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Is the result same? More intensive examination should be performed to diagnose an incidentally detected lung nodule? (Report from JAMA)

[2021.02.21]

Lung Nodules (round shadows in the lungs) may be found in lung cancer screening by chest X-ray or CT scan.  If a nodule is found in your lung and you receive the result that you need to have a reexamination, you must be worried that you finally have lung cancer.  With this result, you may want to go to the hospital for a variety of tests.  

Even if the doctor tells you that you don't need to take so many tests, you can't help but want to look for the other doctors who do more tests.

But, what if the results are the same whether you have many tests or the minimum number of tests?  The more tests you have, the more it will cost, the more radiation exposure you will have, and the more complications you will have.  Would you be able to justify the cost as a peace of mind?

 

The article here is a retrospective study, and the level of evidence is not high enough to draw any conclusions.  However, it is difficult to conduct prospective randomized controlled studies in this area.  Because, It is difficult to obtain patients' consent for a study to see if there is any difference in lung cancer progression between many examination groups and no examination groups.  And so, I think it is difficult to create further evidence in this area.

 

This study showed that there was no significant difference in the stage of lung cancer found two years later whether lung nodules found by screening were intensively examined or not.

This means that while intensive examination may help find lung cancer earlier, but it is possible to find the same stage of lung cancer within two years without intensive evaluation.

In my personal opinion, I do not recommend that all people with lung nodules undergo intensive testing.  However, what kind of pulmonary nodules (nodule characteristics) warrant intensive evaluation including surgery, follow-up, or even no follow-up has always been a vexing question and will be a future challenge (perhaps an eternal challenge).

 

written by the director of the Okino Medical Clinic, a Pulmonologist, M.D., Ph.D.

 

Original Investigation

Association of the Intensity of Diagnostic Evaluation With Outcomes in Incidentally Detected Lung Nodules 

JAMA Intern Med. Published online January 19, 2021. 

doi:10.1001/jamainternmed.2020.8250

 

Key Points

Question  Is the intensity of the diagnostic evaluation of incidentally detected lung nodules associated with patient outcomes and health expenditures?

Findings  In this comparative effectiveness research study of 5057 individuals with an incidentally detected lung nodule, evidence of an association between evaluation intensity and lung cancer stage distribution was inconclusive. Compared with guideline-concordant evaluations, less intensive evaluations were associated with less radiation exposure, fewer procedure-related adverse events, and lower health expenditures, whereas more intensive evaluations were associated with greater radiation exposure, more procedure-related adverse events, and higher health expenditures.

Meaning  Findings from this study underscore the need to increase the level of evidence that supports current guideline recommendations and to decrease unnecessarily intensive diagnostic evaluations of lung nodules.

 

Abstract

Importance  Whether guideline-concordant lung nodule evaluations lead to better outcomes remains unknown.

Objective  To examine the association between the intensity of lung nodule diagnostic evaluations and outcomes, safety, and health expenditures.

Design, Setting, and Participants  This comparative effectiveness research study analyzed health plan enrollees at Kaiser Permanente Washington in Seattle, Washington, and Marshfield Clinic in Marshfield, Wisconsin, with an incidental lung nodule detected between January 1, 2005, and December 31, 2015. Included patients were 35 years or older, had no high suspicion of infection, had no history of malignant neoplasm, and had no evidence of advanced lung cancer on nodule detection. Data analysis was conducted from January 7 to August 19, 2020.

Exposures  With the 2005 Fleischner Society guidelines (selected for their applicability to the time frame under investigation) as the comparator, 2 other intensities of lung nodule evaluation were defined. Guideline-concordant evaluation followed the guidelines. Less intensive evaluation was the absence of recommended testing, longer-than-recommended surveillance intervals, or less invasive testing than recommended. More intensive evaluation consisted of testing when the guidelines recommended no further testing, shorter-than-recommended surveillance intervals, or more invasive testing than recommended.

Main Outcomes and Measures  The main outcome was the proportion of patients with lung cancer who had stage III or IV disease, radiation exposure, procedure-related adverse events, and health expenditures 2 years after nodule detection.

Results  Among the 5057 individuals included in this comparative effectiveness research study, 1925 (38%) received guideline-concordant, 1863 (37%) less intensive, and 1269 (25%) more intensive diagnostic evaluations. The entire cohort comprised 2786 female patients (55%), and the mean (SD) age was 67 (13) years. Adjusted analyses showed that compared with guideline-concordant evaluations, less intensive evaluations were associated with fewer procedure-related adverse events (risk difference [RD], −5.9%; 95% CI, −7.2% to −4.6%), lower mean radiation exposure (−9.5 milliSieverts [mSv]; 95% CI, −10.3 mSv to −8.7 mSv), and lower mean health expenditures (−$10 916; 95% CI, −$16 112 to −$5719); no difference in stage III or IV disease was found among patients diagnosed with lung cancer (RD, 4.6%; 95% CI, −22% to +31%). More intensive evaluations were associated with more procedure-related adverse events (RD, +8.1%; 95% CI, +5.6% to +11%), higher mean radiation exposure (+6.8 mSv; 95% CI, +5.8 mSv to +7.8 mSv), and higher mean health expenditures ($20 132; 95% CI, +$14 398 to +$25 868); no difference in stage III or IV disease was observed (RD, −0.5%; 95% CI, −28% to +27%).

Conclusions and Relevance  This study found inconclusive evidence of an association between less intensive diagnostic evaluations and more advanced stage at lung cancer diagnosis compared with guideline-concordant care; higher intensities of diagnostic evaluations were associated with greater procedural complications, radiation exposure, and expenditures. These findings underscore the need for more evidence on better ways to evaluate lung nodules and to avoid unnecessarily intensive diagnostic evaluations of lung nodules.

 

 

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小児の下気道感染(気管支炎など)に対する抗菌薬は無効(英国プライマリケアでの研究 LANCET誌より)
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サイレントキラーである大気汚染の問題に取り組む時がきた(Lancet Respir Med誌の論説より)
IL-33を阻害する抗体薬イテペキマブは中等症~重症喘息に有効かもしれない(NEJM誌の報告)
睡眠時無呼吸と認知症は関連するのかー睡眠時無呼吸が重症になると、大脳白質病変が増加するー(JAMA誌の報告)
ぜん息も時差ボケをする?(周囲環境とは無関係に、体内時計における夜間に喘息は悪化しやすい;PNAS誌の報告)
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