From the DeCesaris Cancer Institute, Anne Arundel Medical Center, Annapolis, MD.
Abstract
- Objective: To describe the development and outcomes of a centralized evaluation service for patients with abnormalities on thoracic imaging to allow prompt and standardized review by an experienced multidisciplinary team.
- Methods: Patients with abnormal thoracic imaging studies, whether symptom-related or incidental, were referred to a specialized multidisciplinary team by radiologists, primary care physicians, or other providers. Recommendations for immediate or delayed follow-up were made based on professional society guidelines and patient characteristics. Follow-up was maintained within the program with close communication with primary care physicians.
- Results: 238 patients were referred over a 27-month period, 227 with abnormal findings on chest imaging. 171 patients (75%) accepted participation in the program. Radiologists were the most frequent referrers. Pulmonary symptoms were present in 74% of cases but were often unrelated to the findings. Patients and primary care physicians were contacted within a median of 2 days after imaging. Lung cancer was eventually diagnosed in 72 patients (32%), 51% with stage IA-IIB, at a median time of 16 days from first imaging. Physician satisfaction with the program was high.
- Conclusion: The program provided rapid and evidence-based evaluation and management of patients with thoracic imaging abnormalities, resulting in short time to diagnosis and high referring physician satisfaction.
Nonspecific abnormalities after chest imaging are a clinical dilemma for physicians and a source of anxiety for patients concerned about the possibility of malignancy. The range of abnormal findings most often involve the parenchyma but also can include nodal tissue, mediastinum, and the bony thorax. Often these findings are incidental to the symptoms that prompted the evaluation. For example, one study of over 12,000 abdominal computed tomography (CT) scans detected pulmonary nodules in 3% [1], and a study of 586 CT angiograms ordered in an emergency room found nodules in 13% and new adenopathy in 9% [2]. Furthermore, CT imaging in various lung cancer screening trials demonstrate that the prevalence of 1 or more pulmonary nodules is 8% to 51%, but the risk of malignancy is much less: 1.1% to 12% [3]. Indeed, it is estimated that due to a high prevalence of imaging, over 150,000 Americans are diagnosed with solitary pulmonary nodules (SPN) annually [2]. Although nodule characteristics such as size, shape, and stability over time can predict the likelihood of malignancy, the risk that any of these imaging abnormalities are related to a malignancy depends upon characteristics of both the lesion and the patient.
Given the nonspecific nature of many radiographic findings, management strategies and guidelines have been developed for several different types of imaging abnormalities [4–7]. However, gaps in the guidelines exist, and they often are not followed [8,9]. Radiologists are not adherent to any set of guidelines in as many as 64% of cases, despite a high level of awareness of such guidelines [10–13]. Recommendations that are not concordant with guidelines are more likely to involve excessively frequent imaging rather than inappropriately infrequent follow-up [13].
Actual cases of under- and over-imaging in surveillance and a single case of delayed diagnosis despite a radiology report highlighting a high-risk nodule prompted us to developed a centralized program to gather all patients with pulmonary imaging abnormalities into the hands of physicians most familiar with these abnormalities and the proper use of available diagnostic tools. The goals were to rely on existing guidelines tempered with clinical experience to advise patients and their primary care physicians, and to direct the most efficient diagnostic evaluation and management.