Study data published in JAMA Internal Medicine were inconclusive regarding the association of the intensity of lung diagnostic evaluation and advanced stage of lung cancer (stage III or IV disease) at diagnosis. However, findings from the comparative effectiveness evaluation indicated that higher-intensity diagnostic assessment was linked to greater radiation exposure, more procedure-related adverse events (AEs), and costlier health care expenditures.

“These findings underscore the need for more evidence on better ways to evaluate lung nodules and to avoid unnecessarily intensive diagnostic evaluations of lung nodules,” the study authors wrote.

Aims of this study included determining whether evaluation intensity was associated with a higher risk for the diagnosis of stage III or IV disease and/or other negative consequences, and examining whether guideline-concordant lung nodule evaluations lead to better outcomes. Clinical practice guidelines for the evaluation of lung nodules are categorized by the intensity of the evaluation and assign patients to an intensity level based on individual risk factors for lung cancer and nodule characteristics.

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The retrospective study evaluated data from 5057 patients enrolled in the Kaiser Permanente Washington (Seattle, Washington) and Marshfield Clinic in (Marshfield, Wisconsin) health plans with an incidental lung nodule finding between January 1, 2005 and December 31, 2015. Evaluation intensity was based on the 2005 Fleischner Society guideline, which was applicable to the timeframe of the study population’s evaluation.

Less intensive evaluation was defined as lack of testing, longer time than recommended between surveillance intervals, or less invasive testing than recommended. Higher intensity was defined as further testing despite guideline support for testing cessation, a shorter-than-recommended time to chest computed tomography (CT), and more invasive testing than recommended.

At baseline, the median patient age was 67 years. Fifty-five percent of patients were female, 91% were White, and 58% had a smoking history. Multiple nodules were found in 55% of patients, and 73% of patients were recommended to follow-up with a radiologist. No infectious cause was suspected in 98% of cases. Fifty-eight percent of patients were classified as high-risk based on Fleischner Society guideline risk strata.

Guideline-concordant care was delivered to 38% of patients in the cohort while 37% and 25% received less intense and more intense evaluation than recommended, respectively.

Less intensive evaluations did not result in a higher rate of diagnosis of stage III or IV disease among those who were ultimately diagnosed with lung cancer (risk difference [RD], 4.6%; 95% CI, -22% to +31%). Similarly, evaluations of a higher intensity than recommended were not associated with the rate of diagnosis of stage III or IV disease (RD, -0.5%; 95% CI, -28% to +27%).

The time to lung cancer diagnosis was longest for the group that underwent less intensive evaluation at a median of 12.0 months, followed by 2.3 months in the more-intensive-than-recommended evaluation group, and 1.3 months in the guideline-concordant group.

High-intensity evaluations were associated with a greater number of procedure-related AEs (RD, 8.1%; 95% CI, +5.6% to +11%), higher mean radiation exposure (RD, +6.8 milliSieverts [mSV]; 95% CI, +5.8 mSV to +7.8 mSV), and costlier health care expenditures ($20,132; 95% CI, +$14,398 to +$25,868).

The study authors concluded that the evaluation “found inconclusive evidence of an association between evaluation intensity and lung cancer stage distribution.” They added that these findings highlight “the need to increase the level of evidence that supports current guideline recommendations.”

Disclosures: Some of the study authors disclosed financial relationships with the pharmaceutical industry and/or the medical device industry. For a full list of disclosures, please refer to the original study.


Farjah F, Monsell SE, Gould MK, et al. Association of the intensity of diagnostic evaluation with outcomes in incidentally detected lung nodules. JAMA Intern Med. Published online January 19, 2021. doi:10.1001/jamainternmed.2020.8250