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Lumps, Bumps, Spots, and ShadowsSolitary Pulmonary Nodule: The Scary World of the Solitary Pulmonary Nodule FREE TO VIEW

Gerard A. Silvestri, MD
Author and Funding Information

From the Medical University of South Carolina.

Correspondence to: Gerard A. Silvestri, MD, Medical University of South Carolina, 171 Ashley Ave, Rm 812-CSB, Charleston, SC 29425; e-mail: silvestr@musc.edu


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(3):592-594. doi:10.1378/chest.13-0058
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About a decade ago I received a call from a colleague that I will not soon forget. As background, we had “grown up” in the university together, she an ICU nurse and I a pulmonary attending. She was a grizzled hospital veteran and was knowledgeable about all aspects of clinical care. She had worked her way up into management, and I had not seen her for a while when I received the call. She sounded panicked and asked if she could come by my office to review her medical record with me. When we met, she told me she had recently discovered a breast lump. After mammography and ultrasonography, she had her initial appointment with a surgical oncologist. The surgeon, a trusted colleague, had a reputation for having a good bedside manner. I asked her what he said, and her reply was “After he told me it might be a breast cancer, I completely shut down. I don’t remember a thing for the rest of the visit, and I was too embarrassed to ask.” After a good cry, we reviewed her chart, and I was able to reassure her that his interpretation was that the risk of cancer was <10% and that he believed this was likely a fluid-filled cyst in a patient with preexisting fibrocystic breast disease. He wanted a biopsy to rule out the possibility of cancer, but it was low on his list of possible differential diagnoses. I encouraged her to call him to confirm this prior to the biopsy to help alleviate her fears. All turned out well for this patient, but it left me quite unsettled. If this health care-savvy nurse heard something different (or in this case nothing at all) from what a competent, compassionate physician had told her, then what were my patients hearing when I discussed a newly discovered pulmonary nodule that may or may not be cancer?

In this issue of CHEST (see page 672), Wiener and colleagues1 give us a glimpse into how patients interpret what they are told when faced with a newly discovered solitary pulmonary nodule. The study is a qualitative analysis of patients’ reactions of discussions with their doctors about pulmonary nodules. What is remarkable about the quotes from patients are the vivid descriptions they provide about their conversations and, more importantly, the lasting effect these discussions had on their psyche. There were some statements that comforted patients and some that disturbed them greatly. First and foremost, patients wanted to be told about the abnormality in person or at the very least by their physician on the phone, yet some patients in this study were contacted either by letter or voicemail. Previous studies have shown that the most anxiety-provoking time in the trajectory of a cancer continuum of care is the time between being told you may have cancer and when the first treatment is received.2-4 Not being able to immediately discuss the findings and a plan of action with a physician can only worsen a patient’s apprehension.

The study confirmed a finding that most seasoned clinicians already recognized, which is that patients wished to have discussions in layman’s terms. Telling patients they have a “6-mm noncalcified nodule on CT scan” is vastly different from telling them they have “a small growth in their lung that is about the size of a pea.” Showing them their scan can be extremely productive and really does not take much time, especially if you are outlining the plan as you go. Visualizing the nodule provides patients with a frame of reference for size and allows you to review the trade-offs of biopsy, surgery, or watchful waiting. Showing a patient how far a needle would have to traverse through normal lung to reach a small central nodule (especially one that you believe is benign) is likely to make a watchful waiting approach much more attractive to the patient. More than anything, patients want to know if you think this is likely to be cancer or not. This should be followed by a management recommendation and the reasoning behind the choice you recommend. A typical conversation with a patient with a 5-mm, well-circumscribed, lower lobe nodule may go something like this: “Mrs. Jones, you have a small growth in your lung. Although I cannot be 100% sure what this is, the fact that you have never smoked cigarettes and have no history of cancer, and given what it looks like on the scan, I think the likelihood that this is a cancer is extremely low. Still, to be on the safe side, I would like to see you back in 6 months, when we can do another scan and review it together. If there is no growth at that time, we will follow you periodically with scans for a total of 2 years. We choose to follow you for 2 years because if there is no growth after 2 years then the likelihood that this is cancer is virtually zero. If there is growth anywhere along the way, we will discuss doing a biopsy or even taking it out. Both of those options are more aggressive and come with some risk. Since I think the risk of cancer is so low, I would not want to expose you to procedures that might cause you harm.” I often end this discussion with something I have found comforts patients enormously. “Mrs. Jones, if you were my (insert appropriate relative here—mother, sister, aunt, child, and so forth) with a similar finding on a scan, I would recommend the exact same course of action.” I end the visit with a recap of my impression and plan and ask if they understood what they just heard and whether they have any questions or concerns. Their responses often surprise me. Despite a recommendation for watchful waiting, some patients, no matter how low the risk, want a biopsy or even surgery to be 100% sure the lesion is not cancer. Respecting patient preferences is strongly recommended by the authors of this study and the American College of Chest Physicians, who published guidelines on the evaluation and management of pulmonary nodules.5 I believe this patient-centered approach is the key to a satisfying patient-physician relationship.

