Kazerooni EA, Mazzone PJ, Rivera MP, Doria-Rose VP, Rosenthal LS, Simanowith M, Smith RA, Tanner NT, Fedewa S. Characteristics of Persons Screened for Lung Cancer in the United States : A Cohort Study. Ann Intern Med 2022; 175:1501-1505. [PMID: 36215712 DOI: 10.7326/m22-1325] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was recommended by the U.S. Preventive Services Task Force (USPSTF) in 2013, making approximately 8 million Americans eligible for screening. The demographic characteristics and adherence of persons screened in the United States have not been reported at the population level. OBJECTIVE To define sociodemographic characteristics and adherence among persons screened and entered into the American College of Radiology's Lung Cancer Screening Registry (LCSR). DESIGN Cohort study. SETTING United States, 2015 to 2019. PARTICIPANTS Persons receiving a baseline LDCT for LCS from 3625 facilities reporting to the LCSR. MEASUREMENTS Age, sex, and smoking status distributions (percentages) were computed among persons who were screened and among respondents in the 2015 National Health Interview Survey (NHIS) who were eligible for screening. The prevalence between the LCSR and the NHIS was compared with prevalence ratios (PRs) and 95% CIs. Adherence to annual screening was defined as having a follow-up test within 11 to 15 months of an initial LDCT. RESULTS Among 1 159 092 persons who were screened, 90.8% (n = 1 052 591) met the USPSTF eligibility criteria. Compared with adults from the NHIS who met the criteria (n = 1257), screening recipients in the LCSR were older (34.7% vs. 44.8% were aged 65 to 74 years; PR, 1.29 [95% CI, 1.20 to 1.39]), more likely to be female (41.8% vs. 48.1%; PR, 1.15 [CI, 1.08 to 1.23]), and more likely to currently smoke (52.3% vs. 61.4%; PR, 1.17 [CI, 1.11 to 1.23]). Only 22.3% had a repeated annual LDCT. If follow-up was extended to 24 months and more than 24 months, 34.3% and 40.3% were adherent, respectively. LIMITATIONS Underreporting of LCS and missing data may skew demographic characteristics of persons reported to be screened. Underreporting of adherence may result in underestimates of follow-up. CONCLUSION Approximately 91% of persons who had LCS met USPSTF eligibility criteria. In addition to continuing to target all eligible adults, men, those who formerly smoked, and younger eligible patients may be less likely to be screened. Adherence to annual follow-up screening was poor, potentially limiting screening effectiveness. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Gerard A Silvestri
- Division of Pulmonary Medicine, Thoracic Oncology Research Group, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina (G.A.S., N.T.T.)
| | - Lenka Goldman
- American College of Radiology, Reston, Virginia (L.G., J.B., M.S.)
| | - Judy Burleson
- American College of Radiology, Reston, Virginia (L.G., J.B., M.S.)
| | - Michael Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California (M.G.)
| | - Ella A Kazerooni
- Departments of Radiology and Internal Medicine, University of Michigan/Michigan Medicine, Ann Arbor, Michigan (E.A.K.)
| | - Peter J Mazzone
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio (P.J.M.)
| | - M Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina (M.P.R.)
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (V.P.D.)
| | - Lauren S Rosenthal
- Cancer Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia (L.S.R., R.A.S.)
| | | | - Robert A Smith
- Cancer Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia (L.S.R., R.A.S.)
| | - Nichole T Tanner
- Division of Pulmonary Medicine, Thoracic Oncology Research Group, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina (G.A.S., N.T.T.)
| | - Stacey Fedewa
- Intramural Research Department, American Cancer Society, Atlanta, Georgia (S.F.)
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Bade B, Gwin M, Triplette M, Wiener RS, Crothers K. Comorbidity and life expectancy in shared decision making for lung cancer screening. Semin Oncol 2022; 49:S0093-7754(22)00057-4. [PMID: 35940959 DOI: 10.1053/j.seminoncol.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/02/2022] [Accepted: 07/03/2022] [Indexed: 11/11/2022]
Abstract
Shared decision making (SDM) is an important part of lung cancer screening (LCS) that includes discussing the risks and benefits of screening, potential outcomes, patient eligibility and willingness to participate, tobacco cessation, and tailoring a strategy to an individual patient. More than other cancer screening tests, eligibility for LCS is nuanced, incorporating the patient's age as well as tobacco use history and overall health status. Since comorbidities and multimorbidity (ie, 2 or more comorbidities) impact the risks and benefits of LCS, these topics are a fundamental part of decision-making. However, there is currently little evidence available to guide clinicians in addressing comorbidities and an individual's "appropriateness" for LCS during SDM visits. Therefore, this literature review investigates the impact of comorbidities and multimorbidity among patients undergoing LCS. Based on available evidence and guideline recommendations, we identify comorbidities that should be considered during SDM conversations and review best practices for navigating SDM conversations in the context of LCS. Three conditions are highlighted since they concomitantly portend higher risk of developing lung cancer, potentially increase risk of screening-related evaluation and treatment complications and can be associated with limited life expectancy: chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, and human immunodeficiency virus infection.
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Affiliation(s)
- Brett Bade
- Veterans Affairs (VA) Connecticut Healthcare System, Section of Pulmonary, Critical Care, and Sleep Medicine, West Haven, CT, United States of America (USA); Yale University School of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA.
| | - Mary Gwin
- University of Washington School of Medicine, Seattle, WA, USA
| | - Matthew Triplette
- University of Washington School of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA, USA; Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research and Medical Service, VA Boston Healthcare System, Boston, MA, USA; The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Kristina Crothers
- University of Washington School of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA, USA; VA Puget Sound Health Care System, Section of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA, USA
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Impact of Comorbidities on Lung Cancer Screening Evaluation. Clin Lung Cancer 2022; 23:402-409. [PMID: 35641376 PMCID: PMC9814245 DOI: 10.1016/j.cllc.2022.03.012] [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: 10/10/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES We used data from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial to examine the impact of self-reported chronic obstructive pulmonary disease, coronary artery disease, stroke, and diabetes mellitus on diagnostic complications in lung cancer screening evaluation. METHODS In our analysis, we included individuals from the usual care and intervention (annual chest x-ray) of the lung cancer screening trial with equal or greater than 55 years of age with a 20 pack-year smoking history who had undergone an invasive procedure. We performed multivariate logistic regression analysis to estimate the association of comorbidity on procedure complication. Our primary outcome was the incidence of major or moderate complications. RESULTS Features associated with high-risk complication included older age (OR = 1.03 per year, P = .001), history of coronary artery disease (OR = 1.40, P = .03), history of diabetes mellitus (OR = 0.41, P < .001, current smoking status (OR = 1.46, P ≤ .001), surgical biopsy (OR = 7.39, P < .001), needle biopsy (OR = 1.94, P < .001), and other invasive procedure (OR = 1.58, P < .001). We did not find an associated with complication and history of stroke (OR = 0.84, P = .53) or chronic obstructive pulmonary disease (OR = 1.27, P = .06). CONCLUSION Patient and procedure-level factors may alter the benefits of lung cancer screening. Data concerning individual risk factors and high-risk complications should therefore be incorporated into diagnostic algorithms to optimize clinical benefit and minimize harm. Further study and validation of the risk factors identified herein are warranted.
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Byrd C, Ajawara U, Laundry R, Radin J, Bhandari P, Leung A, Han S, Asch SM, Zeliadt S, Harris AHS, Backhus L. Performance of a rule-based semi-automated method to optimize chart abstraction for surveillance imaging among patients treated for non-small cell lung cancer. BMC Med Inform Decis Mak 2022; 22:148. [PMID: 35659230 PMCID: PMC9166440 DOI: 10.1186/s12911-022-01863-0] [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] [Received: 09/17/2021] [Accepted: 03/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
We aim to develop and test performance of a semi-automated method (computerized query combined with manual review) for chart abstraction in the identification and characterization of surveillance radiology imaging for post-treatment non-small cell lung cancer patients.
Methods
A gold standard dataset consisting of 3011 radiology reports from 361 lung cancer patients treated at the Veterans Health Administration from 2008 to 2016 was manually created by an abstractor coding image type, image indication, and image findings. Computerized queries using a text search tool were performed to code reports. The primary endpoint of query performance was evaluated by sensitivity, positive predictive value (PPV), and F1 score. The secondary endpoint of efficiency compared semi-automated abstraction time to manual abstraction time using a separate dataset and the Wilcoxon rank-sum test.
Results
Query for image type demonstrated the highest sensitivity of 85%, PPV 95%, and F1 score 0.90. Query for image indication demonstrated sensitivity 72%, PPV 70%, and F1 score 0.71. The image findings queries ranged from sensitivity 75–85%, PPV 23–25%, and F1 score 0.36–0.37. Semi-automated abstraction with our best performing query (image type) improved abstraction times by 68% per patient compared to manual abstraction alone (from median 21.5 min (interquartile range 16.0) to 6.9 min (interquartile range 9.5), p < 0.005).
Conclusions
Semi-automated abstraction using the best performing query of image type improved abstraction efficiency while preserving data accuracy. The computerized query acts as a pre-processing tool for manual abstraction by restricting effort to relevant images. Determining image indication and findings requires the addition of manual review for a semi-automatic abstraction approach in order to ensure data accuracy.
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Schlabach T, King TS, Browning KK, Kue J. Nurse practitioner-led lung cancer screening clinic: An evidence-based quality improvement evaluation. Worldviews Evid Based Nurs 2022; 19:227-234. [PMID: 35582735 DOI: 10.1111/wvn.12578] [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: 08/31/2021] [Revised: 02/24/2022] [Accepted: 03/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lung cancer is the leading cause of cancer deaths worldwide. Screening for lung cancer using low-dose computed tomography of the chest (LDCT) can reduce mortality associated with lung cancer. LDCT is an under-ordered screening study. AIMS To evaluate the use of a nurse practitioner-led lung cancer screening clinic (LCSC). METHODS The absolute number of LDCT for lung cancer screenings obtained 12 months before implementing the nurse practitioner-led LCSC was compared to the 12 months after clinic implementation using a casual comparison design. An electronic survey was conducted to assess the LCSC key stakeholders' perceptions of the clinic. RESULTS An increase of 60% in the total number of LDCT for lung cancer screenings was observed. Qualitative data obtained through stakeholder evaluation of the clinic revealed that 85% of participants (n = 13) expressed that the LCSC was addressing barriers to lung cancer screening. LINKING EVIDENCE TO ACTION A dedicated nurse practitioner-led LCSC is a practical way to increase lung cancer screening by addressing established barriers to screening in the community setting.
