A. W. Maiga1,2, S. A. Deppen1,2, R. Pinkerman2, C. Callaway-Lane2, R. S. Dittus1,2, E. Lambright1,2, J. Nesbitt1,2, E. L. Grogan1,2 1Vanderbilt University Medical Center,Nashville, TN, USA 2VA TN Valley Healthcare System,Nashville, TN, USA
Introduction:
Clinical guidelines recommend that clinicians estimate the probability of malignancy for patients undergoing evaluation of indeterminate pulmonary nodules (IPN) > 8mm. Adherence to these guidelines is unknown. Our objective was 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 prediction model.
Methods:
We queried our retrospective single-institution surgical database of 298 Veteran patients who underwent lung resections for known or suspected lung cancer from 2003 to 2015. We reviewed preoperative documentation from pulmonary and thoracic surgery providers, as well as multidisciplinary tumor board presentations. Any documented quantitative or qualitative predictions of malignancy were extracted and summarized using descriptive statistics. We compared clinicians’ quantitative and qualitative predictions of malignancy to risk estimates from the Mayo prediction model.
Results:
Cancer prevalence was 88% (261/298). Only 13 patients (4%) had a documented quantitative prediction of malignancy prior to tissue diagnosis; 217 (76%) of the remaining 285 patients had a qualitative risk statement. By service, 62% (185/298), 47% (76/163), and 28% (27/96) of pulmonary, thoracic surgery, and tumor board notes, respectively, documented a qualitative estimate of malignancy risk prior to tissue diagnosis. After the American College of Chest Physicians updated their guidelines in 2007 to include a recommendation to document the pre-test probability of malignancy, the proportion of thoracic surgery notes including a qualitative risk statement increased from 36% (31/86) to 58% (45/77), whereas the portion of pulmonary and tumor board notes documenting this did not change. Qualitative risk statements fell into 32 broad categories. The most frequently used statements (Table 1) aligned well with Mayo model predictions.
Conclusion:
Clinicians do not provide quantitative documentation of the probability of cancer for IPNs in high-risk lesions. Qualitative statements of risk in current practice are highly variable but correlate well to Mayo model predictions. A standard quantitative scale that correlates with predicted risk for IPNs should be used to communicate with patients and other providers.
