AURORA, CO – Comparing VA patients with higher lung cancer risk to a general population group with lower risk underscored the limitations of using risk calculators in a clinical setting, according to a new study.
That comparison revealed important differences in underlying risk, histology of malignant nodules, and stage at diagnosis, according to the researchers from the University of Colorado and the Rocky Mountain Regional VAMC, both in Aurora, CO.
Because indeterminate pulmonary nodules present a common challenge for clinicians, risk calculators have been developed to help them decide whether to recommend surveillance or intervention based on an assessed risk of malignancy.
In this cohort study published in Clinical Lung Cancer, patients presenting for indeterminate pulmonary nodule evaluation were enrolled at sites participating in the Colorado SPORE in Lung Cancer. The participants were followed prospectively and included for analysis if they had a definitive malignant diagnosis, benign diagnosis, or radiographic resolution or stability of their nodule for more than two years.1
While patients evaluated at the VA and non-VA sites were equally as likely to have a malignant diagnosis (48%), the VA cohort represented a higher-risk group than the non-VA cohort regarding smoking history and chronic obstructive pulmonary disease (COPD), according to the authors. VA malignant nodules included more squamous cell carcinoma diagnoses (25% vs. 10%) and a later stage at diagnosis among VA patients, the study reported.
“Discrimination and calibration of risk calculators produced estimates that were wide-ranging and different when comparing between risk score calculators as well as between VA/non-VA cohorts,” the researchers advised. “Application of current American College of Chest Physicians guidelines to our groups could have resulted in inappropriate resection of 12% of benign nodules.”
They added, “Comparison of VA with non-VA patients shows important differences in underlying risk, histology of malignant nodules, and stage at diagnosis. This study highlights the challenge in applying risk calculators to a clinical setting, as the model discrimination and calibration were variable between calculators and between our higher-risk VA and lower-risk non-VA groups.”
Greater accuracy is important in evaluating pulmonary nodules because of the anxiety and distress caused by diagnoses, according to a recent study.
The report in Chest noted that nearly one-half of respondents experienced emotional distress 6 to 8 weeks following pulmonary nodule identification. “Strategies are needed to mitigate the burden of distress, especially in younger, female, ever smoking, and minoritized patients, and those with larger nodules,” wrote the researchers.
The study was led by 1Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, CA, and included participation from VAMCs in Portland, OR, and Boston.
The findings were based on more than 2,000 surveys completed by patients. Impact of Event Scale-Revised scores indicated mild, moderate, or severe distress in 32.2%, 9.4%, and 7.2% of respondents, respectively. Following adjustment, greater emotional distress was linked to larger nodule size and lack of timely notification by a clinician.
Greater distress was also associated with younger age, female sex, ever smoking, African-American race, and Hispanic ethnicity, while anxiety was associated with lack of timely notification, ever smoking, and female sex.
- New ML, Hirsch EA, Feser WJ, Malkoski SP, Garg K, Miller YE, Baron AE. Differences in VA and Non-VA Pulmonary Nodules: All Evaluations Are Not Created Equal. Clin Lung Cancer. 2023 Jul;24(5):407-414. doi: 10.1016/j.cllc.2023.02.006. Epub 2023 Mar 4. PMID: 37012147; PMCID: PMC10293033.
- Gould MK, Creekmur B, Qi L, Golden SE, et. al. Emotional Distress, Anxiety, and General Health Status in Patients With Small Pulmonary Nodules Shortly After Their Identification: Results From the Watch the Spot Trial. 2023 Jun 24:S0012-3692(23)00924-8. doi: 10.1016/j.chest.2023.06.022. Epub ahead of print. PMID: 37356710.