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Affiliation(s)
- Tyra Schlabach
- The Ohio State University Comprehensive Cancer Center-The James Cancer Hospital and Solove Research Institute, Columbus, Ohio, USA
| | - Tara Spalla King
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | | | - Jennifer Kue
- College of Nursing, University of South Florida, Tampa, Florida, USA
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Majeed H, Zhu H, Williams SA, Hamann HA, Natchimuthu VS, Lee J, Santini NO, Browning T, Prasad T, Adesina JO, Do M, Balis D, de Willams JG, Kitchell E, Johnson DH, Lee SJC, Gerber DE. Prevalence and impact of medical comorbidities in a real-world lung cancer screening population. Clin Lung Cancer 2022; 23:419-427. [DOI: 10.1016/j.cllc.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/15/2022]
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Gilbert FJ, Harris S, Miles KA, Weir-McCall JR, Qureshi NR, Rintoul RC, Dizdarevic S, Pike L, Sinclair D, Shah A, Eaton R, Clegg A, Benedetto V, Hill JE, Cook A, Tzelis D, Vale L, Brindle L, Madden J, Cozens K, Little LA, Eichhorst K, Moate P, McClement C, Peebles C, Banerjee A, Han S, Poon FW, Groves AM, Kurban L, Frew AJ, Callister ME, Crosbie P, Gleeson FV, Karunasaagarar K, Kankam O, George S. Dynamic contrast-enhanced CT compared with positron emission tomography CT to characterise solitary pulmonary nodules: the SPUtNIk diagnostic accuracy study and economic modelling. Health Technol Assess 2022; 26:1-180. [PMID: 35289267 DOI: 10.3310/wcei8321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Current pathways recommend positron emission tomography-computerised tomography for the characterisation of solitary pulmonary nodules. Dynamic contrast-enhanced computerised tomography may be a more cost-effective approach. OBJECTIVES To determine the diagnostic performances of dynamic contrast-enhanced computerised tomography and positron emission tomography-computerised tomography in the NHS for solitary pulmonary nodules. Systematic reviews and a health economic evaluation contributed to the decision-analytic modelling to assess the likely costs and health outcomes resulting from incorporation of dynamic contrast-enhanced computerised tomography into management strategies. DESIGN Multicentre comparative accuracy trial. SETTING Secondary or tertiary outpatient settings at 16 hospitals in the UK. PARTICIPANTS Participants with solitary pulmonary nodules of ≥ 8 mm and of ≤ 30 mm in size with no malignancy in the previous 2 years were included. INTERVENTIONS Baseline positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography with 2 years' follow-up. MAIN OUTCOME MEASURES Primary outcome measures were sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computerised tomography. Incremental cost-effectiveness ratios compared management strategies that used dynamic contrast-enhanced computerised tomography with management strategies that did not use dynamic contrast-enhanced computerised tomography. RESULTS A total of 380 patients were recruited (median age 69 years). Of 312 patients with matched dynamic contrast-enhanced computer tomography and positron emission tomography-computerised tomography examinations, 191 (61%) were cancer patients. The sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography were 72.8% (95% confidence interval 66.1% to 78.6%), 81.8% (95% confidence interval 74.0% to 87.7%), 76.3% (95% confidence interval 71.3% to 80.7%) and 95.3% (95% confidence interval 91.3% to 97.5%), 29.8% (95% confidence interval 22.3% to 38.4%) and 69.9% (95% confidence interval 64.6% to 74.7%), respectively. Exploratory modelling showed that maximum standardised uptake values had the best diagnostic accuracy, with an area under the curve of 0.87, which increased to 0.90 if combined with dynamic contrast-enhanced computerised tomography peak enhancement. The economic analysis showed that, over 24 months, dynamic contrast-enhanced computerised tomography was less costly (£3305, 95% confidence interval £2952 to £3746) than positron emission tomography-computerised tomography (£4013, 95% confidence interval £3673 to £4498) or a strategy combining the two tests (£4058, 95% confidence interval £3702 to £4547). Positron emission tomography-computerised tomography led to more patients with malignant nodules being correctly managed, 0.44 on average (95% confidence interval 0.39 to 0.49), compared with 0.40 (95% confidence interval 0.35 to 0.45); using both tests further increased this (0.47, 95% confidence interval 0.42 to 0.51). LIMITATIONS The high prevalence of malignancy in nodules observed in this trial, compared with that observed in nodules identified within screening programmes, limits the generalisation of the current results to nodules identified by screening. CONCLUSIONS Findings from this research indicate that positron emission tomography-computerised tomography is more accurate than dynamic contrast-enhanced computerised tomography for the characterisation of solitary pulmonary nodules. A combination of maximum standardised uptake value and peak enhancement had the highest accuracy with a small increase in costs. Findings from this research also indicate that a combined positron emission tomography-dynamic contrast-enhanced computerised tomography approach with a slightly higher willingness to pay to avoid missing small cancers or to avoid a 'watch and wait' policy may be an approach to consider. FUTURE WORK Integration of the dynamic contrast-enhanced component into the positron emission tomography-computerised tomography examination and the feasibility of dynamic contrast-enhanced computerised tomography at lung screening for the characterisation of solitary pulmonary nodules should be explored, together with a lower radiation dose protocol. STUDY REGISTRATION This study is registered as PROSPERO CRD42018112215 and CRD42019124299, and the trial is registered as ISRCTN30784948 and ClinicalTrials.gov NCT02013063. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Fiona J Gilbert
- Department of Radiology, University of Cambridge School of Clinical Medicine, Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Scott Harris
- Public Health Sciences and Medical Statistics, University of Southampton, Southampton, UK
| | - Kenneth A Miles
- Department of Radiology, University of Cambridge School of Clinical Medicine, Biomedical Research Centre, University of Cambridge, Cambridge, UK
- Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | - Jonathan R Weir-McCall
- Department of Radiology, University of Cambridge School of Clinical Medicine, Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Nagmi R Qureshi
- Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | - Robert C Rintoul
- Department of Thoracic Oncology, Royal Papworth Hospital, Cambridge, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Sabina Dizdarevic
- Departments of Imaging and Nuclear Medicine and Respiratory Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Lucy Pike
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Donald Sinclair
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Andrew Shah
- Radiation Protection Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Rosemary Eaton
- Radiation Protection Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Andrew Clegg
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Valerio Benedetto
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - James E Hill
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Andrew Cook
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Dimitrios Tzelis
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lucy Brindle
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Jackie Madden
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Kelly Cozens
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Louisa A Little
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Kathrin Eichhorst
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Patricia Moate
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Chris McClement
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Charles Peebles
- Department of Radiology and Respiratory Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Anindo Banerjee
- Department of Radiology and Respiratory Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sai Han
- West of Scotland PET Centre, Gartnavel Hospital, Glasgow, UK
| | - Fat Wui Poon
- West of Scotland PET Centre, Gartnavel Hospital, Glasgow, UK
| | - Ashley M Groves
- Institute of Nuclear Medicine, University College London, London, UK
| | - Lutfi Kurban
- Department of Radiology, Aberdeen Royal Hospitals NHS Trust, Aberdeen, UK
| | - Anthony J Frew
- Departments of Imaging and Nuclear Medicine and Respiratory Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew E Callister
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Philip Crosbie
- North West Lung Centre, University Hospital of South Manchester, Manchester, UK
| | - Fergus V Gleeson
- Department of Radiology, Churchill Hospital, Oxford, UK
- University of Oxford, Oxford, UK
| | | | - Osei Kankam
- Department of Thoracic Medicine, East Sussex Healthcare NHS Trust, Saint Leonards-on-Sea, UK
| | - Steve George
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
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12
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Rustagi AS, Byers AL, Keyhani S. Likelihood of Lung Cancer Screening by Poor Health Status and Race and Ethnicity in US Adults, 2017 to 2020. JAMA Netw Open 2022; 5:e225318. [PMID: 35357450 PMCID: PMC8972038 DOI: 10.1001/jamanetworkopen.2022.5318] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Lung cancer screening (LCS) via low-dose chest computed tomography can prevent mortality through surgical resection of early-stage cancers, but it is unknown whether poor health is associated with screening. Though LCS may be associated with better outcomes for non-Hispanic Black individuals, it is unknown whether racial or ethnic disparities exist in LCS use. OBJECTIVE To determine whether health status is associated with LCS and whether racial or ethnic disparities are associated with LCS independently of health status. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, population-based study of community-dwelling US adults used data from Behavioral Risk Factor Surveillance System annual surveys, 2017 to 2020. Participants were aged 55 to 79 years, with a less than 30 pack-year smoking history, and were current smokers or those who quit within 15 years. Data were analyzed from August to November 2021. EXPOSURES Self-reported health status and race and ethnicity. MAIN OUTCOMES AND MEASURES Self-reported LCS in the last 12 months. RESULTS Of 14 550 individuals (7802 men [55.5%]; 7527 [55.0%] aged 65-79 years [percentages are weighted]), representing 3.68 million US residents, 17.0% (95% CI, 15.1%-18.9%) reported undergoing LCS. The prevalence of LCS was lower among non-Hispanic Black than non-Hispanic White individuals but not to a significant degree (12.0% [95% CI, 4.3%-19.7%] vs 17.5% [95% CI, 15.6%-19.5%]; P = .57). Health status was associated with LCS: 468 individuals in poor health vs 96 individuals in excellent health reported LCS (25.2% [95% CI, 20.6%-29.9%] vs 7.6% [95% CI, 5.0%-10.3%]; P < .001), and those with difficulty climbing stairs were more likely to report LCS than those without this functional limitation. Adjusting for sociodemographic factors, functional status, and comorbidities, self-rated health status remained associated with LCS (adjusted odds ratio, 1.19 per each 1-step decline in health; 95% CI, 1.03-1.38), and non-Hispanic Black individuals were 53% less likely to report LCS than non-Hispanic White individuals (adjusted odds ratio, 0.47; 95% CI, 0.24-0.90). Results were robust in sensitivity analyses in which health was alternatively quantified as number of comorbidities. CONCLUSIONS AND RELEVANCE LCS in the US is more common among those who may be less likely to benefit from screening because of poor underlying health. Furthermore, racial or ethnic disparities were evident after accounting for health status, with non-Hispanic Black individuals nearly half as likely as non-Hispanic White individuals to report LCS despite the potential for greater benefit of screening this population.
