Integrated, Multidisciplinary Management of Pulmonary Nodules Can Streamline Care and Improve Adherence to Recommendations

Early Detection and Interception of Lung Cancer

Recent advances in lung cancer treatment have led to dramatic improvements in 5-year survival rates. And yet, lung cancer remains the leading cause of cancer-related mortality, in large part, because it is often diagnosed at an advanced stage, when cure is no longer possible. Lung cancer screening (LCS) is essential for intercepting the disease at an earlier stage. Unfortunately, LCS has been poorly adopted in the United States, with less than 5% of eligible patients being screened nationally. This article will describe the data supporting LCS, the obstacles to LCS implementation, and the promising opportunities that lie ahead.

Incidental pulmonary nodules - current guidelines and management

BACKGROUND

 Due to the greater use of high-resolution cross-sectional imaging, the number of incidental pulmonary nodules detected each year is increasing. Although the vast majority of incidental pulmonary nodules are benign, many early lung carcinomas could be diagnosed with consistent follow-up. However, for a variety of reasons, the existing recommendations are often not implemented correctly. Therefore, potential for improvement with respect to competence, communication, structure, and process is described.

METHODS

 This article presents the recommendations for incidental pulmonary nodules from the current S3 guideline for lung cancer (July 2023). The internationally established recommendations (BTS guidelines and Fleischner criteria) are compared and further studies on optimized management were included after a systematic literature search in PubMed.

RESULTS AND CONCLUSION

 In particular, AI-based software solutions are promising, as they can be used in a support capacity on several levels at once and can lead to simpler and more automated management. However, to be applicable in routine clinical practice, software must fit well into the radiology workflow and be integrated. In addition, "Lung Nodule Management" programs or clinics that follow a high-quality procedure for patients with incidental lung nodules or nodules detected by screening have been established in the USA. Similar structures might also be implemented in Germany in a future screening program in which patients with incidental pulmonary nodules could be included.

KEY POINTS

  · Incidental pulmonary nodules are common but are often not adequately managed. · The updated S3 guideline for lung cancer now includes recommendations for incidental pulmonary nodules. · Competence, communication, structure, and process levels offer significant potential for improvement.

CITATION FORMAT

· Glandorf J, Vogel-Claussen J, . Incidental pulmonary nodules - current guidelines and management. Fortschr Röntgenstr 2024; 196: 582 - 590.

Multidisciplinary virtual management of pulmonary nodules

INTRODUCTION AND OBJECTIVES

Multidisciplinary nodule clinics provide high-quality care and favor adherence to guidelines. Virtual care has shown savings benefits along with patient satisfaction. Our aim is to describe the first year of operation of a multidisciplinary virtual lung nodule clinic, the population evaluated and issued decisions. Secondarily, among discharged patients, we aimed to analyze their follow-up prior to the existence of our consultation, evaluating its adherence to guidelines.

MATERIALS AND METHODS

Observational study including all patients evaluated at the Virtual Lung Nodule Clinic (VLNC) (March 2018- March 2019). Clinical and radiological data were recorded. Recommendations, based on 2017 Fleischner Society guidelines, were categorized into follow-up, discharge or referral to lung cancer consultation. Discharged patients were classified according to adherence to guidelines of their previous management, into adequate, prolonged and non-indicated follow-up.

RESULTS

A total of 365 patients (58.9% men; median age 64.0 years) were included. Sixty-four percent had smoking history and 23% had chronic obstructive pulmonary disease (COPD). Most nodules were solid (87.4%) and multiple (57.5%). The median diameter was 6.00 mm. 43.8% of patients were discharged following first VLNC evaluation. Among them, 27.5% had received appropriate follow-up, but 66.9% had received poor management. Patients with prolonged follow-up (33.1%) were older (67.0 vs 60.5 years) and had larger nodules (6.00 mm vs 5.00). Non-indicated follow-up patients (33.8%) were more non-smokers (77.8% vs 31.8%) and presented smaller nodules (4.00 vs 5.00 mm).

