#197 Pulmonary Nodules and Lung Cancer Screening with Denitza Blagev MD

March 2, 2020 | By Cyrus Askin

Lung Nodules, Masses and Nodes. Oh My! A Primary Care Guide

Join us as we demystify the world of pulmonary nodules & lung cancer screening. During this episode, Dr. Denitza Blagev (@mybetterdoctor) makes her triumphant return to The Curbsiders to help us tackle this topic. She is currently the Medical Director for Quality/Specialty-Based Care at Intermountain Healthcare and a Pulmonary & Critical Care physician. We learn to take command of the recommendations for lung cancer screening, disambiguate the terms used by pulmonologists and radiologists, and appreciate some of the nuances of lung cancer screening all with the hope of making YOU a better primary care physician!

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Credits

Written and Produced by:  Cyrus Askin MD & Leah Witt, MD

Infographic: Leah Witt, MD

Cover Art: Dr. Kate Grant MBChB DipGUMed

CME/MOC: Cyrus Askin, MD

Hosts: Cyrus Askin MD; Leah Witt, Matthew Watto MD, FACP; Paul Williams MD, FACP   

Editors: Matthew Watto MD, FACP (written materials); Clair Morgan of Nodderly.com (audio)

Guest: Denitza Blagev, MD

Sponsor

ACP’s Medical Knowledge Self Assessment Program, MKSAP 18. MKSAP provides the latest and most comprehensive educational content needed by internists today. It’s THE internal medicine go-to resource for continuous learning and Board preparation. Visit http://www.acponline.org/mksapcurbsiders to place your order!

Time Stamps

• 00:00 Sponsor -ACP’s MKSAP 18 http://www.acponline.org/mksapcurbsiders
• 00:15 Intro, disclaimer, guest bio
• 02:15 Guest one-liner; Picks of the Week*: Educated (book) by Tara Westover; Cheer, Netflix series; The Witcher, Netflix series; Uptime /  Downtime -album by The
• 06:24 Sponsor -ACP’s MKSAP 18 http://www.acponline.org/mksapcurbsiders
• 07:25 Case: Incidental pulmonary nodules; Defining terms: mass vs nodule
• 15:20 Spiel/Counseling a patient with an  incidental lung nodule; Analogy about skin findings and lung nodules
• 20:50 Types of nodules, duration of monitoring; Tracking nodules; Recap on incidental pulmonary nodules
• 27:54 Case: Lung cancer screening (USPSTF, NLST criteria and CMS guidelines); Shared decision making
• 41:56 Lung-RADS and lung cancer screening; Types of CT scan; When to refer
• 48:22 Take home points on Lung Cancer screening
• 52:35 Outro

Pulmonary Nodules & Lung Cancer Screening Pearls

1. Pulmonary Nodule definition:  <30mm lesion, surrounded by aerated lung. Nodule can be solid, semi-solid or ground-glass, and certain radiographic (and clinical) features alter the likelihood of malignancy. 
2. Incidental nodules: Use the Fleischner criteria to determine what to do with the incidentally found nodule (meaning, you weren’t looking for it but happened to find it on a test ordered for another reason).
3. Nodules on lung cancer screening testing: Fleischner criteria do not apply here! Use Lung-Rads to risk stratify nodules discovered as part of lung cancer screening.
4. Remember 6mm: incidentally found nodules less than 6mm do not need to be followed up via repeat scan, even in high risk patients, unless a shared decision is explicitly made to do so.
5. Consider using the Mayo Score or Brock Score for more nuanced guidance on determining likelihood of malignancy (for solitary pulmonary nodules) and counseling patients about risk and evaluation.
6. Lung cancer screening is not as simple as just ordering the low-dose CT: counsel your patients on the risks (false-positives, “incidentalomas,” additional tests/procedures, radiation) and benefits and make sure to meaningfully counsel active smokers to stop smoking. Have a plan to follow up the test results and order repeat studies if needed.
7. Who to screen? It’s not just about USPSTF or CMS… consider using ShouldIScreen.com or Is Lung Cancer Screening Right for Me? with your patients. Use a decision aid when discussing lung cancer screening with patients.