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Affiliation(s)
- Alison S. Rustagi
- Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco
| | - Amy L. Byers
- Department of Medicine, University of California, San Francisco
- Research Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Weill Institute for Neurosciences, University of California, San Francisco
| | - Salomeh Keyhani
- Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco
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13
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Gilbert FJ, Harris S, Miles KA, Weir-McCall JR, Qureshi NR, Rintoul RC, Dizdarevic S, Pike L, Sinclair D, Shah A, Eaton R, Jones J, Clegg A, Benedetto V, Hill J, Cook A, Tzelis D, Vale L, Brindle L, Madden J, Cozens K, Little L, Eichhorst K, Moate P, McClement C, Peebles C, Banerjee A, Han S, Poon FW, Groves AM, Kurban L, Frew A, Callister MEJ, Crosbie PA, Gleeson FV, Karunasaagarar K, Kankam O, George S. Comparative accuracy and cost-effectiveness of dynamic contrast-enhanced CT and positron emission tomography in the characterisation of solitary pulmonary nodules. Thorax 2021; 77:988-996. [PMID: 34887348 DOI: 10.1136/thoraxjnl-2021-216948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 10/24/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Dynamic contrast-enhanced CT (DCE-CT) and positron emission tomography/CT (PET/CT) have a high reported accuracy for the diagnosis of malignancy in solitary pulmonary nodules (SPNs). The aim of this study was to compare the accuracy and cost-effectiveness of these. METHODS In this prospective multicentre trial, 380 participants with an SPN (8-30 mm) and no recent history of malignancy underwent DCE-CT and PET/CT. All patients underwent either biopsy with histological diagnosis or completed CT follow-up. Primary outcome measures were sensitivity, specificity and overall diagnostic accuracy for PET/CT and DCE-CT. Costs and cost-effectiveness were estimated from a healthcare provider perspective using a decision-model. RESULTS 312 participants (47% female, 68.1±9.0 years) completed the study, with 61% rate of malignancy at 2 years. The sensitivity, specificity, positive predictive value and negative predictive values for DCE-CT were 95.3% (95% CI 91.3 to 97.5), 29.8% (95% CI 22.3 to 38.4), 68.2% (95% CI 62.4% to 73.5%) and 80.0% (95% CI 66.2 to 89.1), respectively, and for PET/CT were 79.1% (95% CI 72.7 to 84.2), 81.8% (95% CI 74.0 to 87.7), 87.3% (95% CI 81.5 to 91.5) and 71.2% (95% CI 63.2 to 78.1). The area under the receiver operator characteristic curve (AUROC) for DCE-CT and PET/CT was 0.62 (95% CI 0.58 to 0.67) and 0.80 (95% CI 0.76 to 0.85), respectively (p<0.001). Combined results significantly increased diagnostic accuracy over PET/CT alone (AUROC=0.90 (95% CI 0.86 to 0.93), p<0.001). DCE-CT was preferred when the willingness to pay per incremental cost per correctly treated malignancy was below £9000. Above £15 500 a combined approach was preferred. CONCLUSIONS PET/CT has a superior diagnostic accuracy to DCE-CT for the diagnosis of SPNs. Combining both techniques improves the diagnostic accuracy over either test alone and could be cost-effective. TRIAL REGISTRATION NUMBER NCT02013063.
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Affiliation(s)
- Fiona J Gilbert
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Scott Harris
- Public Health Sciences and Medical Statistics, University of Southampton, Southampton, Southampton, UK
| | - Kenneth A Miles
- Institute of Nuclear Medicine, University College London, London, UK
| | - Jonathan R Weir-McCall
- Department of Radiology, University of Cambridge, Cambridge, UK.,Department of Radiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Nagmi R Qureshi
- Department of Radiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Robert Campbell Rintoul
- Department of Thoracic Oncology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.,Department of Oncology, University of Cambridge, Cambridge, UK
| | - Sabina Dizdarevic
- Imaging and Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Lucy Pike
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, Kings College London, London, UK
| | - Donald Sinclair
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, Kings College London, London, UK
| | - Andrew Shah
- Radiation Protection, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Rosemary Eaton
- Radiation Protection, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jeremy Jones
- Centre for Innovation and Leadership in Health Sciences, University of Southampton, Southampton, UK
| | - Andrew Clegg
- Synthesis, Economic Evaluation and Decision Science (SEEDS) Group, Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - Valerio Benedetto
- Synthesis, Economic Evaluation and Decision Science (SEEDS) Group, Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - James Hill
- Synthesis, Economic Evaluation and Decision Science (SEEDS) Group, Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - Andrew Cook
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Dimitrios Tzelis
- Population Health Science Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Science Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lucy Brindle
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Jackie Madden
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Kelly Cozens
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Louisa Little
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Kathrin Eichhorst
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Patricia Moate
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Chris McClement
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Charles Peebles
- Department of Radiology and Respiratory Medicine, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Anindo Banerjee
- Department of Radiology and Respiratory Medicine, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Sai Han
- West of Scotland PET Centre, Gartnavel General Hospital, Glasgow, UK
| | - Fat-Wui Poon
- West of Scotland PET Centre, Gartnavel General Hospital, Glasgow, UK
| | - Ashley M Groves
- Institute of Nuclear Medicine, University College London, London, UK
| | - Lutfi Kurban
- Department of Radiology, Aberdeen Royal Hospitals NHS Trust, Aberdeen, UK
| | - Anthony Frew
- Imaging and Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Phil A Crosbie
- Division of Infection, Immunity and Respiratory Medicine, University Hospital of South Manchester, Manchester, UK
| | - Fergus Vincent Gleeson
- Department of Radiology, Churchill Hospital, Oxford, UK.,Department of Radiology, University of Oxford, Oxford, UK
| | | | - Osei Kankam
- Department of Thoracic Medicine, East Sussex Healthcare NHS Trust, Saint Leonards-on-Sea, UK
| | - Steve George
- Public Health Sciences and Medical Statistics, University of Southampton, Southampton, Southampton, UK
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14
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Mazzone PJ, Silvestri GA, Souter LH, Caverly TJ, Kanne JP, Katki HA, Wiener RS, Detterbeck FC. Screening for Lung Cancer: CHEST Guideline and Expert Panel Report. Chest 2021; 160:e427-e494. [PMID: 34270968 PMCID: PMC8727886 DOI: 10.1016/j.chest.2021.06.063] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/11/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Low-dose chest CT screening for lung cancer has become a standard of care in the United States, in large part because of the results of the National Lung Screening Trial (NLST). Additional evidence supporting the net benefit of low-dose chest CT screening for lung cancer, and increased experience in minimizing the potential harms, has accumulated since the prior iteration of these guidelines. Here, we update the evidence base for the benefit, harms, and implementation of low-dose chest CT screening. We use the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not. METHODS Approved panelists reviewed previously developed key questions using the Population, Intervention, Comparator, Outcome format to address the benefit and harms of low-dose CT screening, and key areas of program implementation. A systematic literature review was conducted using MEDLINE via PubMed, Embase, and the Cochrane Library on a quarterly basis since the time of the previous guideline publication. Reference lists from relevant retrievals were searched, and additional papers were added. Retrieved references were reviewed for relevance by two panel members. The quality of the evidence was assessed for each critical or important outcome of interest using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Meta-analyses were performed when enough evidence was available. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and ungraded statements were drafted, voted on, and revised until consensus was reached. RESULTS The systematic literature review identified 75 additional studies that informed the response to the 12 key questions that were developed. Additional clinical questions were addressed resulting in seven graded recommendations and nine ungraded consensus statements. CONCLUSIONS Evidence suggests that low-dose CT screening for lung cancer can result in a favorable balance of benefit and harms. The selection of screen-eligible individuals, the quality of imaging and image interpretation, the management of screen-detected findings, and the effectiveness of smoking cessation interventions can impact this balance.
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Affiliation(s)
| | | | | | - Tanner J Caverly
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI; University of Michigan Medical School, Ann Arbor, MI
| | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA; Boston University School of Medicine, Boston, MA
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15
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Tailor TD, Bell S, Fendrick AM, Carlos RC. Total and Out-of-Pocket Costs of Procedures After Lung Cancer Screening in a National Commercially Insured Population: Estimating an Episode of Care. J Am Coll Radiol 2021; 19:35-46. [PMID: 34600897 DOI: 10.1016/j.jacr.2021.09.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/12/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Consequences of lung cancer screening (LCS) with low-dose chest CT in clinical settings, including procedures, costs, and complications, are incompletely understood. We evaluated downstream invasive procedures after LCS, total and out-of-pocket (OOP) costs of these procedures, and correlates of procedural rates and costs. METHODS Using the Clinformatics Data Mart, we retrospectively included patients between ages 55 and 79 years receiving LCS between 2015 and 2017. The types and frequency of downstream invasive procedures (including needle biopsy, bronchoscopy, surgery, and cytology) were described. Treating the LCS examination and downstream procedures as a single LCS episode, we described the per-episode total costs (insurance reimbursement + OOP costs of LCS and downstream procedures) and OOP costs. Correlates of costs were determined using linear and logistic regression. RESULTS A total of 6,268 patients received at least one low-dose chest CT; 462 patients (7.4%) received at least one procedure within 12 months after LCS (needle biopsy 69.0%, cytology 23.6%, bronchoscopy 18.6%, surgery 23.8%). Women and patients ≥65 years were more likely to receive a downstream procedure. Ninety-three patients (20.1%) were diagnosed with lung cancer after LCS. The total cost of managing this population of lung screeners was $5,060,511.04, with an average per-episode total cost of $740.06. The aggregate OOP costs to this population of lung screeners was $427,069.74, with an average per-episode OOP cost of $62.46. CONCLUSIONS Rates of invasive procedures after LCS in a commercially insured population exceeded those of clinical trials. Considering LCS and associated downstream procedures as an episode of care results in modest OOP cost.