CONCLUSIONS

During its first year of operation, the VLNC has evaluated a population with a relevant risk profile for lung cancer development, management of which should be cautious and adhere to guidelines. After the first VLNC assessment, approximately one-half of this population was discharged. It was noticeable that previous follow-up of discharged patients was found poorly adherent to guidelines, with a marked tendency to overmanagement.

Cone-beam CT imaging for robotic navigation bronchoscopy

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Barriers to Timely Lung Cancer Care in Early Stage Non-Small Cell Lung Cancer and Impact on Patient Outcomes

BACKGROUND

Optimal time to treatment for early-stage lung cancer is uncertain. We examined causes of delays in care for Veterans who presented with early-stage non-small cell lung cancer (NSCLC) and whether workup time was associated with increased upstaging or all-cause mortality.

METHODS

We performed a retrospective analysis of Veterans referred to our facility with radiographic stage I or II NSCLC between January 2013 to December 2017, with follow-up through October 2021. Patient demographics, tumor characteristics, time intervals of care, and reasons for delays were collected. Guideline concordance (GC) was defined as treatment within 14 weeks of abnormal image. Multivariable analyses were performed to determine association between delays in care, survival, and upstaging.

RESULTS

Data from 203 Veterans were analyzed. Median time between abnormal imaging to treatment was 17.7 weeks (IQR 12.7-26.6). Only 33% of Veterans received GC care. Most common patient-related delays were: intercurrent hospitalization/comorbidity (23%), no-shows (16%) and inability to reach Veteran (17%). Most common system-related delay: lack of scheduling availability (25%). Delays associated with upstaging: transportation issues, request for coordination of appointments, and unforeseen appointment changes. Rates of upstaging did not differ between GC and discordant groups (P = .6). GC care was not an independent predictor of mortality. Post-hoc, treatment within 8 weeks was associated with lower rates of upstaging (P = .05).

CONCLUSION

Although GC care did not impact survival or upstaging for early-stage NSCLC, shorter timeframes may be beneficial. Modifiable delays in care exist which may be addressed at an institutional level to improve timeliness of care.

Program-Based Lung Cancer Care: A Prospective Observational Tumor Registry Linkage Study

Introduction

Low-dose computed tomography screening (LDCT) and lung nodule programs (LNP) promote early lung cancer detection, improve survival; Multidisciplinary Care Programs (MDC) promote guideline-concordant care. The impact of such program-based care on "real-world" lung cancer survival is unquantified. We evaluated outcomes of lung cancer care delivered through structured programs in a community health care system.

Methods

We conducted a cohort study linking institutional prospective observational LDCT, LNP and MDC databases with Tumor Registry of Baptist Cancer Center facilities. We categorized all patients diagnosed with lung cancer between 2011 and 2021 into program-based care versus non-program-based care cohorts. We compared patient characteristics, stage distribution, treatment modalities, survival and mortality in each pathway of care.

Results

Of 12,148 patients, 237, 1,165, 1,140 and 9,606 were diagnosed through the LDCT, LNP, MDC or no program, respectively; non-program-based care sequentially diminished from 96.3% to 66.5%, diagnosis through LDCT increased from 0.5% to 7.1%, LNP from 3.5% to 20.8%; and MDC alone decreased from a high of 12.8% in 2014 to 5.6% in 2021. Program-based care was associated with earlier stage (p < 0.001), higher surgical resection rates (p < 0.001), greater use of adjuvant therapy (p < 0.001), better aggregate and stage-stratified survival (p < 0.001), and lower all-cause and lung cancer-specific mortality (p < 0.001). Recipients of non-program-based care were considerably less likely to receive lung cancer treatment; results remained consistent when patients receiving no treatment were excluded.

Conclusions

Program-based care was associated with substantially better survival. Increasing access to program-based care should be explored as a matter of urgent public policy.

Assessing the impact of socioeconomic status on incidental lung nodules at an urban safety net hospital

INTRODUCTION

Lower socioeconomic status has been identified as an emerging risk factor for health disparities, including lung cancer outcomes. Most research investigating these outcomes includes patients from formal lung cancer screening programs. There is a paucity of studies assessing the relationship between socioeconomic status and incidental lung nodules. This study aimed to investigate the association between socioeconomic status and the size of incidental lung nodules on initial presentation at an urban safety net hospital, which did not have a formal lung cancer screening program or incidental lung nodule program.

