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Editorial |

Viewing All the Trees in the Forest: The Importance of Reporting Abnormal Findings on CT Scan When Screening for Lung Cancer FREE TO VIEW

James G. Ravenel, MD; Nichole T. Tanner, MD, FCCP; Gerard A. Silvestri, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

aDepartment of Radiology and Radiologic Sciences, Charleston, SC

bThoracic Oncology Research Group, Charleston, SC

cHealth Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Hospital, Charleston, SC

CORRESPONDENCE TO: James G. Ravenel, MD, Department of Radiology and Radiologic Sciences, Medical University of South Carolina, 96 Jonathan Lucas St, MSC 323, Charleston, SC 29425


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(3):525-526. doi:10.1016/j.chest.2016.10.053
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Published online

Following the publication of the National Lung Screening Trial (NLST), evaluation by the US Preventive Service Task Force, and approval for reimbursement by the Center for Medicare Services, low-dose CT for lung cancer screening is rapidly being adopted across the United States.,, Because lung cancer screening is a relatively new service, has the potential to cause harm as well as benefit, and has societal costs, there are published guidelines for how to set up, run, report, and properly maintain a screening program., A critical part of the screening process is the reporting and management of screen-detected findings, most notably but not limited to lung nodules. In this issue of CHEST, Mehta et al point out a potential pitfall in the reporting process.

FOR RELATED ARTICLE SEE PAGE 539

The most commonly available structured reporting system for a screening chest CT scan is Lung Imaging Reporting and Data System (Lung-RADS), a system developed by the American College of Radiology to standardize nodule management. It represents an improvement over the nodule management system used to report the findings of the NLST by reducing false-positive results from 26.6% to 12.8%, with a modest decline in sensitivity from 93.5% to 84.9% at baseline. This was accomplished largely by increasing the size of nodule reporting from 4 to 6 mm. This change in sensitivity is recognized as a reason for continued monitoring of screening outcomes with the potential to influence future iterations of Lung-RADS similar to Breast Imaging Reporting and Data System for screening mammography. Although nodules are the most common finding in early lung cancers, they are by no means the only manifestation. In addition, screening may detect other findings that might be of significance to the screened individual. In the NLST, clinically important findings not related to nodules were seen in up to 7.5% of individuals and included enlarged lymph nodes (1.0% of subjects; positive predictive value, 18.5%) and pleural effusions (1.7% of subjects; predictive value, 3.5%).

Lung-RADS recognizes the importance of incidental findings with an additional coding letter, the “S” code. The letter “S” should be attached any time there is an abnormality considered clinically important that is not a pulmonary nodule. In Mehta et al's paper, the appropriate code for the subjects should have been Lung-RADS 1S, with a specific recommendation for the management of the “S” findings. The performance of lung cancer screening does not absolve the interpreter of pointing out clinically important findings whether or not they are related to lung cancer. The Joint American College of Radiology and Society of Thoracic Radiology practice parameter for the performance and reporting of thoracic CT for lung cancer screening states that review of the entire examination for other potentially significant findings should be performed and reported in accordance with applicable standards. In addition to adenopathy and pleural effusion, detection of abnormalities such as severe coronary artery calcifications, aortic aneurysms, severe emphysema, and suspicious masses in the upper abdomen should be called out, not just in the body of the report but also in the final impression so that it is easily available to the reader of the report. Structured reporting is intended to assist in creating reports that are easier to read and interpret, and it allows for the management of both nodules and other incidental findings. It is meant to prevent the heterogeneity of reporting that can often lead to both patient and clinician nonadherence to recommendations.,

Why does all of this matter so much? Lung cancer screening has the potential to reduce disease-specific and overall mortality by 20% and 7%, respectively. However, there is the potential to cause harm to patients who have a screen-detected cancer missed, a benign or malignant nodule mismanaged, and findings other than nodules not reported or acted on. Were that to occur, some of the benefit of screening would be wiped out by our inability to safely implement lung cancer screening broadly, a concern some have raised since the results of the NLST were initially reported. A previous study examining the evaluation and management of nodules by community pulmonologists highlights this issue. In that study, patients with incidentally detected nodules that were determined by prediction models to have a low pretest probability risk for cancer (< 5%) were managed more aggressively than recommended by established practice guidelines. Further, the rate of surgical resection was similar between pretest probability risk groups (low, intermediate, and high), and the proportion of patients undergoing surgery for benign disease was exceedingly high (35%).