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Affiliation(s)
- Tina D Tailor
- Director, Cardiothoracic Radiology Fellowship and Research Director, Duke Lung Cancer Screening Program, Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | - Sarah Bell
- Department of Obstetrics and Gynecology, University of Michigan Health, Ann Arbor, Michigan
| | - A Mark Fendrick
- Director, University of Michigan Center for Value-Based Insurance Design, Department of Internal Medicine and Department of Health Management and Policy, University of Michigan Health, Ann Arbor Michigan
| | - Ruth C Carlos
- Department of Radiology, University of Michigan Health, Ann Arbor, Michigan
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16
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Smith HB, Ward R, Frazier C, Angotti J, Tanner NT. Guideline-Recommended Lung Cancer Screening Adherence Is Superior With a Centralized Approach. Chest 2021; 161:818-825. [PMID: 34536385 DOI: 10.1016/j.chest.2021.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND To recognize fully the benefit of lung cancer screening (LCS), annual adherence must approach the high levels seen in the National Lung Screening Trial. Emerging data suggest that annual adherence is poor and that a centralized approach to screening improves adherence. RESEARCH QUESTIONS Do differences in adherence exist between a centralized and decentralized approach to LCS within a hybrid program and what are predictors of adherence? STUDY DESIGN A retrospective evaluation of a single-center hybrid LCS program was conducted to compare outcomes including patient eligibility and adherence between the centralized and decentralized approaches. METHODS Patient demographics and outcomes were compared between those screened with a centralized and decentralized approach and between adherent and nonadherent patients using two-sample t tests, χ 2 tests, or analyses of variance, as appropriate. Annual adherence analysis was conducted using data from patients who remained eligible for screening with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2. Logistic regression was used to estimate the association between adherence and the primary exposure, adjusting for potential confounders. RESULTS A cohort of 1,117 patients underwent baseline low-dose CT imaging. Two hundred eleven patients (19%) were ineligible by United States Preventative Services Task Force criteria and most (90%) were screened with the decentralized approach. After exclusions, 765 patients with Lung-RADS score of 1 or 2 remained eligible for annual screening. Overall adherence was 56%; however, adherence in the centralized program was 70%, compared with 41% with the decentralized approach (P < .001). Individuals screened in a decentralized approach were 73% less likely to be adherent (OR, 0.27; 95% CI, 0.19-0.37). A greater proportion of patients with three or more comorbidities were screened outside the centralized program. INTERPRETATION Those screened using a centralized approach were more likely to meet eligibility criteria for LCS and more likely to return for annual screening than those screened using a decentralized approach.
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Affiliation(s)
- Harrison B Smith
- Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
| | - Ralph Ward
- Department of Public Health, the Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veteran Affairs Hospital, Charleston, SC
| | - Cassie Frazier
- Department of Public Health, the Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | - Jonathan Angotti
- Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
| | - Nichole T Tanner
- Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC; Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veteran Affairs Hospital, Charleston, SC.
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17
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Melzer AC, Begnaud A, Lindgren BR, Schertz K, Fu SS, Vock DM, Rothman AJ, Joseph AM. Self-reported exercise capacity among current smokers eligible for lung cancer screening: Distribution and association with key comorbidities. Cancer Treat Res Commun 2021; 28:100443. [PMID: 34371253 PMCID: PMC8405582 DOI: 10.1016/j.ctarc.2021.100443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 06/13/2023]
Abstract
ONE CONCERN: as lung cancer screening (LCS) is implemented is that patients will be screened who are too ill to benefit. Poor exercise capacity (EC) predicts adverse outcomes following lung resection. OBJECTIVE Describe the distribution of EC among smokers eligible for LCS and examine associations with comorbidities. METHODS Cross-sectional analysis of baseline data from a randomized controlled trial of tobacco treatment in the context of LCS. Participants responded regarding limitations in moderate activities, ability to climb stairs, and frequency of dyspnea on a scale from never/almost never to all or most of the time. Responses were assigned a numeric score and summed to categorize exercise limitation. Associations between poor EC and key comorbidities were examined using adjusted logistic regression. RESULTS 660 participants completed a survey with the following characteristics: 64.4% male, 89.5% white, mean age 64.5. Overall EC categories were: good 39.0%, intermediate 41.6%, and poor 19.4%. Prevalence of poor EC was higher among patients with COPD (OR 4.62 95%CI 3.05-7.02), heart failure (OR 3.07 95%CI 1.62-5.82) and cardiovascular disease (OR 2.24, 95%CI 1.45-3.47), and was highest among patients with multimorbidity. Among patients with COPD and heart failure, 57% had poor and 0% had good EC. In adjusted logistic regression, only COPD and Charlson comorbidity index remained significantly associated with poor EC. CONCLUSIONS Many patients eligible for LCS reported poor EC, with increased odds of poor EC among patients with comorbidities. More research is needed to determine how to best integrate EC and comorbidity into eligibility and shared decision-making conversations.
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Affiliation(s)
- Anne C Melzer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, United States; Division of Pulmonary, Allergy, Critical Care and Sleep, University of Minnesota Medical School, United States.
| | - Abbie Begnaud
- Division of Pulmonary, Allergy, Critical Care and Sleep, University of Minnesota Medical School, United States
| | | | - Kelsey Schertz
- Department of Medicine, University of Minnesota Medical School, United States
| | - Steven S Fu
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, United States; Department of Medicine, University of Minnesota Medical School, United States
| | - David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, United States
| | | | - Anne M Joseph
- Masonic Cancer Center, University of Minnesota, United States; Department of Medicine, University of Minnesota Medical School, United States
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18
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Comorbidity Profiles and Lung Cancer Screening among Older Adults: U.S. Behavioral Risk Factor Surveillance System 2017 to 2019. Ann Am Thorac Soc 2021; 18:1886-1893. [PMID: 33939595 DOI: 10.1513/annalsats.202010-1276oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Although lung cancer screening (LCS) with low-dose computed tomography (LDCT) is now recommended for those meeting standard risk factor-based eligibility criteria, the role of comorbidity in the uptake of LCS with LDCT in an older real-world U.S. population is not well established. OBJECTIVE To examine the relationships between comorbidity, functional status and LCS utilization in the United States. METHODS Using population-based data from the 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS), we examined the association of comorbid conditions and functional limitations regarding activities of daily living with LCS utilization among participants that met the LCS criteria based on the US Preventive Service Taskforce guidelines. We employed multivariable weighted logistic regression models to evaluate these associations, both overall and within subgroups defined by age (<65 vs. ≥65 years), gender, and smoking history. RESULTS Of 11,214 participants that met the eligibility criteria for LCS, 1731 (16%) underwent LCS with LDCT. The majority were white (90%), male (55%), former smokers (52%) and living with at least one chronic comorbid condition (77%). Over 28% had 3 or more comorbid conditions and approximately 40% of participants reported having some form of functional limitations. In the multivariable models, the likelihood of undergoing LCS with LDCT within the past year was positively associated with higher levels of comorbidity (≥5 vs. 0: aOR=2.34, 95% CI=1.22,4.48) but not with functional limitations (≥3 vs. 0: aOR=1.00, 95% CI=0.66, 1.50). CONCLUSION The presence of comorbid conditions is associated with a higher likelihood of undergoing LCS with LDCT. Because poor health status may diminish the benefits of screening, future research is needed to precisely characterize the health status of LCS-eligible individuals.
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Weir-McCall JR, Harris S, Miles KA, Qureshi NR, Rintoul RC, Dizdarevic S, Pike L, Cheow HK, Gilbert FJ. Impact of solitary pulmonary nodule size on qualitative and quantitative assessment using 18F-fluorodeoxyglucose PET/CT: the SPUTNIK trial. Eur J Nucl Med Mol Imaging 2021; 48:1560-1569. [PMID: 33130961 PMCID: PMC8113131 DOI: 10.1007/s00259-020-05089-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE To compare qualitative and semi-quantitative PET/CT criteria, and the impact of nodule size on the diagnosis of solitary pulmonary nodules in a prospective multicentre trial. METHODS Patients with an SPN on CT ≥ 8 and ≤ 30 mm were recruited to the SPUTNIK trial at 16 sites accredited by the UK PET Core Lab. Qualitative assessment used a five-point ordinal PET-grade compared to the mediastinal blood pool, and a combined PET/CT grade using the CT features. Semi-quantitative measures included SUVmax of the nodule, and as an uptake ratio to the mediastinal blood pool (SURBLOOD) or liver (SURLIVER). The endpoints were diagnosis of lung cancer via biopsy/histology or completion of 2-year follow-up. Impact of nodule size was analysed by comparison between nodule size tertiles. RESULTS Three hundred fifty-five participants completed PET/CT and 2-year follow-up, with 59% (209/355) malignant nodules. The AUCs of the three techniques were SUVmax 0.87 (95% CI 0.83;0.91); SURBLOOD 0.87 (95% CI 0.83; 0.91, p = 0.30 versus SUVmax); and SURLIVER 0.87 (95% CI 0.83; 0.91, p = 0.09 vs. SUVmax). The AUCs for all techniques remained stable across size tertiles (p > 0.1 for difference), although the optimal diagnostic threshold varied by size. For nodules < 12 mm, an SUVmax of 1.75 or visual uptake equal to the mediastinum yielded the highest accuracy. For nodules > 16 mm, an SUVmax ≥ 3.6 or visual PET uptake greater than the mediastinum was the most accurate. CONCLUSION In this multicentre trial, SUVmax was the most accurate technique for the diagnosis of solitary pulmonary nodules. Diagnostic thresholds should be altered according to nodule size. TRIAL REGISTRATION ISRCTN - ISRCTN30784948. ClinicalTrials.gov - NCT02013063.
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Affiliation(s)
- J R Weir-McCall
- Department of Radiology, Biomedical Research Centre, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | - S Harris
- Public Health Sciences and Medical Statistics, University of Southampton, Southampton, UK
| | - K A Miles
- Institute of Nuclear Medicine, University College London, London, UK
| | - N R Qureshi
- Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | - R C Rintoul
- Department of Thoracic Oncology, Royal Papworth Hospital / Department of Oncology, University of Cambridge, Cambridge, UK
| | - S Dizdarevic
- Departments of Imaging and Nuclear Medicine and Respiratory Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton and Sussex Medical School, Brighton, UK
| | - L Pike
- King's College London and Guy's & St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Heok K Cheow
- Addenbrookes Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Fiona J Gilbert
- Department of Radiology, Biomedical Research Centre, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK.