METHODS

A retrospective chart review was conducted on patients with incidental lung nodules on CT chest imaging who were referred from primary care to a pulmonology clinic at a safety net hospital. Patients with incomplete nodule characteristics information were excluded. Data on demographics, comorbidities, smoking history, insurance type, immigration status, and geographical factors were collected. Less commonly studied determinants such as crime index, cost of living, and air quality index were also assessed. Logistic regression analysis was performed to assess relationships between nodule size and socioeconomic determinants.

RESULTS

Out of 3,490 patients with chest CT scans, 268 patients with ILNs were included in the study. 84.7% of patients represented racial or ethnic minorities, and most patients (67.8%) had federal insurance. Patients with non-commercial insurance were more likely to have larger, inherently higher-risk nodules (> 8 mm) compared to those with commercial insurance (OR 2.18, p 0.01). Patients from areas with higher unemployment rates were also less likely (OR 0.75, p 0.04) to have smaller nodules (< 6 mm). Patients representing racial or ethnic minorities were also more likely to have nodules > 8 mm (OR 1.6, p 0.24), and less likely to have nodules < 6 mm (OR 0.6, p 0.32), however, these relationships were not statistically significant.

CONCLUSION

This study found that lower socioeconomic status, indicated by having non-commercial insurance, was associated with larger incidental lung nodule size on initial presentation. While it is established that socioeconomic status is associated with disparities in lung cancer screening, these findings suggest that inequalities may also be present in those with incidental lung nodules. Further research is needed to understand the underlying mechanisms and develop interventions to address these disparities in incidental lung nodule evaluation and improve outcomes.

High risk lung nodule: A multidisciplinary approach to diagnosis and management

Pulmonary nodules are often discovered incidentally during CT scans performed for other reasons. While the vast majority of nodules are benign, a small percentage may represent early-stage lung cancer with the potential for curative treatments. With the growing use of CT for both clinical purposes and lung cancer screening, the number of pulmonary nodules detected is expected to increase substantially. Despite well-established guidelines, many nodules do not receive proper evaluation due to a variety of factors, including inadequate coordination of care and financial and social barriers. To address this quality gap, novel approaches such as multidisciplinary nodule clinics and multidisciplinary boards may be necessary. As pulmonary nodules may indicate early-stage lung cancer, it is crucial to adopt a risk-stratified approach to identify potential lung cancers at an early stage, while minimizing the risk of harm and expense associated with over investigation of low-risk nodules. This article, authored by multiple specialists involved in nodule management, delves into the diagnostic approach to lung nodules. It covers the process of determining whether a patient requires tissue sampling or continued surveillance. Additionally, the article provides an in-depth examination of the various biopsy and therapeutic options available for malignant lung nodules. The article also emphasizes the significance of early detection in reducing lung cancer mortality, especially among high-risk populations. Furthermore, it addresses the creation of a comprehensive lung nodule program, which involves smoking cessation, lung cancer screening, and systematic evaluation and follow-up of both incidental and screen-detected nodules.

Establishing a Pulmonary Nodule Clinic Service for Early Diagnosis of Lung Cancer - Review of International Options and Considerations for Greece

Early diagnosis of lung cancer in pulmonary nodules identified by computed tomography (CT) may be critical in reducing the epidemiological burden of the disease, particularly in countries where such a burden is considerably high and risk factors for lung cancer very prevalent. The establishment and operation of pulmonary nodule clinics (PNCs), ie, multidisciplinary services that watch and evaluate nodules found through deliberate screening efforts or as incidental findings, is increasingly becoming a key tool to implement such early-intervention, cancer-risk management policies elsewhere in the world. This review aims to research and present in a structured manner findings from published sources on options and considerations for setting up a PNC in a country such as Greece. These refer to the type of services a PNC would provide to optimize diagnosis of suspect pulmonary nodules, its structure and organization, including processes, human resources and technology infrastructure, its target audience, ie, who would be eligible to use its services, and the expected outcomes of its operation, in terms of a set of key performance indicators. Our review also revealed critical key success factors that should be considered when designing the introduction of a PNC in a health care setting, including optimal referral pathways, aligned clinical decision making and patient preferences and participation/empowerment. Our findings may inform health care systems with a high lung cancer burden and no available PNC service on options and considerations before introducing such a service in their respective settings.

