Pulmonologists' Reported Use of Guidelines and Shared Decision-making in Evaluation of Pulmonary Nodules

Abstract

BACKGROUND:Selecting a strategy (surveillance, biopsy, resection) for pulmonary nodule evaluation can be complex given the absence of high-quality data comparing strategies and the important tradeoff s among strategies. Guidelines recommend a three-step approach: (1) assess the likelihood of malignancy, (2) evaluate whether the patient is a candidate for invasive intervention, and (3) elicit the patient's preferences and engage in shared decision-making. We sought to characterize how pulmonologists select a pulmonary nodule evaluation strategy and the extent to which they report following the guideline-recommended approach.

Patients’ Knowledge, Beliefs, and Distress Associated with Detection and Evaluation of Incidental Pulmonary Nodules for Cancer: Results from a Multicenter Survey

“…Indeed, clinicians themselves have reported they often do not supply cancer risk information or even discuss cancer at all for fear of worrying patients with incidental nodules. 40,41 However, those patients in our survey who reported receiving cancer risk estimates more often found this information reassuring rather than scary, perhaps because the actual risk was much lower than the patients’ assumption of what their risk might be. 3,8,9 Another possibility, however, is that clinicians did provide cancer risk information but that patients were too overwhelmed by news of a nodule to process this information.…”

Effect of an Automated Tracking Registry on the Rate of Tracking Failure in Incidental Pulmonary Nodules

“…Nodules are often tracked more frequently and for longer periods of time than what is recommended by the literature when following the recommendations of the radiologist reading the CT [4][5][6][7][8][9]19,20]. This failure in following published guidelines does not occur just with radiologists, as pulmonologists yield similar results in terms of frequency and duration of imaging [5,6]. Our centralized system of tracking incorporates published guidelines to avoid both over-and under-imaging.…”

“…Published reports indicate that pulmonary nodules incidentally discovered on CT imaging are not pursued according to published guidelines in up to 70% of cases, potentially resulting in delays in diagnosis and harm to patients [3][4][5][6][7][8][9][10]. With the recent recommendation for lung cancer screening with low-dose chest CT in high-risk patient populations, the incidence of pulmonary nodules will increase, highlighting the need to find novel solutions for efficient and reliable monitoring of these patients for the development of lung cancer [11].…”

Development of Guidelines for the Management of Pulmonary Nodules Toward Better Implementation

“…So why is this? Wiener and colleagues 6 (see page 1415 ) qualitatively evaluated the reported use of guidelines by 14 pulmonologists by asking about adherence to three key elements of the recommendations. Th ey found that physicians reported adherence to calculating the probability of malignancy and evaluating the appropriateness of invasive intervention but were less consistent in their approach to involving the patient in the decision, something apparently driven more by patient and physicianrelated factors unrelated to guidance, including aggressive questioning by the patient, patient anxiety, malpractice concerns, and physician preference.…”