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20
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Jacobson FL, Dezube AR, Bravo-Iñiguez C, Kucukak S, Bay CP, Wee JO, Coppolino AA, Jaklitsch MT, Ducko CT. Preserving NLST mortality benefits and acceptable morbidity for lung cancer surgery in a community hospital. J Surg Oncol 2021; 124:124-134. [PMID: 33844848 DOI: 10.1002/jso.26483] [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: 03/19/2021] [Revised: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to demonstrate whether academic thoracic surgeons could achieve morbidity and mortality rates in community hospitals equivalent to those seen in National Lung Screening Trial (NLST). METHODS This was a retrospective review of community hospital lung cancer procedures for clinical Stage I-III non-small-cell lung cancers from 2007 through 2014. Variables include age, comorbidities, computed tomography (CT) characterization, and operative techniques. RESULTS There were 177 patients who had lung cancers removed by a minimally invasive approach (79%), including lobectomy in 127 (72%), segmentectomy in 4 (2%), and wedge-resections in 46 (26%). The median patient age was 71 years (interquartile range [IQR], 63-76). The cohort was primarily female (58%), clinical Stage I (82%), with a median tumor size of 2.3 cm (IQR, 1.5-3.3). The median length of stay was 6 days (range: 1-35). Complications were experienced by 78 (44.1%) patients, most commonly atrial fibrillation in 20 (11.3%) followed by air-leak in 19 (10.7%). There were no in-hospital deaths. Tumor location and extent of resection were associated with complications, while larger tumor size, margin contour, and resection method were associated with air-leak (all p < 0.05). Higher clinical stage and larger tumor size were associated with occult Stage III disease (both p < 0.05). CONCLUSIONS The low morbidity and mortality rates from the NLST were achievable in a community setting for early-stage lung cancer. Characterization of cancers using CT imaging identified factors most commonly associated with postoperative complications and the presence of occult Stage III disease.
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Affiliation(s)
- Francine L Jacobson
- Division of Thoracic Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carlos Bravo-Iñiguez
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Camden P Bay
- Division of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Antonio A Coppolino
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher T Ducko
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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Shin DW, Cho JH, Yoo JE, Cho J, Yoon DW, Lee G, Shin S, Kim HK, Choi YS, Kim J, Zo JI, Shim YM. Conditional Survival of Surgically Treated Patients with Lung Cancer: A Comprehensive Analyses of Overall, Recurrence-free, and Relative Survival. Cancer Res Treat 2021; 53:1057-1071. [PMID: 33705624 PMCID: PMC8524014 DOI: 10.4143/crt.2020.1308] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/06/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Survival probability changes over time in cancer survivors. This study examined conditional survival in patients undergoing curative resection for non-small cell lung cancer (NSCLC). Materials and Methods Five-year conditional recurrence-free survival (CRFS), conditional overall survival (COS), and conditional relative survival (CRS) up to 10 years after surgery were calculated in patients who underwent NSCLC resection from 1994 to 2016. These rates were stratified according to age, sex, year of diagnosis, pathological stage, tumor histology, smoking status, comorbidity, and lung function. Results Five-year CRFS increased from 65.6% at baseline to 90.9% at 10 years after surgery. Early differences in 5-year CRFS according to stratified patient characteristics disappeared, except for age: older patients exhibited persistently lower 5-year CRFS. Five-year COS increased from 72.7% to 78.3% at 8 years and then decreased to 75.4% at 10 years. Five-year CRS increased from 79.0% at baseline to 86.8% at 10 years. Older age and higher pathologic stage were associated with lower 5-year COS and CRS up to 10 years after surgery. Female patients, those with adenocarcinoma histology, non-smokers, patient without comorbidities and had good lung function showed higher COS and CRS. Conclusion CRFS improved over time, but significant risk remained after 5 years. CRS slightly improved over time but did not reach 90%, suggesting significant excess mortality compared to the general population. Age and stage remained significant predictors of conditional survival several years after surgery. Our conditional survival estimates should help clinicians and patients make informed treatment and personal life decisions based on survivorship status.
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Affiliation(s)
- Dong Wook Shin
- Department of Family Medicine, Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea.,Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Eun Yoo
- Healthcare system Gangnan Center, Seoul National University Hospital, Seoul, Korea
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea.,Cancer Education Center, Samsung Medical Center, Seoul, Korea.,Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea.,Departments of Health, Behavior, and Society and Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dong Woog Yoon
- Department of Thoracic and Cardiovascular Surgery, Armed Forces Capital Hospital, Seongnam, Korea
| | - Genehee Lee
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
| | - Sumin Shin
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jhingook Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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22
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Callister MEJ, Sasieni P, Robbins HA. Overdiagnosis in lung cancer screening. THE LANCET. RESPIRATORY MEDICINE 2021; 9:7-9. [PMID: 33412118 PMCID: PMC8021885 DOI: 10.1016/s2213-2600(20)30553-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Matthew E J Callister
- Department of Respiratory Medicine, Leeds Teaching Hospitals, St James's University Hospital, Leeds LS9 7TF, UK.
| | - Peter Sasieni
- School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
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Liu F, Yuan X, Jiang J, Zhang P, Chen Y, Chu Q. Lower lobe origin is related to unfavorable outcomes in patients with stage I-III lung cancer treated with radical chemoradiotherapy. TUMORI JOURNAL 2020; 107:400-406. [PMID: 33225858 DOI: 10.1177/0300891620971359] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE The influence of tumor location on survival was investigated in patients with lung cancer who received radical chemoradiotherapy. METHODS We examined the relationships between radiation site and survival outcome in patients with lung cancer. A total of 14,640 patients with lung cancer who received radical chemoradiotherapy for stage I-III disease were reviewed from Surveillance, Epidemiology, and End Results Program (SEER) datasets. We further retrospectively collected cases from a cohort of 148 eligible patients diagnosed between December 2013 and December 2019. RESULTS Female sex, adenocarcinoma, and stage III disease were significantly correlated with right lung lobe tumor. Advanced age at diagnosis was associated with lower lung tumor origin. For the patients who received radical chemoradiotherapy, 1- and 3-year survival rates were 56.5% and 22.9%. Lower lobe origin was closely related to a shorter overall survival compared to non-right lower lobe tumors (p < 0.001). We also validated the difference in our cohort (p = 0.004). CONCLUSIONS Our results suggest that lower lobe tumor increases mortality risk in patients with lung cancer treated with radical chemoradiotherapy.
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Affiliation(s)
- Fangfang Liu
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xun Yuan
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jizong Jiang
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peng Zhang
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuan Chen
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qian Chu
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Abstract
Robust evidence exists in support of lung cancer (LC) screening with low-dose computed tomography in patients at high risk of developing LC; however, judicious patient selection is necessary to obtain optimal benefit while minimizing harm. Several professional societies have published recommendations regarding patient selection criteria for screening. Multiple risk prediction models that include additional patient-specific risk factors have since been developed to more accurately predict risk of developing LC. Implementation of a new screening program requires thorough multidisciplinary planning and maintenance. Multisociety guidelines highlight 9 principal components to implement and maintain a successful program.
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Affiliation(s)
- Nina A Thomas
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB Suite 816, MSC 630, Charleston, SC 29425, USA
| | - Nichole T Tanner
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB Suite 816, MSC 630, Charleston, SC 29425, USA; Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Hospital, 109 Bee Street, Charleston, SC 29401, USA.
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25
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Enewold L, Parsons H, Zhao L, Bott D, Rivera DR, Barrett MJ, Virnig BA, Warren JL. Updated Overview of the SEER-Medicare Data: Enhanced Content and Applications. J Natl Cancer Inst Monogr 2020; 2020:3-13. [PMID: 32412076 PMCID: PMC7225666 DOI: 10.1093/jncimonographs/lgz029] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was first created almost 30 years ago. Over time, additional data have been added to the SEER-Medicare database, allowing for expanded insights into the delivery of health care across the cancer continuum from screening to end of life. METHODS This article includes an overview of the current SEER-Medicare database, presenting potential users with an introduction to how the data can facilitate innovative epidemiologic and health services research studies. With a focus on the population 65 years and older, this article presents descriptive data on beneficiary demographics, cancer characteristics, service settings, Medicare coverage (eg, Parts A, B, C, and D), and use (number of services or bills) from 2011 to 2015. RESULTS From 2011 to 2015, 857 056 cancer patients and 601 470 population-based noncancer controls were added to the database. The database includes detailed tumor characteristics and clinical assessments for cancer cases, and demographics and health-care use (eg, hospitals, outpatient facilities, individual providers, hospice, home health-care providers, and pharmacies) for both cases and controls. Although characteristics varied overall between cases and controls, sufficient cancer-specific matched controls are available. Roughly 60% of cases were enrolled in fee for service at cancer diagnosis. The annual average number of claims per case was 60.7 and 92.3 during the year before and after cancer diagnosis, respectively, and 127.5 during the year before death. CONCLUSIONS The large sample size and diverse array of data on cancer patients and noncancer controls in the SEER-Medicare database make it a unique resource for conducting cancer health services research.
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Affiliation(s)
- Lindsey Enewold
- National Cancer Institute, Division of Cancer Control and Population Sciences, Healthcare Delivery Research Program, Bethesda, MD
| | - Helen Parsons
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Lirong Zhao
- Research and Rapid Cycle Evaluation Group, Center for Medicare & Medicaid Innovation, CMS, Baltimore, MD
| | - David Bott
- Research and Rapid Cycle Evaluation Group, Center for Medicare & Medicaid Innovation, CMS, Baltimore, MD
| | - Donna R Rivera
- National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Bethesda, MD
| | | | - Beth A Virnig
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Joan L Warren
- National Cancer Institute, Division of Cancer Control and Population Sciences, Healthcare Delivery Research Program, Bethesda, MD
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Carroll NM, Burnett-Hartman AN, Joyce CA, Kinnard W, Harker EJ, Hall V, Steiner JS, Blum-Barnett E, Ritzwoller DP. Real-world Clinical Implementation of Lung Cancer Screening-Evaluating Processes to Improve Screening Guidelines-Concordance. J Gen Intern Med 2020; 35:1143-1152. [PMID: 31974902 PMCID: PMC7174472 DOI: 10.1007/s11606-019-05539-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 10/18/2019] [Accepted: 10/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Lung cancer screening (LCS) requires complex processes to identify eligible patients, provide appropriate follow-up, and manage findings. It is unclear whether LCS in real-world clinical settings will realize the same benefits as the National Lung Screening Trial (NLST). OBJECTIVE To evaluate the impact of process modifications on compliance with LCS guidelines during LCS program implementation, and to compare patient characteristics and outcomes with those in NLST. DESIGN Retrospective cohort study. SETTING Kaiser Permanente Colorado (KPCO), a non-profit integrated healthcare system. PATIENTS A total of 3375 patients who underwent a baseline lung cancer screening low-dose computed tomography (S-LDCT) scan between May 2014 and June 2017. MEASUREMENTS Among those receiving an S-LDCT, proportion who met guidelines-based LCS eligibility criteria before and after LCS process modifications, differences in patient characteristics and outcomes between KPCO LCS patients and the NLST cohort, and factors associated with a positive screen. RESULTS After modifying LCS eligibility confirmation processes, patients receiving S-LDCT who met guidelines-based LCS eligibility criteria increased from 45.6 to 92.7% (P < 0.001). Prior to changes, patients were older (68 vs. 67 years; P = 0.001), less likely to be current smokers (51.3% vs. 52.5%; P < 0.001), and less likely to have a ≥ 30-pack-year smoking history (50.0% vs. 95.3%; P < 0.001). Compared with NLST participants, KPCO LCS patients were older (67 vs. 60 years; P < 0.001), more likely to currently smoke (52.3% vs. 48.1%; P < 0.001), and more likely to have pulmonary disease. Among those with a positive baseline S-LDCT, the lung cancer detection rate was higher at KPCO (9.4% vs. 3.8%; P < 0.001) and was positively associated with prior pulmonary disease. CONCLUSION Adherence to LCS guidelines requires eligibility confirmation procedures. Among those with a positive baseline S-LDCT, comorbidity burden and lung cancer detection rates were notably higher than in NLST, suggesting that the study of long-term outcomes in patients undergoing LCS in real-world clinical settings is warranted.
