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Rebuttal From Drs Farjah and WoodRebuttal From Drs Farjah and Wood FREE TO VIEW

Farhood Farjah, MD, MPH; Douglas E. Wood, MD, FCCP
Author and Funding Information

From the Department of Surgery/Division of Cardiothoracic Surgery, University of Washington.

Correspondence to: Farhood Farjah, MD, MPH, Department of Surgery/Division of Cardiothoracic Surgery, University of Washington, Box 356310, 1959 NE Pacific, AA-115, Seattle, WA 98195-6310; e-mail: ffarjah@uw.edu


Financial/nonfinancial disclosures: The authors have 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. 2014;145(3):452-453. doi:10.1378/chest.13-2725
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We do not agree with Drs Wahidi and Ernst’s1 claims about the diagnostic yield and costs of endosonography, nor do we agree with the notion of invasiveness as a sole driver of clinical decision-making. To legitimately claim that a new diagnostic procedure is equivalent to a standard, one needs to conduct a noninferiority randomized trial.2 Such trials are designed to rule out clinically important differences between competing diagnostic or therapeutic interventions. Because a noninferiority trial comparing staging modalities has not been performed, one cannot claim that endosonography is as sensitive as mediastinoscopy. A more objective interpretation of the existing data reveals no evidence of inferiority or superiority of one diagnostic modality over the other. This interpretation, adopted by the National Comprehensive Cancer Network, has led to the recommendation that either mediastinoscopy or endosonography may be used for first-line invasive mediastinal staging.3

There is no evidence that endosonography results in cost savings, and there remains substantial concern that endosonography may lead to higher costs by increasing the number of diagnostic procedures and provider visits. The best available data on the comparative costs of invasive mediastinal staging come from the Assessment of Surgical Staging vs Endosonographic Ultrasound in Lung Cancer (ASTER) trial.4 Careful examination of the CIs reveals no statistically significant differences in costs, even though the ASTER authors erroneously concluded that endosonography is cheaper. All cost comparisons have characterized mediastinoscopy as a stand-alone procedure with significant anesthesia and operating rooms costs. An efficient and patient-centered model of delivery performs mediastinoscopy as an initial step during the same anesthetic for the planned surgical resection. This results in fewer clinic and procedural visits, with a modest increase in costs due to a slight increase in operating room time that are substantially less than a separate endosonography procedure. Drs Wahidi and Ernst and their references do not account for efficient use of staging modalities sensitive to patient expectations.

We reassert that the benefits of mediastinoscopy include a more extensive evaluation of the mediastinum as well as acquisition of sufficient tissue for molecular testing. Because there is no evidence of a difference in diagnostic yield between endosonography and mediastinoscopy, patients and providers will have to carefully weigh the potential oncologic benefits of mediastinoscopy against the slightly higher (albeit very low) risks of associated complications. Although endosonography is less invasive than mediastinoscopy, it is important to remember that mediastinoscopy is a minimally invasive procedure.

We welcome endosonography as an important addition to our diagnostic armamentarium for evaluating lung cancer and use it in our own practice. Instead of quibbling about which procedure to use in a looming era of accountability, we should focus on optimizing the value of lung cancer staging. A potential strategy for increasing value is to become more selective about invasive mediastinal staging to maintain high-quality staging while avoiding unnecessary procedures. Research is currently under way to identify a uniform approach to mediastinal staging that safeguards the delivery of personalized lung cancer care.5

References

Wahidi MM, Ernst A. Point: should ultrasonographic endoscopy be the preferred modality for staging of lung cancer? Yes. Chest. 2014;145(3):447-449.
 
Farjah F, Flum DR. When not being superior may not be good enough. JAMA. 2007;298(8):924-925. [CrossRef] [PubMed]
 
National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology–υ.2.2013: Non-small Cell Lung Cancer. Fort Washington, PA: National Comprehensive Cancer Network; 2013.
 
Sharples LD, Jackson C, Wheaton E, et al. Clinical effectiveness and cost-effectiveness of endobronchial and endoscopic ultrasound relative to surgical staging in potentially resectable lung cancer: results from the ASTER randomised controlled trial. Health Technol Assess. 2012;16(18):1,75.
 
Farjah F, Lou F, Sima C, Rusch VW, Rizk NP. A prediction model for pathologic N2 disease in lung cancer patients with a negative mediastinum by positron emission tomography. J Thorac Oncol. 2013;8(9):1170-1180. [CrossRef] [PubMed]
 

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References

Wahidi MM, Ernst A. Point: should ultrasonographic endoscopy be the preferred modality for staging of lung cancer? Yes. Chest. 2014;145(3):447-449.
 
Farjah F, Flum DR. When not being superior may not be good enough. JAMA. 2007;298(8):924-925. [CrossRef] [PubMed]
 
National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology–υ.2.2013: Non-small Cell Lung Cancer. Fort Washington, PA: National Comprehensive Cancer Network; 2013.
 
Sharples LD, Jackson C, Wheaton E, et al. Clinical effectiveness and cost-effectiveness of endobronchial and endoscopic ultrasound relative to surgical staging in potentially resectable lung cancer: results from the ASTER randomised controlled trial. Health Technol Assess. 2012;16(18):1,75.
 
Farjah F, Lou F, Sima C, Rusch VW, Rizk NP. A prediction model for pathologic N2 disease in lung cancer patients with a negative mediastinum by positron emission tomography. J Thorac Oncol. 2013;8(9):1170-1180. [CrossRef] [PubMed]
 
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