Determinants of Practice Patterns and Quality Gaps in Lung Cancer Staging and Diagnosis

Abstract

Background: Guidelines recommend mediastinal lymph node sampling as the fi rst invasive diagnostic procedure in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases. Methods: Patients were a retrospective cohort of 15,316 patients with lung cancer with regional spread without metastatic disease in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) or Texas Cancer Registry Medicare-linked databases. Patients were categorized based on the sequencing of invasive diagnostic tests performed: (1) evaluation consistent with guidelines, mediastinal sampling done fi rst; (2) evaluation inconsistent with guidelines, non-small cell lung cancer (NSCLC) present, mediastinal sampling performed but not as part of the fi rst invasive test; (3) evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling never done; and (4) evaluation inconsistent with guidelines, small cell lung cancer. The primary outcome was whether guideline-consistent care was delivered. Secondary outcomes included whether patients with NSCLC ever had mediastinal sampling and use of transbronchial needle aspiration (TBNA) among pulmonologists. Results: Only 21% of patients had a diagnostic evaluation consistent with guidelines. Only 56% of patients with NSCLC had mediastinal sampling prior to treatment. There was signifi cant regional variability in guideline-consistent care (range, 12%-29%). Guideline-consistent care was associated with lower patient age, metropolitan areas, and if the physician ordering or performing the test was male, trained in the United States, had seen more patients with lung cancer, and was a pulmonologist or thoracic surgeon who had graduated more recently. More recent pulmonary graduates were also more likely to perform TBNA ( P , .001). Conclusions: Guideline-consistent care varied regionally and was associated with physician-level factors, suggesting that a lack of effective physician training may be contributing to the quality gaps observed. CHEST 2014; 145(5):1097-1113Abbreviations: EBUS 5 endobronchial ultrasound; NSCLC 5 non-small cell lung cancer; SEER 5 Surveillance, Epidemiology, and End Results; TBNA 5 transbronchial needle aspiration; TCR 5 Texas Cancer Registry

Vascular endothelial growth factor C complements the ability of positron emission tomography to predict nodal disease in lung cancer

“…Nodal staging among patients with suspected NSCLC represents guideline-concordant practice 1,2 and is increasingly recognized as a marker of high-quality, high-value oncologic care. 24,25 Our study provides an understanding of the diagnostic value of VEGF-C in a real-world setting.…”

Bronchoscopy with endobronchial ultrasound guided transbronchial needle aspiration vs. transthoracic needle aspiration in lung cancer diagnosis and staging

“…In a secondary analysis, EBUS biopsies outperformed conventional bronchoscopy and TTNAguided biopsies in these outcomes as well. It is expected that higher-volume centers would have lower complication rates (3,(12)(13)(14). Previously published data describe an overall lower rate of complications for EBUS-TBNA in comparison to TTNA or conventional transbronchial biopsy; pneumothorax rates have been reported at 0.5%, 4% and 15% for EBUS-TBNA, conventional transbronchial biopsy, and TTNA respectively (5,15,16).…”

“…Unfortunately, some of these procedures cannot evaluate mediastinal nodes and thus are not guideline-consistent, but are still widely used at many institutions. In a recent review of Medicare databases, only 56% of patients had mediastinal sampling before treatment, and only 21% had guideline-consistent diagnostic evaluations (1)(2)(3)(4).…”

Complications and Economic Burden Associated with Obtaining Tissue for Diagnosis and Molecular Analysis in Patients with Non-Small Cell Lung Cancer (NSCLC) in the US (Preprint)

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