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Affiliation(s)
- Nikki M Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
| | | | - Caroline A Joyce
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - William Kinnard
- Colorado Permanente Medical Group, Kaiser Permanente Colorado, Denver, CO, USA
| | - Eric J Harker
- Colorado Permanente Medical Group, Kaiser Permanente Colorado, Denver, CO, USA
| | - Virginia Hall
- Kaiser Foundation Health Plan, Kaiser Permanente Colorado, Denver, CO, USA
| | - Julie S Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Erica Blum-Barnett
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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Rai A, Doria-Rose VP, Silvestri GA, Yabroff KR. Evaluating Lung Cancer Screening Uptake, Outcomes, and Costs in the United States: Challenges With Existing Data and Recommendations for Improvement. J Natl Cancer Inst 2020; 111:342-349. [PMID: 30698792 DOI: 10.1093/jnci/djy228] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/14/2018] [Accepted: 12/10/2018] [Indexed: 12/17/2022] Open
Abstract
The National Lung Screening Trial (NLST) reported substantial reduction in lung cancer mortality among high-risk individuals screened annually with low-dose helical computed tomography (LDCT). As a result, the US Preventive Services Task Force issued a B recommendation for annual LDCT in high-risk individuals, which requires private insurers to cover it without cost-sharing. The Medicare program also covers LDCT for high-risk beneficiaries without cost-sharing. However, the NLST findings may not be generalizable to the community setting because of differences in patients, providers, and practices participating in the NLST. Thus, examining uptake of LDCT screening in community practice is critical, as is evaluating the immediate and downstream outcomes of screening, including false-positive scans, follow-up examinations and adverse events, costs, stage of disease at diagnosis, and survival. This commentary presents an overview of the landscape of the data resources currently available to evaluate the uptake, outcomes, and costs of LDCT screening in the United States. We describe the strengths and limitations of existing data sources, including administrative databases, surveys, and registries. Thereafter, we provide recommendations for improving the data infrastructure pertaining to three overarching research areas: receipt of guideline-consistent screening and follow-up, weighing benefits and harms of screening, and costs of screening.
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Affiliation(s)
- Ashish Rai
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, GA (AR, KRY)
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, NCI, Bethesda, MD (VPDR)
| | - Gerard A Silvestri
- Thoracic Oncology Research Group, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC (GAS)
| | - K Robin Yabroff
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, GA (AR, KRY)
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Weir-McCall JR, Joyce S, Clegg A, MacKay JW, Baxter G, Dendl LM, Rintoul RC, Qureshi NR, Miles K, Gilbert FJ. Dynamic contrast-enhanced computed tomography for the diagnosis of solitary pulmonary nodules: a systematic review and meta-analysis. Eur Radiol 2020; 30:3310-3323. [PMID: 32060716 DOI: 10.1007/s00330-020-06661-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/12/2019] [Accepted: 01/17/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION A systematic review and meta-analysis were performed to determine the diagnostic performance of dynamic contrast-enhanced computed tomography (DCE-CT) for the differentiation between malignant and benign pulmonary nodules. METHODS Ovid MEDLINE and EMBASE were searched for studies published up to October 2018 on the diagnostic accuracy of DCE-CT for the characterisation of pulmonary nodules. For the index test, studies with a minimum of a pre- and post-contrast computed tomography scan were evaluated. Studies with a reference standard of biopsy for malignancy, and biopsy or 2-year follow-up for benign disease were included. Study bias was assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies). The sensitivities, specificities, and diagnostic odds ratios were determined along with 95% confidence intervals (CIs) using a bivariate random effects model. RESULTS Twenty-three studies were included, including 2397 study participants with 2514 nodules of which 55.3% were malignant (1389/2514). The pooled accuracy results were sensitivity 94.8% (95% CI 91.5; 96.9), specificity 75.5% (69.4; 80.6), and diagnostic odds ratio 56.6 (24.2-88.9). QUADAS 2 assessment showed intermediate/high risk of bias in a large proportion of the studies (52-78% across the domains). No difference was present in sensitivity or specificity between subgroups when studies were split based on CT technique, sample size, nodule size, or publication date. CONCLUSION DCE-CT has a high diagnostic accuracy for the diagnosis of pulmonary nodules although study quality was indeterminate in a large number of cases. KEY POINTS • The pooled accuracy results were sensitivity 95.1% and specificity 73.8% although individual studies showed wide ranges of values. • This is comparable to the results of previous meta-analyses of PET/CT (positron emission tomography/computed tomography) diagnostic accuracy for the diagnosis of solitary pulmonary nodules. • Robust direct comparative accuracy and cost-effectiveness studies are warranted to determine the optimal use of DCE-CT and PET/CT in the diagnosis of SPNs.
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Affiliation(s)
- Jonathan R Weir-McCall
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
| | - Stella Joyce
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Andrew Clegg
- School of Health Sciences, Faculty of Health and Wellbeing, University of Central Lancashire, Lancashire, UK
| | - James W MacKay
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Gabrielle Baxter
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | | | - Robert C Rintoul
- Department of Thoracic Oncology, Royal Papworth Hospital, Cambridge, UK.,Department of Oncology, University of Cambridge, Cambridge, UK
| | - Nagmi R Qureshi
- Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | - Ken Miles
- Institute of Nuclear Medicine, University College London, London, UK
| | - Fiona J Gilbert
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
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Cheung LC, Berg CD, Castle PE, Katki HA, Chaturvedi AK. Life-Gained-Based Versus Risk-Based Selection of Smokers for Lung Cancer Screening. Ann Intern Med 2019; 171:623-632. [PMID: 31634914 PMCID: PMC7191755 DOI: 10.7326/m19-1263] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Although risk-based selection of ever-smokers for screening could prevent more lung cancer deaths than screening according to the U.S. Preventive Services Task Force (USPSTF) guidelines, it preferentially selects older ever-smokers with shorter life expectancies due to comorbidities. OBJECTIVE To compare selection of ever-smokers for screening based on gains in life expectancy versus lung cancer risk. DESIGN Cohort analyses and model-based projections. SETTING U.S. population of ever-smokers aged 40 to 84 years. PARTICIPANTS 130 964 National Health Interview Survey participants, representing about 60 million U.S. ever-smokers during 1997 to 2015. INTERVENTION Annual computed tomography (CT) screening for 3 years versus no screening. MEASUREMENTS Estimated number of lung cancer deaths averted and life-years gained after development of a mortality model. RESULTS Using the calibrated and validated mortality model in U.S. ever-smokers aged 40 to 84 years and selecting 8.3 million ever-smokers to match the number selected by the USPSTF criteria in 2013 to 2015, the analysis estimated that life-gained-based selection would increase the total life expectancy from CT screening (633 400 vs. 607 800 years) but prevent fewer lung cancer deaths (52 600 vs. 55 000) compared with risk-based selection. The 1.56 million persons selected by the life-gained-based strategy but not the risk-based strategy were younger (mean age, 59 vs. 75 years) and had fewer comorbidities (mean, 0.75 vs. 3.7). LIMITATION Estimates are model-based and assume implementation of lung cancer screening with short-term effectiveness similar to that from trials. CONCLUSION Life-gained-based selection could maximize the benefits of lung cancer screening in the U.S. population by including ever-smokers who have both high lung cancer risk and long life expectancy. PRIMARY FUNDING SOURCE Intramural Research Program of the National Cancer Institute, National Institutes of Health.
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Affiliation(s)
- Li C Cheung
- National Cancer Institute, Bethesda, Maryland (L.C.C., C.D.B., H.A.K., A.K.C.)
| | - Christine D Berg
- National Cancer Institute, Bethesda, Maryland (L.C.C., C.D.B., H.A.K., A.K.C.)
| | - Philip E Castle
- Albert Einstein School of Medicine, Bronx, New York (P.E.C.)
| | - Hormuzd A Katki
- National Cancer Institute, Bethesda, Maryland (L.C.C., C.D.B., H.A.K., A.K.C.)
| | - Anil K Chaturvedi
- National Cancer Institute, Bethesda, Maryland (L.C.C., C.D.B., H.A.K., A.K.C.)
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Young RP, Hopkins R. The potential impact of chronic obstructive pulmonary disease in lung cancer screening: implications for the screening clinic. Expert Rev Respir Med 2019; 13:699-707. [PMID: 31274043 DOI: 10.1080/17476348.2019.1638766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Following the findings of the National Lung Screening Trial (NLST), lung cancer screening is now recommended in the United States. However, post-hoc analyses of the NLST suggest that reducing lung cancer mortality through screening is highly dependent on the underlying characteristics of the screening participants, in particular, the presence of chronic obstructive pulmonary disease (COPD). Areas covered: In this review, we outline how outcomes in lung cancer screening are significantly affected by the presence of airflow limitation, as caused by COPD, and how this might impact the assessment of eligible smokers in a lung cancer screening clinic. Expert opinion: There is growing evidence showing that CT-based screening for lung cancer reduces lung cancer mortality. The benefits of screening exceed those seen in the NLST when screening is carried out in lower risk populations, for a longer duration, and when outcomes are compared with usual care control cohorts. In this article, we review data from a post-hoc analysis of the NLST. We suggest that whilst worsened airflow limitation is associated with greater lung cancer risk, there is also more aggressive lung cancer, reduced lung cancer operability, and for advanced COPD, reduced benefits from screening. We advocate an 'outcomes-based' approach to screening over a 'risk-based' approach.
