Lack of Communication Regarding Malignancy Risk in Indeterminate Pulmonary Nodules

Pulmonologists and surgeons do not provide routine quantitative assessment of cancer risk to patients with high-risk indeterminate pulmonary nodules (IPNs) or other clinicians, according to a study published in JAMA Surgery.

The qualitative statements for cancer risk often used in current practice are imprecise and vary greatly, although they do correlate well with Mayo Clinic Model predictions. Therefore, investigators set out to determine whether clinicians document the probability of malignancy in high-risk IPNs and to compare these quantitative or qualitative predictions with the validated Mayo Clinic Model using a single-institution, retrospective cohort study of patients from a tertiary care Department of Veterans Affairs hospital.

Data used were collected from January 1, 2003 through December 31, 2015. The study included 2 cohorts: the first comprised 291 veterans who underwent surgical resection for known or suspected lung cancer and the second included a random sample of 239 veterans undergoing inpatient or outpatient pulmonary evaluation of IPNs at the hospital.

Cancer prevalence in the first cohort was 88.7% vs 48.9% in the second cohort. Only 4.5% of patients in the first cohort and 1.3% of those in second cohort had a documented quantitative prediction of cancer before tissue diagnosis, whereas 78.1% in the first cohort and 63.1% in the second cohort had qualitative statements of cancer risk.

The authors argued that qualitative risk statements of malignancy for IPNs are imprecise, highly variable, and should be replaced by a standard scale that correlates with predicted risk for cancer.

However, they also noted that as the study was limited to a single facility, the findings may not be broadly generalizable. Data regarding the primary surgical procedure performed and complete staging were also lacking. Selection bias may have occurred in the first cohort, as these patients were already being referred to the surgical clinic.

Reference

Maiga AW, Deppen SA, Massion PP, et al. Communication about the probability of cancer in indeterminate pulmonary nodules [published online December 20, 2017]. JAMA Surg. doi:10.1001/jamasurg.2017.4878