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Editorial |

Wise Choices to Improve the Quality of Lung Cancer Care

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.,,

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