Original Research: Lung Cancer |

Quality Gaps and Comparative Effectiveness in Lung Cancer StagingComparative Effectiveness in Lung Cancer Staging: The Impact of Test Sequencing on Outcomes

Francisco A. Almeida, MD, FCCP; Roberto F. Casal, MD; Carlos A. Jimenez, MD, FCCP; George A. Eapen, MD; Mateen Uzbeck, MBBS; Mona Sarkiss, MD; David Rice, MD; Rodolfo C. Morice, MD, FCCP; David E. Ost, MD, MPH, FCCP
Author and Funding Information

From the Department of Pulmonary, Allergy, and Critical Care Medicine (Dr Almeida), Cleveland Clinic, Cleveland, OH; the Department of Pulmonary and Critical Care Medicine (Dr Casal), Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX; the Department of Pulmonary Medicine (Drs Jimenez, Eapen, Morice, and Ost), the Department of Anesthesia (Dr Sarkiss), and the Department of Thoracic Surgery (Dr Rice), The University of Texas MD Anderson Cancer Center, Houston, TX; and The Department of Pulmonary Medicine (Dr Uzbeck), Our Lady of Lourdes and Beaumont Hospitals, Dublin, Ireland.

Correspondence to: David E. Ost, MD, MPH, FCCP, The University of Texas MD Anderson Cancer Center, Department of Pulmonary Medicine Unit 1462, 1515 Holcombe Blvd, Houston, TX 77030; e-mail: dost@mdanderson.org

For editorial comment see page 1747

Funding/Support: The authors have reported to CHEST that no funding was received for this study.

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

Chest. 2013;144(6):1776-1782. doi:10.1378/chest.12-3046
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Background:  Evidence-based guidelines recommend mediastinal sampling as the first invasive test in patients with suspected lung cancer and mediastinal adenopathy. The goal of this study was to assess practice patterns and outcomes of diagnostic strategies in this patient population.

Methods:  We conducted a retrospective analysis of all patients in 2009 who had mediastinal adenopathy without distant metastatic disease to determine whether guideline-consistent care was delivered. Guideline-consistent care was defined as mediastinal lymph node sampling being performed as part of the first invasive procedure.

Results:  One hundred thirty-seven patients were included. Guideline-consistent care was provided in 30 cases (22%). Patients receiving guideline-consistent care had fewer invasive tests than patients with guideline-inconsistent care (1.3 ± 0.5 tests/patient vs 2.3 ± 0.5 tests/patient, respectively; P < .0001) and fewer complications (0 of 30, 0% vs 18 of 108, 17%; P = .01). Most of the complications (16 of 18) were related to CT image-guided needle biopsy. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was sufficient to guide treatment decisions without any other invasive tests in 88 patients (64%). Although not all the complications and costs due to CT image-guided biopsies could have been avoided, roughly two-thirds could have been eliminated by just changing the testing sequence.

Conclusion:  Quality gaps in lung cancer staging in patients with mediastinal adenopathy are common and lead to unnecessary testing and increased complications. In patients with suspected lung cancer without distant metastatic disease with mediastinal adenopathy, EBUS-TBNA should be the first test.

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