Surgical Evaluation in Patients Undergoing Radiation Therapy for Early-Stage Lung Cancer

BACKGROUND

Stereotactic body radiation therapy (SBRT) is used to treat stage I non-small cell lung cancer (NSCLC) in nonsurgical candidates, although guidelines specify that inoperability be determined in multidisciplinary fashion. We characterized NSCLC patients treated with SBRT undergoing thoracic surgical evaluation (TSUe) and quantified TSUe's impact on time to treatment, receipt of diagnostic staging procedures, and health care costs.

METHODS

Adults with newly diagnosed NSCLC undergoing SBRT were identified in the MarketScan all-payer claims database (2014-2018). TSUe was defined as an outpatient encounter with a thoracic surgeon or multispecialty group. Time to treatment and total costs in the 6 months preceding treatment were examined using multivariable regression by receipt of TSUe, adjusting for demographic and clinical factors.

RESULTS

Of 1894 patients, 36.3% (n = 687) underwent TSUe. Compared with patients without TSUe, these patients were younger (mean age, 73.6 vs 76.3 years) and more likely to undergo invasive biopsy/staging procedures (90% vs 82%) or pulmonary function testing (80.6% vs 69.5%). Patients undergoing TSUe had a median time to treatment of 64 days (interquartile range, 43-98 days), compared with 44 days (interquartile range, 29-70 days) for no TSUe. Adjusted time to treatment was 43% longer (incident rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001) with TSUe. Patients undergoing TSUe also incurred 30% higher costs (adjusted cost ratio, 1.30; 95% CI, 1.20-1.41; P < .001).

CONCLUSIONS

Among patients with early-stage NSCLC undergoing SBRT as primary treatment, a minority are evaluated by a thoracic surgeon. Because they have a longer time to treatment, more invasive diagnostic procedures, and higher costs, this represents a targetable gap to make workup protocols more efficient.

Effectiveness of mind-body exercise via Baduanjin on physical and psychological outcomes in patients with pulmonary ground-glass nodules: A non-randomized controlled pilot study

BACKGROUND

With the increasing incidence and mortality of lung cancer, ground-glass nodules (GGNs) have become an ongoing public health concern. In clinical practice, the physical and psychological distress of GGN patients is easy to overlook during the follow-up after diagnosis. Such patients typically have limited medical options and few of these options involve mind-body exercises.

OBJECTIVE

The purpose of this pilot study was to explore the effectiveness of the mind-body exercise Baduanjin on physical and psychological outcomes among GGN patients.

DESIGN

We conducted a prospective, non-randomized, controlled, assessor-blinded trial (ClinicalTrials.gov: NCT03420885).

SETTING

This trial was conducted at three medical sites, both located in Shanghai, China, between April 2017 and January 2020.

PARTICIPANTS

Patients with GGN.

INTERVENTION

Sixty GGN participants were divided into a health education control group only receiving health education (n = 30) and a Baduanjin intervention group receiving health education plus a Baduanjin training program (n = 30). Both groups were treated for 16 weeks.

OUTCOME MEASUREMENTS

Outcomes were assessed at baseline and week 16. The primary outcomes included pulmonary function (FVC, FVC%, FEV₁, FEV₁/FVC, PEF) and psychological condition (SAS score, SDS score). The secondary outcome was quality of life (SF-36).

RESULTS

Compared with the health education control group, the Baduanjin intervention group had significant improvements in pulmonary function (FVC, FVC%, FEV₁), psychological outcomes (SAS score, SDS score), and quality of life (SF-36). The significant differences in pre-intervention and post-intervention between groups were as follows: FVC (MD = 0.21, 95%CI: 0.10 to 0.33, P = 0), FVC% (MD = 6.90, 95%CI: 3.10 to 10.70, P = 0.001), FEV₁ (MD = 0.18, 95%CI: 0.07 to 0.29, P = 0.001); SAS score (MD = -4.90, 95%CI: -8.28 to -1.52, P = 0.005), SDS score (MD = -5.83, 95%CI: -9.46 to -2.21, P = 0.002); physical component summary (PCS) of SF-36 (MD = 5.03, 95%CI: 2.54 to 7.51, P = 0), mental component summary (MCS) of SF-36 (MD = 5.78, 95%CI: 2.64 to 8.92, P = 0.001). Linear regression analysis was performed to study the influence of confounder variables on the improvements of primary outcomes, and no significant change was found. Moreover, Pearson correlation coefficient analysis demonstrated that ameliorations in lung function (FVC, FVC%, FEV₁, FEV₁/FVC, and PEF) were significantly associated with a decrease in anxious symptoms and depressive symptoms.

