Background: Appropriate management of lung nodules detected incidentally or through lung cancer screening can increase the rate of early-stage diagnoses and potentially improve treatment outcomes. However, the implementation and management of comprehensive lung nodule programs is challenging. Methods: This single-center, retrospective report describes the development and outcomes of a comprehensive lung nodule program at a community practice in Tennessee. Computed tomography (CT) scans potentially revealing incidental lung nodules were identified by a computerized search. Incidental or screening-identified lung nodules that were enlarging or not seen in prior scans were entered into a nodule database and guideline-based review determined whether to conduct a diagnostic intervention or radiologic follow-up. Referral rates, diagnosis methods, stage distribution, treatment modalities, and days to treatment are reported. Results: The number of patients with lung nodules referred to the program increased over 2 years, from 665 patients in Year 1 to 745 patients in Year 2. Most nodules were incidental (62-65%). Nodules identified with symptoms (15.2% in Year 1) or through screening (12.6% in Year 1) were less common. In Year 1, 27% (182/665) of nodules required a diagnostic intervention and 18% (121/665) were malignant. Most diagnostic interventions were image-guided bronchoscopy (88%) or percutaneous biopsy (9%). The proportion of Stage I-II cancer diagnoses increased from 23% prior to program implementation to 36% in Year 1 and 38% in Year 2. In screening cases, 71% of patients completed follow-up scans within 18 months. Only 2% of Year 1 patients under watchful waiting required a diagnostic intervention, of which 1% received a cancer diagnosis. Conclusions: The current study reports outcomes over the first 2 years of a lung cancer screening and incidental nodule program. The results show that the program was successful, given the appropriate level of data management and oversight. Comprehensive lung nodule programs have the potential to benefit the patient, physician, and hospital system.

BackgroundAppropriate management of lung nodules detected incidentally or through lung cancer screening can increase the rate of early-stage diagnoses and potentially improve treatment outcomes. However, the implementation and management of comprehensive lung nodule programs is challenging. MethodsA single-center, retrospective study was conducted to describe the development and outcomes of a lung nodule program at a community practice in Tennessee.ResultsThe number of patients with lung nodules referred to the program increased over 2 years, with 665 patients in Year 1 and 745 patients in Year 2. Most nodules were incidental (60% Year 1, 65% Year 2). In Year 1, 17% of nodules were symptomatic and 12% were identified through screening. Of the 665 nodules in Year 1, 182 underwent a diagnostic intervention and 121 (18%) received a cancer diagnosis. Most diagnostic interventions were image-guided bronchoscopy (88%) or percutaneous biopsy (9%). The proportion of Stage I-II cancer diagnoses increased from 23% prior to program implementation to 36% in Year 1 and 38% in Year 2. Among screening cases, follow-up scans were conducted within 18 months in 71%. Only 2% of patients under watchful waiting required a diagnostic intervention, of which 1% received a cancer diagnosis.ConclusionsThe current study reports outcomes over the first two years of a lung cancer screening and incidental nodule program. The program was successful and manageable, given the appropriate level of data management and oversight. Comprehensive lung nodule programs have the potential to benefit the patient, physician, and hospital system.

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Background: Appropriate management of lung nodules detected incidentally or through lung cancer screening can increase the rate of early-stage diagnoses and potentially improve treatment outcomes. However, the implementation and management of comprehensive lung nodule programs is challenging. Methods: This single-center, retrospective report describes the development and outcomes of a comprehensive lung nodule program at a community practice in Tennessee. Computed tomography (CT) scans potentially revealing incidental lung nodules were identified by a computerized search. Incidental or screening-identified lung nodules that were enlarging or not seen in prior scans were entered into a nodule database and guideline-based review determined whether to conduct a diagnostic intervention or radiologic follow-up. Referral rates, diagnosis methods, stage distribution, treatment modalities, and days to treatment are reported. Results: The number of patients with lung nodules referred to the program increased over 2 years, from 665 patients in Year 1 to 745 patients in Year 2. Most nodules were incidental (62%-65%). Nodules identified with symptoms (15.2% in Year 1) or through screening (12.6% in Year 1) were less common. In Year 1, 27% (182/665) of nodules required a diagnostic intervention and 18% (121/665) were malignant. Most diagnostic interventions were image-guided bronchoscopy (88%) or percutaneous biopsy (9%). The proportion of Stage I-II cancer diagnoses increased from 23% prior to program implementation to 36% in Year 1 and 38% in Year 2. In screening cases, 71% of patients completed follow-up scans within 18 months. Only 2% of Year 1 patients under watchful waiting required a diagnostic intervention, of which 1% received a cancer diagnosis. Conclusions: The current study reports outcomes over the first two years of a lung cancer screening and incidental nodule program. The results show that the program was successful, given the appropriate level of data management and oversight. Comprehensive lung nodule programs have the potential to benefit the patient, physician, and hospital system.

Direct nuclear deterrence should provide significant stability considering the defender's capability to inflict enormous costs on the challenger and its high level of resolve to protect its territory and people. In the past, however, nuclear powers' deterrence strategy to prevent adversaries from escalating a crisis has failed. We argue that to manage deterrence failure crises, nuclear weapons would not matter much until the crisis actors overcome the inherent political difficulties in following through on the threat of nuclear punishment. If a defender passes this bar, then it would escalate the crisis after the deterrence failure. Conversely, if the challenger possesses high political feasibility to follow through on a threat of nuclear use, then the crisis will be terminated less violently as most defenders will view nuclear escalation as more likely and decide to compromise. We identify a total of 156 cases of direct deterrence failure after 1947 from the International Crisis Behavior Data data set. Then, using ordered logistic regression analysis, we find evidence for this feasibility of punishment hypothesis.