Pulmonary Nodules & Lung Cancer Screening: Detailed Show-Notes

Nodules & Masses – A glossary of terms:

• Pulmonary Nodule: a rounded opacity, well or poorly defined, measuring up to 3 cm (i.e. < 30mm) in maximal diameter and surrounded completely by aerated lung (Cruickshank 2019)
  • Sub-cm nodules are generally considered lower risk (Dr. Blagev)
    • ≤ 5 mm have a risk of malignancy of <1%, even in high‐risk patient groups (Horeweg 2014)
  • Multiple nodules? Think endocarditis, vasculitis, fungal infection/pneumonia, metastatic disease, etc –  most clinical algorithms are designed for the Solitary Pulmonary Nodule (SPN)
• Pulmonary Mass: same definition as above, however, the size must be 3 cm or greater (Cruickshank 2019)
• Incidental Pulmonary Nodule: a pulmonary nodule discovered on imaging that was not ordered for the sole-purpose of identifying such nodules
• Lung Cancer Screening CT: a low-dose (~1.5 millisieverts) CT scan used in high-risk patients to identify nodules and allow risk-stratification based on malignant potential (Fintelmann 2017)
  • For reference: Yearly background radiation in the United States is approximately 3.5 millisieverts per the United States Nuclear Regulatory Commision 
• High-Resolution CT: 1mm cuts (just like all chest CTs, more-or-less) with inspiratory, expiratory and prone imaging

So you’ve found an incidental pulmonary nodule. Now What?

• The recommendations most commonly followed are the Fleischner Society Guidelines,  for patients over age 35 who are not immunocompromised (Macmahon 2017).
• This is in comparison to the Lung-Rads classification of SPNs, which is generally used for SPNs found on lung cancer screening CT scans ordered to identify suspicious nodules in patients with a significant smoking history (Fintelmann 2017).

Dr. Blagev’s Approach to SPNs:

• Is it solid?
  • No: Proceed directly to determining follow-up based upon Fleischner Criteria
  • Yes:  Determine malignancy risk based on the largest nodule + risk factors
• Per ACCP (Gould 2013)
  • <5% likelihood of malignancy = Low Risk
  • 5-65% likelihood of malignancy = Intermediate Risk
  • >65% likelihood of malignancy = High Risk
• However, for the purposes of risk stratifying per Fleischner Criteria, the society recommends combining the ACCP  intermediate and high risk categories into one “high-risk category” (Macmahon 2017)
  • <5% likelihood of malignancy = Low Risk
  • 5+% likelihood of malignancy = High Risk
• Option One: estimate high vs low risk based upon presence of  risk factors such as:
  • “Heavy” smoking history
  • Occupational exposures (ex: asbestos, radium, uranium)
  • Family history of lung cancer 
  • Older age
  • Sex (females > males)
  • Race (African American and Native Hawaiian > Caucasian)
  • Marginal spiculation 
  • Upper lobe location
  • Prior history of pulmonary disease (ex: pulmonary fibrosis)
• Option Two: if greater granularity is needed, there are calculators available which will yield percentages that in turn can allow stratification:
  • Mayo Score for SPNs
  • Brock Score for SPNs
• Kashlak Pearl from Dr. Blagev: Is this person actually eligible for lung cancer screening per USPSTF guidelines? If so, consider using Lung-Rads as opposed to Fleischner.
• Semi solid & ground glass nodules: these nodules have malignant potential and tend to be slow growing – hence they are monitored for longer
• Size in a nutshell:
  • <6mm – If low risk, no follow up is necessary, if high-risk, follow up should  be discussed/considered
  • >6mm – All should be offered follow up with interval/modality varying depending on size (6-8 vs 8+mm) and high vs. low risk

Counseling patients

• Be open: Share the likelihood of malignancy with your patient (i.e. communicate your patient’s risk), use this as a means to set expectations.
• Educate: Take time to explain what a nodule is and consider sharing the thought process behind determination of follow up. If you can, show the patient their CT scan.
• Shared decision-making: Give the recommendation, explain the reasoning, but at the end of the day, the decision to follow up, how to follow up and when to follow up should be made jointly.
• Be consistent: Use the terms the patient may see in their CT report (such as nodule!) to avoid introducing new terms and confusion.
• Use analogies: For example, Cyrus compares pulmonary nodules to cutaneous findings (scars, moles, etc.) because patients may be able to conceptualize lung findings through this paradigm with greater ease.