CONCLUSION

GGN patients in the Baduanjin intervention group showed greater benefits in pulmonary function and psychological outcomes than those in the health education control group, and the effectiveness was stable. The findings support Baduanjin as an effective, safe, enjoyable, and promising complementary intervention for management of GGN in patients with physical and psychological distress.

Incidental Pulmonary Nodules - What Do We Know in 2022

Lung cancer (LC) is the leading cause of cancer-related mortality worldwide, and early LC diagnosis can significantly improve outcomes and survival rates in affected patients. Implementation of LC screening programs using low-dose computed tomography CT in high-risk subjects aims to detect LC as early as possible, but so far, adoption of screening programs into routine clinical care has been very slow. In recent years, the use of CT has significantly increased the rate of incidentally detected pulmonary nodules. Although most of those incidental pulmonary nodules (IPNs) are benign, some of them represent early-stage LC. Given the large number of IPNs detected in the range of several millions each year, this represents an additional, maybe even larger, opportunity to drive stage shift in LC diagnosis, next to LC screening programs. Comprehensive evaluation and targeted work-up of IPNs are mandatory to identify the malignant nodules from the crowd, and several guidelines provide radiologists and physicians' guidance on IPN assessment and management. However, IPNs still seem to be inadequately processed due to various reasons including insufficient reporting in the radiological report, missing communication between stakeholders, absence of patient tracking systems, and uncertainty regarding responsibilities for the IPN management. In recent years, several approaches such as lung nodule programs, patient tracking software, artificial intelligence, and communication software were introduced into clinical practice to address those shortcomings. This review evaluates the current situation of IPN management and highlights recent developments in process improvement to achieve first steps toward stage shift in LC diagnosis.

Clinical value of CT-guided biopsy of small (≤1.5 cm) suspicious lung nodules: Diagnostic accuracy, molecular characterization and long-term clinical outcomes

Small pulmonary nodules (≤1.5 cm) are frequently detected on routine chest imaging and lung cancer screening studies. Our goal was to determine the clinical value of CT-guided core needle biopsy (CNB) in the evaluation of such nodules. In this single-center study, we retrospectively analyzed patient data (n = 44) for CNBs on lung nodules (≤1.5 cm) performed at our biopsy center between May 2017 and March 2020. We analyzed for the rate of pathology diagnosis, molecular/biomarker analysis, complications, and change in clinical management and outcome over a period ranging up to 60 months after biopsy. A pathology diagnosis of malignancy or benign lesion was obtained in 97.9% of biopsies in this cohort. The rate of complications was low with only 6.8% of patients requiring the insertion of a temporary small profile interventional radiology (IR) pigtail chest tube for pneumothorax. Out of the subset of biopsy specimens that were sent for tissue molecular analysis, 90% had enough tissue preserved after initial pathological analysis to obtain at least one molecular marker. Our data show that CT-guided CNB is safe and reliable, and should be considered for the evaluation of small, suspicious lung nodules found on routine screenings for the early detection and evaluation of malignant lesions.

Incidence of Radiation Therapy Among Patients Enrolled in a Multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic

IMPORTANCE

The number of pulmonary nodules discovered incidentally or through screening programs has increased markedly. Multidisciplinary review and management are recommended, but the involvement of radiation oncologists in this context has not been defined.

