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Original Research |

Physician assessment of pre-test probability of malignancy and adherence with guidelines for pulmonary nodule evaluation

Nichole T. Tanner; Alexander Porter; Michael Gould; Xiao-Jun Li; Anil Vachani; Gerard A. Silvestri
Author and Funding Information

Funding: Integrated Diagnostics, INC

Conflict of Interest: Dr. Tanner has received foundation grant funding from the American Cancer Society and the Chest Foundation, industry grant funding from Exact Sciences, Veracyte, Integrated Diagnostics and Olympus, consulting monies from Integrated Diagnostics, Olympus, Veran and Oncocyte and participated in advisory board meetings for Veracyte. Dr. Porter and Dr. Li are employees of Integrated Diagnostics. Dr. Gould has received a research award from PCORI, research grant from NIH/NCI and research support from Medial, Inc. Dr. Vachani has served on advisory boards for Integrated Diagnostics, Veracyte, Oncocyte and Nucleix. Dr. Silvestri has received grant funding from Integrated Diagnostics.

1Thoracic Oncology Research Group (TORG), Division of Pulmonary and Critical Care, Medical University of South Carolina

2Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Hospital

3Integrated Diagnostics, Inc, Seattle, WA

4Kaiser Permanente Southern California, Pasadena, CA

5Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

Corresponding Author: Nichole T. Tanner, MD, MSCR 96 Johnathan Lucas Street CSB 816.


Copyright 2017, . All Rights Reserved.


Chest. 2017. doi:10.1016/j.chest.2017.01.018
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Published online

Abstract

Background  The annual incidence of pulmonary nodules is estimated at 1.57 million. Guidelines recommend utilizing an initial assessment of nodule probability for malignancy (pCA). A previous study found that despite this recommendation, physicians did not follow guidelines.

Methods  Physician (n= 337) and two previously validated risk model assessment of cancer pre-test probability were evaluated for performance in 337 patients with pulmonary nodules based on final diagnosis and compared. Physician assessed pCA was categorized into low, intermediate and high risk and the next test ordered was evaluated.

Results  The prevalence of malignancy was 47% (n=158) at one year. Physician assessed pCA performed better than nodule prediction calculators (AUC 0.85 vs 0.75, p<0.001 and 0.78, p=0.0001). Physicians did not follow indicated guidelines when selecting the next test in 61% of cases (n=205). Despite recommendations for serial CT imaging in those with low pCA, 52%(n=13) were managed more aggressively with PET imaging or biopsy; 12%(n=3) had biopsy for benign disease. Alternatively, in the high risk category, the majority (n=103, 75%) were managed more conservatively. Stratified by diagnosis, 92% (n=22) with benign disease underwent more conservative management with CT scan (20%), PET scan(15%), or biopsy(8%) though 3(8%) had surgery.

Conclusions  Physician assessment as a means for predicting malignancy in pulmonary nodules is more accurate than previously validated nodule prediction calculators. Despite the accuracy of clinical intuition, physicians did not follow guideline based recommendations when selecting the next diagnostic test. To provide optimal patient care, focus in the areas of guideline refinement, implementation and dissemination is needed.


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