Finding the Right Balance in Lung Nodule Evaluations

We read with great interest the article by Manyak et al1Manyak A. Seaburg L. Bohreer K. Kirtland S.H. Hubka M. Gerbino A.J. Invasive procedures associated with lung cancer screening in clinical practice.Chest. 2023; 164: 544-555Abstract Full Text Full Text PDF Google Scholar published in this issue of CHEST. The interesting finding of this study is that it demonstrated low rates of invasive procedures and complications for false-positive lung nodules in a community-based lung cancer screening program. The authors attributed that to multidisciplinary approach and adherence to Lung Imaging Reporting and Data System (Lung-RADS) guidelines. However, this study has an important limitation regarding delay in malignant diagnosis of LungRADS 4A nodules with a median of 154 days. The authors justified that such longer delays to diagnosis were still likely to be diagnosed as stage IA as compared with those with shorter delays. However, they did not show whether there was any staging shift among stage IA (IA1, IA2, and IA3). Furthermore, the sample size was too small to detect any significant difference in outcomes between longer and shorter delay arms. The eighth TNM stage of lung cancer divides the T1 classification into T1mi, T1a (≤ 1 cm), T1b (1 to 2 cm), and T1c (≤ 3 cm) with a significantly different 5-year survival rate among such groups.2Goldstraw P. Chansky K. Crowley J. et al.The IASLC Lung Cancer Staging Project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer.J Thorac Oncol. 2016; 11: 39-51Abstract Full Text Full Text PDF PubMed Google Scholar The impact of delays in lung cancer treatment has been associated with worse outcomes. Heiden et al3Heiden B.T. Eaton Jr., D.B. Engelhardt K.E. et al.Analysis of delayed surgical treatment and oncologic outcomes in clinical stage I non-small cell lung cancer.JAMA Netw Open. 2021; 4e2111613Crossref PubMed Scopus (37) Google Scholar found that time to surgical procedures of more than 12 weeks was associated with increased risk of recurrence and worse survival in a large cohort. Another study demonstrated that patients with early-stage lung cancer with time to surgery within 4 weeks experienced lower rates of recurrence.4Banks K.C. Dusendang J.R. Schmittdiel J.A. et al.Association of surgical timing with outcomes in early-stage lung cancer.World J Surg. 2023; 47: 1323-1332Crossref PubMed Scopus (0) Google Scholar A recent systematic review of seven major cancer types that include lung cancer and three different treatment modalities (surgery, systemic treatment, and radiotherapy) showed that a 4-week treatment delay was associated with increased mortality rates.5Hanna T.P. King W.D. Thibodeau S. et al.Mortality due to cancer treatment delay: systematic review and meta-analysis.BMJ. 2020; 371: m4087Crossref PubMed Scopus (455) Google Scholar In summary, timely malignant lung nodule diagnosis is a quality metric for lung cancer care, and delay in the treatment of lung cancer can have adverse consequences on patient-related outcomes such as survival and recurrence. None declared. Invasive Procedures Associated With Lung Cancer Screening in Clinical PracticeCHESTVol. 164Issue 2PreviewThe use of invasive procedures to resolve false-positive findings was uncommon in the clinical practice of a nonuniversity LCS program that adhered to a nodule management algorithm and used a multidisciplinary approach. Incidental findings considered benign but clinically important resulted in invasive procedure rates that were similar to those for false-positive findings and frequently had clinical value. Full-Text PDF Open AccessResponseCHESTVol. 164Issue 2PreviewDrs Kheir's and Omballi’s call for balance raises several important questions about the delay to diagnosis in lung cancer screening (LCS), especially those cancers that present as LungRADS1 category 4A: Full-Text PDF