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Lung Cancer |

Factors That Influence Physician Decision-Making for Indeterminate Pulmonary Nodules

Gregory Diette, MD; Anil Vachani, MD; Nichole Tanner, MD; Jyoti Aggarwal, MHS; Charles Mathews, MA; Paul Kearney, PhD; Kenneth Fang, MD; Gerard Silvestri, MD
Author and Funding Information

Johns Hopkins University, Baltimore, MD


Chest. 2013;144(4_MeetingAbstracts):647A. doi:10.1378/chest.1703085
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Abstract

SESSION TITLE: Decision-Making in Lung Cancer

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 30, 2013 at 07:30 AM - 09:00 AM

PURPOSE: Pulmonologists frequently encounter indeterminate pulmonary nodules (8 to 20 mm) in practice. The relative role of different clinical factors in guiding diagnostic evaluation is unclear. We undertook this study to assess physicians’ current approaches to pulmonary nodule management.

METHODS: Pulmonologists were invited to complete an online survey involving a choice-based conjoint exercise. Twenty randomly-generated patient cases varying age, smoking history, and lung nodule size were shown. Participants reported their decisions to proceed with major invasive procedures (i.e., thoractomy/VATS), minor invasive procedures (i.e., FNA/biopsy, bronchosocopy), or monitoring (i.e., CT/PET scans). Univariate analyses of chi-squared values and multivariate logistic regression modeling were used to measure the statistical significance of the various factors on decision-making.

RESULTS: 153 physicians with a broad geographic distribution completed the survey and conjoint exercise. The use of invasive diagnostic procedures increased with nodule size: 23% of 6 mm nodules, and 54%, 66%, 77%, and 84% of 10, 14, 18, and 22 mm nodules, respectively (overall chi-squared p<0.001). Procedures were increasingly recommended with greater smoking history: 45% of never smokers and 62%, 65%, and 68% with 12-, 24-, and 36-pack-years, respectively (p<0.001). Older age limited patients from undergoing recommended procedures: 54% of 80 year olds vs. 61%, 64%, 63%, and 61% of patients ages 71, 62, 53, and 44 years, respectively (p<0.001). Academic physicians were more likely to suggest procedures: (62%) versus community physicians (56%) (p=0.01). In multivariate analyses, after adjusting for physician practice and region, nodule size, smoking history, and age all significantly influenced decision making (p<0.001).

CONCLUSIONS: Pulmonologists are more likely to proceed with invasive diagnostic procedures, instead of observation, as the size of the nodule increases and in extensive smokers. In addition, they appear to withhold procedures from octogenarians, even when knowing they are surgical candidates, a finding that deserves further study.

CLINICAL IMPLICATIONS: Nodule size plays a key role in driving physician decision-making. More research is needed to determine whether these procedures result in identification of malignancy or non-malignancy.

DISCLOSURE: Gregory Diette: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to company developing lung nodule test, Integrated Diagnostics Anil Vachani: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to company developing lung nodule test, Integrated Diagnostics Nichole Tanner: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to company developing lung nodule test, Integrated Diagnostics Jyoti Aggarwal: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to company developing lung nodule test, Integrated Diagnostics Charles Mathews: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to company developing lung nodule test, Integrated Diagnostics Paul Kearney: Employee: President of Integrated Diagnostics a company developing a lung nodule test. Kenneth Fang: Employee: CMO of Integrated Diagnostics, a company developing a lung nodule test Gerard Silvestri: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to company developing lung nodule test, Integrated Diagnostics

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