Evaluating Pulmonary Nodules for Cancer: Patients May Receive Too Much, Too Little Care

Renda Soylemez Wiener, MD, MPH Assistant Professor of Medicine The Pulmonary Center Boston University School of Medicine Center for Healthcare Organization & Implementation Research Edith Nourse Rogers Memorial VA HospitalMedicalResearch.com Interview with:
Renda Soylemez Wiener, MD, MPH
Assistant Professor of Medicine
The Pulmonary Center
Boston University School of Medicine
Center for Healthcare Organization & Implementation Research
Edith Nourse Rogers Memorial VA Hospital

MedicalResearch.com: What are the main findings of the study?

Dr. Soylemez Wiener: The main finding is that evaluation of pulmonary nodules to determine whether or not they are cancerous is inconsistent with clinical practice guideline recommendations in almost half of cases, suggesting there is room for improvement in clinical care of these patients. Patients with pulmonary nodules are sometimes evaluated more aggressively than they should be (18%), which can cause harms to patients from unnecessary invasive tests (biopsies or surgery) or unneeded radiation exposure from imaging studies. Still more patients (27%) are followed less aggressively than they should be, which in the worst case scenario could lead to delays in the diagnosis and treatment of cancer. It is particularly important to improve care of these patients now, because new guidelines from the US Preventive Services Task Force recommend CT screening for lung cancer screening, which often finds pulmonary nodules that require evaluation.

MedicalResearch.com: Were any of the findings unexpected?

Dr. Soylemez Wiener: I was surprised that almost half of patients with a pulmonary nodule received care that was inconsistent with guidelines. I was also surprised by the extent of overevaluation we observed in some cases, with some patients with very small nodules subjected to testing for years for an incidentally detected radiographic finding with a very low likelihood of cancer. Unfortunately, I was not surprised that many patients with pulmonary nodules received underevaluation. Given how many pulmonary nodules are detected with today’s highly sensitive CT scans, it is difficult to ensure all patients receive appropriate evaluation unless there are systems in place to track patients with pulmonary nodules.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Soylemez Wiener: It is important for clinicians and patients alike to recognize that there is a real gap between care that is currently being delivered to patients with pulmonary nodules and what clinical practice guidelines consider optimal care. I would like both clinicians and patients to understand the harms that inappropriate evaluation of pulmonary nodules can cause, including both harms of overly aggressive evaluation (unneeded radiation exposure with the associated risk of radiation-induced tumors, physical complications from unnecessary biopsies and surgeries) and harms of under-evaluation (potential for delays in cancer diagnosis and treatment). Part of the solution will be drawing attention to the fact that a problem exists, which may prompt clinicians to be more attentive to nodule evaluation and to educate patients about the importance of adherence to evaluation. Clinicians should educate patients about what a pulmonary nodule is, the likelihood of cancer, and what the evaluation process will entail. If patients understand the process better and why it is important, I believe they will be more likely to follow through with the necessary testing and advocate for themselves.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Soylemez Wiener: I believe our work makes it clear that systems must be implemented to improve quality of care of pulmonary nodule evaluation. For example, in some cases, there were delays in evaluation because of failures of communication between providers (such as the primary care provider not being informed of a pulmonary nodule that was detected during a hospitalization or on a pre-operative chest x-ray). In other cases, radiologists recommended evaluation strategies that were not consistent with guideline recommendations, and the treating clinician simply followed the radiologist’s recommendations. A logical next step for future research is to study the impact of different systems designed to improve pulmonary nodule evaluation. Some possible quality improvement strategies to be tested include better flagging of clinicians when a nodule is identified, templated radiographic reporting of pulmonary nodules that include a summary of relevant guideline recommendations, registries to track patients with pulmonary nodules to make sure they are receiving evaluation in a timely fashion, improved communication and educational materials explaining to patients what pulmonary nodules are and why it is important to complete the evaluation process, and dedicated nurse coordinators to facilitate evaluation of patients with pulmonary nodules

Citation:

Resource Use and Guideline Concordance in Evaluation of Pulmonary Nodules for Cancer: Too Much and Too Little Care

Wiener R, Gould MK, Slatore CG, Fincke BG, Schwartz LM, Woloshin S. Resource Use and Guideline Concordance in Evaluation of Pulmonary Nodules for Cancer: Too Much and Too Little Care. JAMA Intern Med. 2014;():. doi:10.1001/jamainternmed.2014.561