Before concluding, a side note on qualitative research and focus group discussions is warranted. For reasons that escape me, well-structured interviews performed by experts who follow rigorously defined methodology and provide thematic content that can help us better understand a clinical problem are often labeled “soft science.” I could not disagree more. A quantitative survey method used to describe patient satisfaction with nodule evaluation might have left us with a mean rating of 2 out of 5 on a Likert scale for satisfaction with discussions about nodule diagnosis. It would not have had nearly the same impact as “My kidney doctor calls me up and says, ‘oh by the way, we found a tumor on your lungs.’…They didn’t even know what it was, but it was just the way (he) came out and said it. I was devastated….I bawled through Christmas.”1 Qualitative research better identifies which variables in the process are important to patients. This methodology, in turn, leads to the development of projects that improve physician-patient communication, with an emphasis on the aspects that patients find dissatisfying, and ultimately results in a better patient experience and increased patient compliance with care plans.

We perform evaluations for solitary pulmonary nodules so commonly that it is easy to forget that for the one hearing the news for the first time, it is likely to be one of the scariest days of their life. This study highlights some of those fears and provides practical advice on how to help alleviate them.

Acknowledgments

Other contributions: The patient described in this editorial gave permission to recount her story.

Wiener RS, Gould MK, Woloshin S, Schwartz LM, Clark JA. What do you mean, a spot? A qualitative analysis of patients’ reactions to discussions with their doctors about pulmonary nodules. Chest. 2013;143(3)::672-677.
 
Brocken P, Prins JB, Dekhuijzen PN, van der Heijden HF. The faster the better?—A systematic review on distress in the diagnostic phase of suspected cancer, and the influence of rapid diagnostic pathways. Psychooncology. 2012;21(1):1-10. [CrossRef] [PubMed]
 
Graves KD, Arnold SM, Love CL, Kirsh KL, Moore PG, Passik SD. Distress screening in a multidisciplinary lung cancer clinic: prevalence and predictors of clinically significant distress. Lung Cancer. 2007;55(2):215-224. [CrossRef] [PubMed]
 
Montazeri A, Milroy R, Hole D, McEwen J, Gillis CR. Anxiety and depression in patients with lung cancer before and after diagnosis: findings from a population in Glasgow, Scotland. J Epidemiol Community Health. 1998;52(3):203-204. [CrossRef] [PubMed]
 
Gould MK, Fletcher J, Iannettoni MD, et al. Evaluation of patients with pulmonary nodules: When is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition).Chest. 2007;132(suppl 3):108S-130S.
 

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References

Wiener RS, Gould MK, Woloshin S, Schwartz LM, Clark JA. What do you mean, a spot? A qualitative analysis of patients’ reactions to discussions with their doctors about pulmonary nodules. Chest. 2013;143(3)::672-677.
 
Brocken P, Prins JB, Dekhuijzen PN, van der Heijden HF. The faster the better?—A systematic review on distress in the diagnostic phase of suspected cancer, and the influence of rapid diagnostic pathways. Psychooncology. 2012;21(1):1-10. [CrossRef] [PubMed]
 
Graves KD, Arnold SM, Love CL, Kirsh KL, Moore PG, Passik SD. Distress screening in a multidisciplinary lung cancer clinic: prevalence and predictors of clinically significant distress. Lung Cancer. 2007;55(2):215-224. [CrossRef] [PubMed]
 
Montazeri A, Milroy R, Hole D, McEwen J, Gillis CR. Anxiety and depression in patients with lung cancer before and after diagnosis: findings from a population in Glasgow, Scotland. J Epidemiol Community Health. 1998;52(3):203-204. [CrossRef] [PubMed]
 
Gould MK, Fletcher J, Iannettoni MD, et al. Evaluation of patients with pulmonary nodules: When is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition).Chest. 2007;132(suppl 3):108S-130S.
 
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