Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis

Ost, David; Niu, Jiangong; Elting, Linda S.; Buchholz, Thomas A.; Giordano, Sharon H.

doi:10.1378/chest.13-1599

Cited by 54 publications

(15 citation statements)

References 34 publications

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“…When combined with EUS-FNA, EBUS-TBNA offers nearly complete assessment of the mediastinum and may have higher diagnostic accuracy than the previous gold standard, Med in patients with metastatic disease in EBUS-TBNA-inaccessible LNs. When performed by a skilled bronchoscopist EBUS-TBNA can not only provide mediastinal LN staging but also, in some patients, offer diagnosis of the primary tumor including information on its molecular profile (110,111).…”

Section: Discussionmentioning

confidence: 99%

The role of endobronchial ultrasound versus mediastinoscopy for non-small cell lung cancer

Czarnecka‐Kujawa¹,

Yasufuku²

2017

J. Thorac. Dis.

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This review provides an update on the current role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and mediastinoscopy (Med) in assessment of patients with non-small cell lung cancer (NSCLC). Invasive mediastinal lymph node (LN) staging is the major application for both of these techniques. Up until recently, Med was the gold standard for invasive mediastinal LN staging in NSCLC. However, EBUS-TBNA has shown to be equivalent, and in some studies better than Med for invasive staging of lung cancer. EBUS-TBNA offers access to N1 LNs and development of the thin convex probe EBUS (TCP-EBUS) will expand EBUS-TBNA access from the paratracheal region and central airways to more distal parabronchial regions allowing for more extensive N1 LN assessment and sampling more distal lung tumors. EBUS-TBNA is more cost-effective than Med and it is currently recommended as the test of first choice for invasive mediastinal LN staging in lung cancer. ConfirmatoryMed should be performed selectively in patients with high pretest probability of metastatic disease. Addition of esophageal ultrasound fine needle aspiration (EUS-FNA) may increase diagnostic yield of EBUS-TBNA mediastinal staging. Both Med and EBUS-TBNA can be used in primary lung cancer diagnosis, restaging of the mediastinum following neoadjuvant therapy and in diagnosis of lung cancer recurrence. In the future, a combination of EBUS-TBNA with or without EUS-FNA and Med is most likely going to provide the most optimal invasive assessment of the mediastinum in patients with lung cancer. The decision on test choice and sequence should be made on a case-by-case basis and factoring in local resources and expertise.

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Section: Discussionmentioning

confidence: 99%

The role of endobronchial ultrasound versus mediastinoscopy for non-small cell lung cancer

Czarnecka‐Kujawa¹,

Yasufuku²

2017

J. Thorac. Dis.

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“…This dataset has been used to evaluate the comparative effectiveness of alternative staging strategies and presented in abstract form. 19 Patient Population guided biopsy ( Table 2 ). The breakdown of patients according to diagnostic strategy (guideline-consistent vs guideline-inconsistent) and type of lung cancer is shown in Figure 2 .…”

Section: Data Sourcementioning

confidence: 99%

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

Ost

Niu

Elting

et al. 2014

Chest

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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

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“…Numerous studies have shown significant delays in delivery of treatment, after initial detection of a potentially malignant pulmonary lesion [3,4]. Furthermore, reviews of national databases reveal a low rate of use of staging tests in patients with lung cancer, with significant detriment to survival [5,6].…”

mentioning

confidence: 99%