We applaud the authors for sharing the potential pitfalls of structured reporting related to screening with the clinical community, as all too often we report only the best outcomes, leaving us with little to improve on. Pointing out the issues related to how a screening episode of care is managed throughout the continuum from ordering, performing, reporting, and follow-up of screen-detected abnormalities will allow us to improve our systems of care to ensure safe and effective screening. Reporting data to approved lung cancer screening registries allows practices to benchmark their results against others and enhance the quality of their program.

In summary, it is incumbent on individuals interpreting these examinations to appropriately account for and report all significant findings, not simply lung nodules, and to be familiar with and understand Lung-RADS. Judicious use of the Lung-RADS “S” code along with specific discussion in the report's final impression is recommended as a means of improving communication. We encourage all members in a comprehensive screening program to review the CT images and work as a team to detect all significant abnormalities, since all of us, especially those being screened, have a vested interest in screening outcomes.

References

Moyer V.A. . U.S. Preventive Services Task Force Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:330-338 [PubMed]journal. [PubMed]
 
Aberle D.R. .Adams A.M. .Berg C.D. .et al Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409 [PubMed]journal. [CrossRef] [PubMed]
 
Center For Medicare and Medicaid Services. Decision memo for screening for lung cancer with low dose computed tomography (LDCT). 2015.https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274. Accessed December 1, 2016.
 
Mazzone P. .Powell C.A. .Arenberg D. .et al Components necessary for high-quality lung cancer screening: American College of Chest Physicians and American Thoracic Society policy statement. Chest. 2015;147:295-303 [PubMed]journal. [CrossRef] [PubMed]
 
Wiener R.S. .Gould M.K. .Arenberg D.A. .et al An official American Thoracic Society/American College of Chest Physicians policy statement: implementation of low-dose computed tomography lung cancer screening programs in clinical practice. Am J Respir Crit Care Med. 2015;192:881-891 [PubMed]journal. [CrossRef] [PubMed]
 
Mehta H.J. .Mohammed T.L. .Jantz M.A. . The American College of Radiology lung imaging reporting and data system: potential drawbacks and need for revision. Chest. 2017;151:539-543 [PubMed]journal
 
Pinsky P.F. .Gierada D.S. .Black W. .et al Performance of Lung-RADS in the National Lung Screening Trial: a retrospective assessment. Ann Intern Med. 2015;162:485-491 [PubMed]journal. [CrossRef] [PubMed]
 
Aberle D.R. .DeMello S. .Berg C.D. .et al Results of the two incidence screenings in the National Lung Screening Trial. N Engl J Med. 2013;369:920-931 [PubMed]journal. [CrossRef] [PubMed]
 
Kazerooni E.A. .Austin J.H. .Black W.C. .et al ACR-STR practice parameter for the performance and reporting of lung cancer screening thoracic computed tomography (CT): 2014 (resolution 4). J Thorac Imaging. 2014;29:310-316 [PubMed]journal. [CrossRef] [PubMed]
 
Moseson E.M. .Wiener R.S. .Golden S.E. .et al Patient and clinician characteristics associated with adherence. A cohort study of veterans with incidental pulmonary nodules. Ann Am Thorac Soc. 2016;13:651-659 [PubMed]journal. [CrossRef] [PubMed]
 