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Affiliation(s)
- Robert P Young
- a School of Biological Sciences, University of Auckland , Auckland , New Zealand.,b Faculty of Medical and Health Sciences, University of Auckland , Auckland , New Zealand
| | - Raewyn Hopkins
- b Faculty of Medical and Health Sciences, University of Auckland , Auckland , New Zealand
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Huo J, Xu Y, Sheu T, Volk RJ, Shih YCT. Complication Rates and Downstream Medical Costs Associated With Invasive Diagnostic Procedures for Lung Abnormalities in the Community Setting. JAMA Intern Med 2019; 179:324-332. [PMID: 30640382 PMCID: PMC6440230 DOI: 10.1001/jamainternmed.2018.6277] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The Centers for Medicare & Medicaid Services added lung cancer screening with low-dose computed tomography (LDCT) as a Medicare preventive service benefit in 2015 following findings from the National Lung Screening Trial (NLST) that showed a 16% reduction in lung cancer mortality associated with LDCT. A challenge in developing and promoting a national lung cancer screening program is the high false-positive rate of LDCT because abnormal findings from thoracic imaging often trigger subsequent invasive diagnostic procedures and could lead to postprocedural complications. OBJECTIVE To determine the complication rates and downstream medical costs associated with invasive diagnostic procedures performed for identification of lung abnormalities in the community setting. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of non-protocol-driven community practices captured in MarketScan Commercial Claims & Encounters and Medicare supplemental databases was conducted. A nationally representative sample of 344 510 patients aged 55 to 77 years who underwent invasive diagnostic procedures between 2008 and 2013 was included. MAIN OUTCOMES AND MEASURES One-year complication rates were calculated for 4 groups of invasive diagnostic procedures. The complication rates and costs were further stratified by age group. RESULTS Of the 344 510 individuals aged 55 to 77 years included in the study, 174 702 comprised the study group (109 363 [62.6%] women) and 169 808 served as the control group (106 007 [62.4%] women). The estimated complication rate was 22.2% (95% CI, 21.7%-22.7%) for individuals in the young age group and 23.8% (95% CI, 23.0%-24.6%) for those in the Medicare group; the rates were approximately twice as high as those reported in the NLST (9.8% and 8.5%, respectively). The mean incremental complication costs were $6320 (95% CI, $5863-$6777) for minor complications to $56 845 (95% CI, $47 953-$65 737) for major complications. CONCLUSIONS AND RELEVANCE The rates of complications after invasive diagnostic procedures were higher than the rates reported in clinical trials. Physicians and patients should be aware of the potential risks of subsequent adverse events and their high downstream costs in the shared decision-making process.
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Affiliation(s)
- Jinhai Huo
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville
| | - Ying Xu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Tommy Sheu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
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Do the surgical results in the National Lung Screening Trial reflect modern thoracic surgical practice? J Thorac Cardiovasc Surg 2018; 157:2038-2046.e1. [PMID: 31288364 DOI: 10.1016/j.jtcvs.2018.11.139] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/15/2018] [Accepted: 11/25/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Surgical data from the National Lung Screening Trial (NLST) has yet to be closely examined. We sought to analyze surgical procedures and complications from the NLST to determine their relevance to modern surgical practice. METHODS The NLST database was queried for patients who underwent surgical resection for confirmed lung cancer, specifically evaluating postoperative complications. Numerical variables were compared using the Mann-Whitney U test. Categorical variables were compared using the χ2 test. Logistic regression uni- and multivariable analysis of independent risk factors of postoperative complications was performed. RESULTS At operation, 80% of patients (n = 821) had lobectomy, 4.1% (n = 42) had pneumonectomy, and 16.1% (n = 166) had sublobar resection, among whom 69% (n = 114) had wedge resection. Only 29.6% (n = 305) of the cohort had a thoracoscopic resection. Although the overall rate of surgical patients with any complication was 31% (n = 318), only 15.5% of patients (n = 160) had major complications, most commonly prolonged air leaks (n = 67, 6.5%). Respiratory failure (n = 28, 2.7%), prolonged ventilation (n = 9, 0.9%), myocardial infarction or cardiac arrest (n = 7, 0.7%), and stroke (n = 2, 0.2%) were rare events. Overall 30-day mortality in patients undergoing resection was 1.7% (n = 18). On multivariable analysis, greater smoking pack history (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.001-1.01) and pulmonary comorbidities (OR, 1.34; 95% CI, 0.98-1.82) were significant or approached significance for an association with complications/death, whereas sublobar resection (OR, 0.59; 95% CI, 0.38-0.94) and video-assisted thoracoscopic surgery approach (OR, 0.76; 95% CI, 0.56-1.04) were significant or approached significance for an association with decreased rates of complications/death. CONCLUSIONS Operative mortality and postoperative morbidity were very low in patients undergoing resection for screen-detected lung cancer. Increased use of sublobar resection and minimally invasive surgical approaches may be associated with fewer complications.
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Seijo LM, Peled N, Ajona D, Boeri M, Field JK, Sozzi G, Pio R, Zulueta JJ, Spira A, Massion PP, Mazzone PJ, Montuenga LM. Biomarkers in Lung Cancer Screening: Achievements, Promises, and Challenges. J Thorac Oncol 2018; 14:343-357. [PMID: 30529598 DOI: 10.1016/j.jtho.2018.11.023] [Citation(s) in RCA: 288] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/20/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022]
Abstract
The present review is an update of the research and development efforts regarding the use of molecular biomarkers in the lung cancer screening setting. The two main unmet clinical needs, namely, the refinement of risk to improve the selection of individuals undergoing screening and the characterization of undetermined nodules found during the computed tomography-based screening process are the object of the biomarkers described in the present review. We first propose some principles to optimize lung cancer biomarker discovery projects. Then, we summarize the discovery and developmental status of currently promising molecular candidates, such as autoantibodies, complement fragments, microRNAs, circulating tumor DNA, DNA methylation, blood protein profiling, or RNA airway or nasal signatures. We also mention other emerging biomarkers or new technologies to follow, such as exhaled breath biomarkers, metabolomics, sputum cell imaging, genetic predisposition studies, and the integration of next-generation sequencing into study of circulating DNA. We also underline the importance of integrating different molecular technologies together with imaging, radiomics, and artificial intelligence. We list a number of completed, ongoing, or planned trials to show the clinical utility of molecular biomarkers. Finally, we comment on future research challenges in the field of biomarkers in the context of lung cancer screening and propose a design of a trial to test the clinical utility of one or several candidate biomarkers.
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Affiliation(s)
- Luis M Seijo
- Clinica Universidad de Navarra, Madrid, Spain; CIBERES, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Nir Peled
- Oncology Division, The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center and Ben-Gurion University, Beer-Sheva, Israel
| | - Daniel Ajona
- Solid Tumors Program, Centro de Investigación Médica Aplicada, Pamplona, Spain; Navarra Institute for Health Research, Pamplona, Spain; CIBERONC, Centro de Investigación Biomédica en Red de Cáncer, Madrid, Spain; Department of Biochemistry and Genetics, School of Sciences, University of Navarra, Pamplona, Spain
| | - Mattia Boeri
- Department of Experimental Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - John K Field
- The Roy Castle Lung Cancer Research Programme, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Gabriella Sozzi
- Department of Experimental Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Ruben Pio
- Solid Tumors Program, Centro de Investigación Médica Aplicada, Pamplona, Spain; Navarra Institute for Health Research, Pamplona, Spain; CIBERONC, Centro de Investigación Biomédica en Red de Cáncer, Madrid, Spain; Department of Biochemistry and Genetics, School of Sciences, University of Navarra, Pamplona, Spain
| | - Javier J Zulueta
- Department of Pulmonology, Clinica Universidad de Navarra, Pamplona, Spain; Visiongate Inc., Phoenix, Arizona
| | - Avrum Spira
- Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Luis M Montuenga
- Solid Tumors Program, Centro de Investigación Médica Aplicada, Pamplona, Spain; Navarra Institute for Health Research, Pamplona, Spain; CIBERONC, Centro de Investigación Biomédica en Red de Cáncer, Madrid, Spain; Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, Pamplona, Spain.
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Características al diagnóstico y supervivencia de estadios i y ii de cáncer de pulmón. Arch Bronconeumol 2018; 54:420-426. [DOI: 10.1016/j.arbres.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 12/18/2022]
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Rivera MP, Tanner NT, Silvestri GA, Detterbeck FC, Tammemägi MC, Young RP, Slatore CG, Caverly TJ, Boyd CM, Braithwaite D, Fathi JT, Gould MK, Iaccarino JM, Malkoski SP, Mazzone PJ, Tanoue LT, Schoenborn NL, Zulueta JJ, Wiener RS. Incorporating Coexisting Chronic Illness into Decisions about Patient Selection for Lung Cancer Screening. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2018; 198:e3-e13. [DOI: 10.1164/rccm.201805-0986st] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Affiliation(s)
- William C Black
- From the Department of Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756
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Mazzone PJ. COUNTERPOINT: Should Lung Cancer Screening Be Expanded to Persons Who Don't Currently Meet Accepted Criteria Set Forth by the CHEST Guidelines on Lung Cancer Screening? No. Chest 2018; 153:1303-1305. [PMID: 29884251 DOI: 10.1016/j.chest.2018.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 03/14/2018] [Indexed: 12/25/2022] Open
Affiliation(s)
- Peter J Mazzone
- Lung Cancer Program and Lung Cancer Screening Program, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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Fabrikant MS, Wisnivesky JP, Marron T, Taioli E, Veluswamy RR. Benefits and Challenges of Lung Cancer Screening in Older Adults. Clin Ther 2018; 40:526-534. [PMID: 29573852 DOI: 10.1016/j.clinthera.2018.03.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/02/2018] [Accepted: 03/02/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE Lung cancer screening with low-dose computed tomography has been shown to significantly reduce lung cancer-related mortality in high-risk patients. However, patients diagnosed with lung cancer are typically older and often have multiple age- and smoking-related comorbidities. As a result, cancer screening in older adults remains a complex decision, requiring careful consideration of patients' risk characteristics and life expectancy to ensure that the benefits outweigh the risks of screening. In this review, we evaluate the evidence regarding lung cancer screening, with a focus on older patients. METHODS PubMed was searched to identify relevant studies evaluating the clinical outcomes of lung cancer screening. The key words used in our search included non-small cell lung cancer (NSCLC), screening, older, comorbidities, computed tomography, and survival. While we primarily looked for articles specific to older patients, we also focused on subgroup analysis in older patients in larger studies. Finally, we reviewed all relevant guidelines regarding lung cancer screening. FINDINGS Guidelines recommend that lung cancer screening be considered in adults aged 55 to 80 years who are at high risk based on smoking history (ie, 30-pack-year smoking history; having smoked within the past 15 years). Patients who fit these criteria have been shown to have a 20% reduction in lung cancer-related mortality with the use of low-dose computed tomography versus chest radiography. High rates of false-positive results and potential overdiagnoses were also observed. Therefore, screening is generally not recommended in adults with severe comorbidities or short life expectancy, who may experience limited benefit and higher risks with screening. However, several studies have shown a benefit with continued lung cancer screening with appropriate selection of older individuals at the highest risk and with the lowest comorbidities. IMPLICATIONS Older patients experience the highest risk for lung cancer incidence and mortality, and stand to be the most likely to benefit from lung cancer screening. However, careful consideration must be given to higher rates of false-positives and overdiagnosis in this population, as well as tolerability of surgery and competing risks for death from other causes. The appropriate selection of older individuals for lung cancer screening can be greatly optimized by using validated risk-based targeting.
