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Editorial |

Wise Choices to Improve the Quality of Lung Cancer Care FREE TO VIEW

David E. Ost, MD, MPH, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: David E. Ost, MD, MPH, FCCP, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1462, Houston, TX 77030


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


Chest. 2016;149(4):889-890. doi:10.1016/j.chest.2015.09.015
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The American Board of Internal Medicine Foundation’s Choosing Wisely campaign is intended to promote discussion and to help patients choose care that is supported by evidence, not duplicative of other tests or procedures, free from harm, and deemed truly necessary. National organizations, including the American College of Chest Physicians (CHEST) and the Society of Thoracic Surgeons (STS), have identified commonly used tests and procedures whose necessity should be questioned and discussed. One recommendation from the STS is that brain imaging is not required prior to definitive care in the absence of neurologic symptoms in patients with suspected or proven stage I non-small cell lung cancer (NSCLC). Brain imaging to evaluate for possible metastatic disease as part of the initial evaluation is recommended in other situations.,, The CHEST lung cancer guidelines support brain imaging in patients with specific symptoms suggestive of central nervous system involvement (Grade 1B) and in asymptomatic patients with clinical stage III or IV NSCLC (Grade 2C). These recommendations were based on an evidence review of 18 studies with 1,830 patients that was part of the 2007 CHEST lung cancer guidelines. Nine of the 18 studies limited enrollment to patients with negative clinical evaluations. The median prevalence of brain metastasis was 3% (range, 0%-21%) and the median negative predictive value (NPV) of the clinical evaluation was 97% (range, 79%-100%). In nine studies that enrolled patients with positive and negative clinical evaluations, the pooled sensitivity and specificity of the clinical evaluation were 73% and 85%, respectively. These studies were predominantly retrospective, however, and the guidelines correctly note that the use of routine MRI in staging disease in patients with NSCLC and negative clinical evaluations has not been sufficiently studied.,,

FOR RELATED ARTICLE SEE PAGE 943

In this issue of CHEST (see page 943), Balekian et al provide additional data on the use of brain imaging for patients with clinical stage IA disease that is detected as part of a lung cancer screening program. The investigators conducted a secondary analysis of data collected as part of the National Lung Screening Trial. Of the 643 patients with clinical T1N0M0 or T1N0MX disease included in the study, brain imaging was performed in 77 (12%). All patients who underwent brain imaging went on to undergo surgery with a curative intent, suggesting that the brain imaging results were negative; the actual images were not available for review, however. In addition, the presence or absence of central nervous system symptoms during clinic visits could not be ascertained. Even given these limitations, it seems reasonable to infer that the prevalence of brain metastases in this population was very low. However, utilization of brain imaging varied significantly between centers, ranging from 0% to 80%.

These findings support the position that brain imaging is not useful in asymptomatic patients with stage I NSCLC that has been identified as part of a lung cancer screening program. The 2007 CHEST evidence-based lung cancer guidelines found that the published data on the NPV of a clinical evaluation varied significantly between reports. If the NPV of a clinical evaluation for brain metastasis in a particular population is approximately 80%, this level would be too low to suggest that brain imaging is unwarranted based solely on a negative evaluation. However, it is possible that in certain well-defined populations, the NPV of a clinical evaluation, given a very low pretest probability, is sufficient to make brain imaging unnecessary. Balekian et al identified a low pretest probability group (ie, screen-detected clinical stage I NSCLC) that meets these criteria. Based on the data presented (as well as on previously published data), it seems reasonable to recommend foregoing brain imaging in asymptomatic patients with screen-detected clinical stage I NSCLC.

These findings do not mean, however, that the evidence is sufficient to recommend for or against brain imaging in other asymptomatic patients with stage IB or II NSCLC. Patients with large adenocarcinomas with N1 disease may have a sufficiently high pretest probability that even with a negative clinical examination, brain imaging might be warranted. The National Comprehensive Cancer Network guidelines recommend a brain MRI for stage IB (recommendation category 2B) and stages II and IIIA (category 2A) disease. This recommendation differs slightly from the CHEST guidelines, which review the data but do not make explicit recommendations for stage IB and stage II disease.,, Future studies are needed to determine whether brain imaging is warranted in asymptomatic patients with clinical stages IB and II disease.