Blagev D.P. .Lloyd J.F. .Conner K. .et al Follow-up of incidental pulmonary nodules and the radiology report. J Am Coll Radiol. 2016;13:R18-R24 [PubMed]journal. [CrossRef] [PubMed]
 
Silvestri G.A. . Screening for lung cancer: it works, but does it really work? Ann Intern Med. 2011;155:537-539 [PubMed]journal. [CrossRef] [PubMed]
 
Tanner N.T. .Aggarwal J. .Gould M.K. .et al Management of pulmonary nodules by community pulmonologists: a multicenter observational study. Chest. 2015;148:1405-1414 [PubMed]journal. [CrossRef] [PubMed]
 
Gould M.K. .Donington J. .Lynch W.R. .et al Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:- [PubMed]journal
 

Figures

Tables

References

Moyer V.A. . U.S. Preventive Services Task Force Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:330-338 [PubMed]journal. [PubMed]
 
Aberle D.R. .Adams A.M. .Berg C.D. .et al Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409 [PubMed]journal. [CrossRef] [PubMed]
 
Center For Medicare and Medicaid Services. Decision memo for screening for lung cancer with low dose computed tomography (LDCT). 2015.https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274. Accessed December 1, 2016.
 
Mazzone P. .Powell C.A. .Arenberg D. .et al Components necessary for high-quality lung cancer screening: American College of Chest Physicians and American Thoracic Society policy statement. Chest. 2015;147:295-303 [PubMed]journal. [CrossRef] [PubMed]
 
Wiener R.S. .Gould M.K. .Arenberg D.A. .et al An official American Thoracic Society/American College of Chest Physicians policy statement: implementation of low-dose computed tomography lung cancer screening programs in clinical practice. Am J Respir Crit Care Med. 2015;192:881-891 [PubMed]journal. [CrossRef] [PubMed]
 
Mehta H.J. .Mohammed T.L. .Jantz M.A. . The American College of Radiology lung imaging reporting and data system: potential drawbacks and need for revision. Chest. 2017;151:539-543 [PubMed]journal
 
Pinsky P.F. .Gierada D.S. .Black W. .et al Performance of Lung-RADS in the National Lung Screening Trial: a retrospective assessment. Ann Intern Med. 2015;162:485-491 [PubMed]journal. [CrossRef] [PubMed]
 
Aberle D.R. .DeMello S. .Berg C.D. .et al Results of the two incidence screenings in the National Lung Screening Trial. N Engl J Med. 2013;369:920-931 [PubMed]journal. [CrossRef] [PubMed]
 
Kazerooni E.A. .Austin J.H. .Black W.C. .et al ACR-STR practice parameter for the performance and reporting of lung cancer screening thoracic computed tomography (CT): 2014 (resolution 4). J Thorac Imaging. 2014;29:310-316 [PubMed]journal. [CrossRef] [PubMed]
 
Moseson E.M. .Wiener R.S. .Golden S.E. .et al Patient and clinician characteristics associated with adherence. A cohort study of veterans with incidental pulmonary nodules. Ann Am Thorac Soc. 2016;13:651-659 [PubMed]journal. [CrossRef] [PubMed]
 
Blagev D.P. .Lloyd J.F. .Conner K. .et al Follow-up of incidental pulmonary nodules and the radiology report. J Am Coll Radiol. 2016;13:R18-R24 [PubMed]journal. [CrossRef] [PubMed]
 
Silvestri G.A. . Screening for lung cancer: it works, but does it really work? Ann Intern Med. 2011;155:537-539 [PubMed]journal. [CrossRef] [PubMed]
 
Tanner N.T. .Aggarwal J. .Gould M.K. .et al Management of pulmonary nodules by community pulmonologists: a multicenter observational study. Chest. 2015;148:1405-1414 [PubMed]journal. [CrossRef] [PubMed]
 
Gould M.K. .Donington J. .Lynch W.R. .et al Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:- [PubMed]journal
 
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