OBJECTIVE

To assess the role of stereotactic body radiation therapy among patients enrolled in a lung cancer screening program.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study was performed at a pulmonary nodule and lung cancer screening clinic from October 1, 2012, to September 31, 2019. Referrals were based on chest computed tomography with Lung Imaging Reporting and Data System category 4 finding or an incidental nodule 6 mm or larger. A multidisciplinary team of practitioners from radiology, thoracic surgery, pulmonology, medical oncology, and radiation oncology reviewed all nodules and coordinated workup and treatment as indicated.

EXPOSURES

Patients referred to the pulmonary nodule and lung cancer screening clinic with an incidental or screen-detected pulmonary nodule.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of patients undergoing therapeutic intervention with radiation therapy, stratified by the route of detection of their pulmonary nodules (incidental vs screen detected). Secondary outcomes were 2-year local control and metastasis-free survival.

RESULTS

Among 1150 total patients (median [IQR] age, 66.5 [59.3-73.7] years; 665 [57.8%] female; 1024 [89.0%] non-Hispanic White; 841 [73.1%] current or former smokers), 234 (20.3%) presented with screen-detected nodules and 916 (79.7%) with incidental nodules. For patients with screen-detected nodules requiring treatment, 41 (17.5%) received treatment, with 31 (75.6%) undergoing surgery and 10 (24.4%) receiving radiation therapy. Patients treated with radiation therapy were older (median [IQR] age, 73.8 [67.1 to 82.1] vs 67.6 [61.0 to 72.9] years; P < .001) and more likely to have history of tobacco use (67 [95.7%] vs 128 [76.6%]; P = .001) than those treated with surgery. Fifty-eight patients treated with radiation therapy (82.9%) were considered high risk for biopsy, and treatment recommendations were based on a clinical diagnosis of lung cancer after multidisciplinary review. All screened patients who received radiation therapy had stage I disease and were treated with stereotactic body radiation therapy. For all patients receiving stereotactic body radiation therapy, 2-year local control was 96.3% (95% CI, 91.1%-100%) and metastasis-free survival was 94.2% (95% CI, 87.7%-100%).

CONCLUSIONS AND RELEVANCE

In this unique prospective cohort, 1 in 4 patients with screen-detected pulmonary nodules requiring intervention were treated with stereotactic body radiation therapy. This finding highlights the role of radiation therapy in a lung cancer screening population and the importance of including radiation oncologists in the multidisciplinary management of pulmonary nodules.

Factors affecting the rates of adherence to surveillance recommendations for incidental pancreatic cystic lesions in a large urban safety net hospital

Background

Pancreatic cystic lesions (PCLs) are a heterogenous group of lesions with varying degrees of malignant potential. PCLs are often incidentally detected on imaging. Management for patients without an immediate indication for resection or tissue sampling entails radiographic surveillance to assess for features concerning for malignant transformation. This study aims to determine the rates of adherence to surveillance recommendations for incidental PCLs, and identify factors associated with adherence or loss of follow-up.

Methods

We conducted a single-centre retrospective study of patients at a tertiary safety net hospital with incidentally discovered asymptomatic PCLs. Follow-up was defined as having undergone repeat imaging as recommended in the radiology report. Data were analysed using logistic regression.

Results

Within our cohort (n=172), 123 (71.5%) subjects completed follow-up imaging. Attending a gastroenterology appointment was most strongly associated with completing follow-up for PCLs and remained significant (p=0.001) in a multivariate logistic regression model. Subjects without a documented primary care provider were less likely to have follow-up (p=0.028). Larger cyst size was associated with completion of follow-up in univariate only (p=0.067).

Conclusion

We found that follow-up of an incidentally discovered PCLs was completed in the majority of our subjects. Incomplete follow-up for PCLs occurred in up to one in three to four patients in our cohort. Access to primary care and utilisation of subspecialty gastroenterology care are associated with completion of follow-up for PCLs. If validated, our findings can guide potential interventions to improve follow-up rates for PCLs.