The variations between guidelines and the absence of definitive studies in the literature serve to highlight the importance of developing a strong evidence base if we are to truly improve quality of care. Guidelines will often conflict in the absence of high-quality evidence. Adherence to guidelines as a measure of quality is only useful if the evidence base behind the guidelines is very strong, the populations involved are well defined, the interventions required are clear, and there is an impact on outcomes. In the case of brain imaging for patients with NSLC, different sets of guidelines vary in terms of some very important details. The reason for this variation is partially related to the lack of sufficient high-quality data. The solution to this problem is not monitoring to improve adherence to a weak standard but rather performing additional high-quality studies to improve the evidence base that forms the foundation for the standards. The present study in this issue is one step in that direction.

In summary, the study by Balekian et al provides new and useful data which strongly support the concept that brain imaging in asymptomatic patients with screen-detected clinical stage I NSCLC is unwarranted. This finding is consistent with recommendations from the STS and should inform future evidence-based guidelines.,, There is currently heterogeneity of practice regarding the use of brain imaging, and locally driven quality initiatives may prove useful in this regard. To improve outcomes and quality of care for patients with lung cancer, the wisest path would be to focus on developing high-quality evidence to inform physicians and patients about the best available options. Once the evidence base is strong, standardization will be more effective. Without a strong evidence base, however, unwarranted monitoring for adherence to weak guidelines would be counterproductive, wasteful of resources, and unwise.

References

Ost D.E. .Yeung S.C. .Tanoue L.T. .Gould M.K. . Clinical and organizational factors in the initial evaluation of patients with lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e121S-e141S [PubMed]journal. [CrossRef] [PubMed]
 
Silvestri G.A. .Gonzalez A.V. .Jantz M.A. .et al Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e211S-e250S [PubMed]journal. [CrossRef] [PubMed]
 
Silvestri G.A. .Gould M.K. .Margolis M.L. .et al Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest. 2007;132:178S-201S [PubMed]journal. [CrossRef] [PubMed]
 
Tanaka K. .Kubota K. .Kodama T. .Nagai K. .Nishiwaki Y. . Extrathoracic staging is not necessary for non-small-cell lung cancer with clinical stage T1-2 N0. Ann Thorac Surg. 1999;68:1039-1042 [PubMed]journal. [CrossRef] [PubMed]
 
Balekian A.A. .Fisher J.M. .Gould M.K. . Brain imaging for staging of patients with clinical stage IA non-small cell lung cancer in the National Lung Screening Trial: adherence with recommendations from the Choose Wisely Campaign. Chest. 2016;149:943-950 [PubMed]journal. [CrossRef] [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]
 
Hochstenbag M.M. .Twijnstra A. .Hofman P. .Wouters E.F. .ten Velde G.P. . MR-imaging of the brain of neurologic asymptomatic patients with large cell or adenocarcinoma of the lung. Does it influence prognosis and treatment? Lung Cancer. 2003;42:189-193 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Ost D.E. .Yeung S.C. .Tanoue L.T. .Gould M.K. . Clinical and organizational factors in the initial evaluation of patients with lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e121S-e141S [PubMed]journal. [CrossRef] [PubMed]
 
Silvestri G.A. .Gonzalez A.V. .Jantz M.A. .et al Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e211S-e250S [PubMed]journal. [CrossRef] [PubMed]
 
Silvestri G.A. .Gould M.K. .Margolis M.L. .et al Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest. 2007;132:178S-201S [PubMed]journal. [CrossRef] [PubMed]
 
Tanaka K. .Kubota K. .Kodama T. .Nagai K. .Nishiwaki Y. . Extrathoracic staging is not necessary for non-small-cell lung cancer with clinical stage T1-2 N0. Ann Thorac Surg. 1999;68:1039-1042 [PubMed]journal. [CrossRef] [PubMed]
 
Balekian A.A. .Fisher J.M. .Gould M.K. . Brain imaging for staging of patients with clinical stage IA non-small cell lung cancer in the National Lung Screening Trial: adherence with recommendations from the Choose Wisely Campaign. Chest. 2016;149:943-950 [PubMed]journal. [CrossRef] [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]
 
Hochstenbag M.M. .Twijnstra A. .Hofman P. .Wouters E.F. .ten Velde G.P. . MR-imaging of the brain of neurologic asymptomatic patients with large cell or adenocarcinoma of the lung. Does it influence prognosis and treatment? Lung Cancer. 2003;42:189-193 [PubMed]journal. [CrossRef] [PubMed]
 
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