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Affiliation(s)
- Meytal S Fabrikant
- Department of Medicine, Icahn School of Medicine at Mount Sinai Beth Israel, New York, New York.
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas Marron
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emanuela Taioli
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York; Institute of Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rajwanth R Veluswamy
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, New York, New York; Institute of Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Mazzone PJ, Silvestri GA, Patel S, Kanne JP, Kinsinger LS, Wiener RS, Soo Hoo G, Detterbeck FC. Screening for Lung Cancer: CHEST Guideline and Expert Panel Report. Chest 2018; 153:954-985. [PMID: 29374513 DOI: 10.1016/j.chest.2018.01.016] [Citation(s) in RCA: 179] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/20/2017] [Accepted: 01/10/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Low-dose chest CT screening for lung cancer has become a standard of care in the United States in the past few years, in large part due to the results of the National Lung Screening Trial. The benefit and harms of low-dose chest CT screening differ in both frequency and magnitude. The translation of a favorable balance of benefit and harms into practice can be difficult. Here, we update the evidence base for the benefit, harms, and implementation of low radiation dose chest CT screening. We use the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not. METHODS Approved panelists developed key questions using the PICO (population, intervention, comparator, and outcome) format to address the benefit and harms of low-dose CT screening, as well as key areas of program implementation. A systematic literature review was conducted by using MEDLINE via PubMed, Embase, and the Cochrane Library. Reference lists from relevant retrievals were searched, and additional papers were added. The quality of the evidence was assessed for each critical or important outcome of interest using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and ungraded statements were drafted, voted on, and revised until consensus was reached. RESULTS The systematic literature review identified 59 studies that informed the response to the 12 PICO questions that were developed. Key clinical questions were addressed resulting in six graded recommendations and nine ungraded consensus based statements. CONCLUSIONS Evidence suggests that low-dose CT screening for lung cancer results in a favorable but tenuous balance of benefit and harms. The selection of screen-eligible patients, the quality of imaging and image interpretation, the management of screen-detected findings, and the effectiveness of smoking cessation interventions can affect this balance. Additional research is needed to optimize the approach to low-dose CT screening.
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Affiliation(s)
| | - Gerard A Silvestri
- Division of Pulmonary and Critical Care, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | | | - Jeffrey P Kanne
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Linda S Kinsinger
- VHA National Center for Health Promotion and Disease Prevention, Durham, NC
| | - 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
| | - Guy Soo Hoo
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Frank C Detterbeck
- Section of Thoracic Surgery, Department of Surgery, Yale University, New Haven, CT
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Carr LL, Jacobson S, Lynch DA, Foreman MG, Flenaugh EL, Hersh CP, Sciurba FC, Wilson DO, Sieren JC, Mulhall P, Kim V, Kinsey CM, Bowler RP. Features of COPD as Predictors of Lung Cancer. Chest 2018; 153:1326-1335. [PMID: 29452098 DOI: 10.1016/j.chest.2018.01.049] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/09/2018] [Accepted: 01/26/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Lung cancer is a leading cause of death and hospitalization for patients with COPD. A detailed understanding of which clinical features of COPD increase risk is needed. METHODS We performed a nested case-control study of Genetic Epidemiology of COPD (COPDGene) Study subjects with and without lung cancer, age 45 to 80 years, who smoked at least 10-pack years to identify clinical and imaging features of smokers, with and without COPD, that are associated with an increased risk of lung cancer. The baseline evaluation included spirometry, high-resolution chest CT scanning, and respiratory questionnaires. New lung cancer diagnoses were identified over 8 years of longitudinal follow-up. Cases of lung cancer were matched 1:4 with control subjects for age, race, sex, and smoking history. Multiple logistic regression analyses were used to determine features predictive of lung cancer. RESULTS Features associated with a future risk of lung cancer included decreased FEV1/FVC (OR, 1.28 per 10% decrease [95% CI, 1.12-1.46]), visual severity of emphysema (OR, 2.31, none-trace vs mild-advanced [95% CI, 1.41-3.86]), and respiratory exacerbations prior to study entry (OR, 1.39 per increased events [0, 1, and ≥ 2] [95% CI, 1.04-1.85]). Respiratory exacerbations were also associated with small-cell lung cancer histology (OR, 3.57 [95% CI, 1.47-10]). CONCLUSIONS The degree of COPD severity, including airflow obstruction, visual emphysema, and respiratory exacerbations, was independently predictive of lung cancer. These risk factors should be further studied as inclusion and exclusion criteria for the survival benefit of lung cancer screening. Studies are needed to determine if reduction in respiratory exacerbations among smokers can reduce the risk of lung cancer.
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Affiliation(s)
- Laurie L Carr
- Department of Medicine, National Jewish Health, Denver, CO.
| | - Sean Jacobson
- Department of Medicine, National Jewish Health, Denver, CO
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO
| | - Marilyn G Foreman
- Division of Pulmonary and Critical Care, Morehouse School of Medicine, Atlanta, GA
| | - Eric L Flenaugh
- Division of Pulmonary and Critical Care, Morehouse School of Medicine, Atlanta, GA
| | - Craig P Hersh
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA
| | - Frank C Sciurba
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - David O Wilson
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Patrick Mulhall
- Division of Pulmonary and Critical Care Medicine, Temple University Hospital, Philadelphia, PA
| | - Victor Kim
- Division of Pulmonary and Critical Care Medicine, Temple University Hospital, Philadelphia, PA
| | - C Matthew Kinsey
- Division of Pulmonary and Critical Care, University of Vermont College of Medicine, Burlington, VT
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An overview of perioperative considerations in elderly patients for thoracic surgery. Curr Opin Anaesthesiol 2018; 31:1-5. [DOI: 10.1097/aco.0000000000000535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Stokes WA, Bronsert MR, Meguid RA, Blum MG, Jones BL, Koshy M, Sher DJ, Louie AV, Palma DA, Senan S, Gaspar LE, Kavanagh BD, Rusthoven CG. Post-Treatment Mortality After Surgery and Stereotactic Body Radiotherapy for Early-Stage Non-Small-Cell Lung Cancer. J Clin Oncol 2018; 36:642-651. [PMID: 29346041 DOI: 10.1200/jco.2017.75.6536] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose In early-stage non-small cell lung cancer (NSCLC), post-treatment mortality may influence the comparative effectiveness of surgery and stereotactic body radiotherapy (SBRT), with implications for shared decision making among high-risk surgical candidates. We analyzed early mortality after these interventions using the National Cancer Database. Patients and Methods We abstracted patients with cT1-T2a, N0, M0 NSCLC diagnosed between 2004 and 2013 undergoing either surgery or SBRT. Thirty-day and 90-day post-treatment mortality rates were calculated and compared using Cox regression and propensity score-matched analyses. Results We identified 76,623 patients who underwent surgery (78% lobectomy, 20% sublobar resection, 2% pneumonectomy) and 8,216 patients who received SBRT. In the unmatched cohort, mortality rates were moderately increased with surgery versus SBRT (30 days, 2.07% v 0.73% [absolute difference (Δ), 1.34%]; P < .001; 90 days, 3.59% v 2.93% [Δ, 0.66%]; P < .001). Among the 27,200 propensity score-matched patients, these differences increased (30 days, 2.41% v 0.79% [Δ, 1.62%]; P < .001; 90 days, 4.23% v 2.82% [Δ, 1.41%]; P < .001). Differences in mortality between surgery and SBRT increased with age, with interaction P < .001 at both 30 days and 90 days (71 to 75 years old: 30-day Δ, 1.87%; 90-day Δ, 2.02%; 76 to 80 years old: 30-day Δ, 2.80%; 90-day Δ, 2.59%; > 80 years old: 30-day Δ, 3.03%; 90-day Δ, 3.67%; all P ≤ .001). Compared with SBRT, surgical mortality rates were higher with increased extent of resection (30-day and 90-day multivariate hazard ratio for mortality: sublobar resection, 2.85 and 1.37; lobectomy, 3.65 and 1.60; pneumonectomy, 14.5 and 5.66; all P < 0.001). Conclusion Differences in 30- and 90-day post-treatment mortality between surgery and SBRT increased as a function of age, with the largest differences in favor of SBRT observed among patients older than 70 years. These representative mortality data may inform shared decision making among patients with early-stage NSCLC who are eligible for both interventions.
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Affiliation(s)
- William A Stokes
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Michael R Bronsert
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Robert A Meguid
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Matthew G Blum
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Bernard L Jones
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Matthew Koshy
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - David J Sher
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Alexander V Louie
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - David A Palma
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Suresh Senan
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Laurie E Gaspar
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Brian D Kavanagh
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - Chad G Rusthoven
- William A. Stokes, Michael R. Bronsert, Robert A. Meguid, Bernard L. Jones, Laurie E. Gaspar, Brian D. Kavanagh, and Chad G. Rusthoven, University of Colorado School of Medicine, Aurora; Matthew G. Blum, Memorial Hospital, Colorado Springs, CO; Matthew Koshy, University of Chicago School of Medicine, Chicago, IL; David J. Sher, University of Texas Southwestern School of Medicine, Dallas, TX; Alexander V. Louie and David A. Palma, London Health Sciences Centre, London, Ontario, Canada; and Suresh Senan, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
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Ruparel M, Navani N. Young at Heart: Is That Good Enough for Computed Tomography Screening? Am J Respir Crit Care Med 2017; 196:539-541. [PMID: 28806529 DOI: 10.1164/rccm.201707-1504ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Mamta Ruparel
- 1 Lungs for Living Research Centre University College London London, United Kingdom and
| | - Neal Navani
- 2 University College London Hospital London, United Kingdom
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