Status of Multidisciplinary Collaboration in Neonatal Cardiac Care in the United States

While outcomes for neonates with congenital heart disease have improved, it is apparent that substantial variability exists among centers with regard to the multidisciplinary approach to care for this medically fragile patient population. We endeavored to understand the landscape of neonatal cardiac care in the United States. A survey was distributed to physicians who provide neonatal cardiac care in the United States regarding (1) collaborative efforts in care of neonates with congenital heart disease (CHD); (2) access to neonatal cardiac training; and (3) barriers to the implementation of protocols for neonatal cardiac care. Responses were collected from 10/2018 to 6/2019. We received responses from 172 of 608 physicians (28% response rate) from 89 centers. When compared to responses received from physicians at low-volume centers (< 300 annual bypass cases), those at high-volume centers reported more involvement from the neurodevelopmental teams (58% vs. 29%; P = 0.012) and a standardized transition to outpatient care (68% vs. 52%; P = 0.038). While a majority of cardiothoracic surgery and anesthesiology respondents reported multidisciplinary involvement, less than half of cardiology and neonatology supported this statement. The most commonly reported obstacles to multidisciplinary engagement were culture (61.6%) and logistics (47.1%). Having a standardized neonatal cardiac curriculum for neonatal fellows was positively associated with the perception that multidisciplinary collaboration was "always" in place (53% vs. 40%; P = 0.09). There is considerable variation among centers in regard to personnel involved in neonatal cardiac care, related education, and perceived multidisciplinary collaboration among team members. The survey findings suggest the need to establish concrete standards for neonatal cardiac surgical programs, with ongoing quality improvement processes.

Exploring Ways to Improve Access to and Minimize Risk from Lung Cancer Screening

Despite ample evidence of benefit, adoption of lung cancer screening efforts remains low. This commentary focuses on current efforts to improve awareness of the benefits of lung cancer screening and the available screening programs.

Development and outcomes of a comprehensive multidisciplinary incidental lung nodule and lung cancer screening program

BACKGROUND

Appropriate management of lung nodules detected incidentally or through lung cancer screening can increase the rate of early-stage diagnoses and potentially improve treatment outcomes. However, the implementation and management of comprehensive lung nodule programs is challenging.

METHODS

This single-center, retrospective report describes the development and outcomes of a comprehensive lung nodule program at a community practice in Tennessee. Computed tomography (CT) scans potentially revealing incidental lung nodules were identified by a computerized search. Incidental or screening-identified lung nodules that were enlarging or not seen in prior scans were entered into a nodule database and guideline-based review determined whether to conduct a diagnostic intervention or radiologic follow-up. Referral rates, diagnosis methods, stage distribution, treatment modalities, and days to treatment are reported.

RESULTS

The number of patients with lung nodules referred to the program increased over 2 years, from 665 patients in Year 1 to 745 patients in Year 2. Most nodules were incidental (62-65%). Nodules identified with symptoms (15.2% in Year 1) or through screening (12.6% in Year 1) were less common. In Year 1, 27% (182/665) of nodules required a diagnostic intervention and 18% (121/665) were malignant. Most diagnostic interventions were image-guided bronchoscopy (88%) or percutaneous biopsy (9%). The proportion of Stage I-II cancer diagnoses increased from 23% prior to program implementation to 36% in Year 1 and 38% in Year 2. In screening cases, 71% of patients completed follow-up scans within 18 months. Only 2% of Year 1 patients under watchful waiting required a diagnostic intervention, of which 1% received a cancer diagnosis.

CONCLUSIONS

The current study reports outcomes over the first 2 years of a lung cancer screening and incidental nodule program. The results show that the program was successful, given the appropriate level of data management and oversight. Comprehensive lung nodule programs have the potential to benefit the patient, physician, and hospital system.

Patient-Centered, Guideline-Concordant Discussion and Management of Pulmonary Nodules

Providing guideline-concordant management of pulmonary nodules can present challenges when a patient's anxiety about cancer or fear of invasive procedures colors judgment. The way in which providers discuss and make decisions about how to evaluate a pulmonary nodule can affect patient satisfaction, distress, and adherence to evaluation. This article discusses the complexity of tailoring patient-provider communication, decision-making, and implementation of guidelines for pulmonary nodule evaluation to the individual patient, emphasizing the importance of how information is conveyed and the value of listening to and addressing patients' concerns. We summarize the relevant guideline recommendations and literature, and provide two case scenarios to illustrate a patient-centered approach to discussing and managing pulmonary nodules from our perspectives as a pulmonologist and thoracic surgeon.