Lung Cancer Screening

The question: Is this person at high-enough risk to warrant annual CT scans to look for lung cancer?

The National Lung Screening Trial (NLST):  

• A seminal 2011 study of > 50,000 U.S. patients enrolled in the early 2000’s,  looking at the utility of LDCTs in patients deemed “high-risk” with respect to risk of developing lung cancer (Aberle 2011).
  • “participants… between 55 and 74 years of age at the time of randomization, had a history of cigarette smoking of at least 30 pack-years, and, if former smokers, had quit within the previous 15 years” – this forms the basis for our screening. 
• “There were 247 deaths from lung cancer per 100,000 person-years in the low-dose CT group and 309 deaths per 100,000 person-years in the radiography group, representing a relative reduction in mortality from lung cancer with low-dose CT screening of 20% (95% CI, 6.8 to 26.7; P=0.004).”
• “The rate of death from any cause was reduced in the low-dose CT group, as compared with the radiography group, by 6.7% (95% CI, 1.2 to 13.6; P=0.02).”

The NLST laid the framework for current screening parameters (based on age and tobacco history), however, due to various analyses done after the NLST, there are some slightly different recommendations from USPSTF & CMS:

• USPSTF: 55-80 y/o, 30+ pack-year smoking history, active smoker or quit less than 15 years ago.
• CMS: 55-77 y/o, 30+ pack-year smoking history, active smoker or quit less than 15 years ago (**correction from the show, where 55-78 was mentioned).
  • Screening only covered if done along with tobacco cessation counseling for those who are active smokers & risks of screening / need for continued screening.
  • Kashlak Pearl: Dr. Blagev shares that from a quality / risk-mitigation standpoint,  it’s important that follow up scans (i.e. those after the first scan) also be low-dose CT scans, even if a 7mm nodule is found on the prior scan.
• The findings from these screening CTs should be stratified based upon LungRads
  • Spectrum from 1-4, negative to suspicious

Tools for Screening

Dr. Denitza Blagev: False positives are a big deal! How do you choose who to screen?

• Consider ShouldIScreen.com – allows you to provide your patients a visual representation of the potential benefits from screening and can thus aid in shared decision making.

Dr. Leah Witt: Could also consider using the AHRQs resource: Is Lung Cancer Screening Right for Me?

• Despite the importance of shared decision making, Leah shares a JAMA IM article from Brenner et al highlighting some shortcomings in shared decision making, specifically as pertaining to discussion of the risks associated with lung-cancer screening CTs (Brenner 2018).

Goal

Listeners will develop an approach to incidentally found pulmonary nodules, lung cancer screening and what to do with the suspicious lung nodule or mass.

Learning objectives

After listening to this episode listeners will…

1. …be familiar with the differences between nodules & masses and some of the common etiologies for these findings.
2. … appreciate the difference between the incidental pulmonary nodule and those found during lung cancer screening and thus the different systems (Fleischner vs. Lung-Rads) used to assess nodules.
3. … have a framework for how to approach incidental pulmonary nodules, particularly with respect to the 2017 Fleischner Society Guidelines .
4. … be able to educate peers & patients regarding who qualifies for lung cancer screening and who does not.
5. … understand what makes a patient “high risk” vs. “standard risk” with respect to incidentally found pulmonary nodules.
6. … appreciate the background and reasoning behind the current recommendation for lung cancer screening
7. … discover how to determine follow up of a lung nodule found as part of a lung cancer screening CT using Lung-Rads.
8. … learn strategies regarding how to discuss incidental nodules and nodules found on screening CTs with patients, as well as how to approach the discussion of whether or not to screen with the use of various readily available resources .

Links*

1. Educated by Tara Westover – Dr. Blagev’s pick-of-the-week
2. Cheer, Netflix series – Leah’s pick -of-the-week
3. The Witcher, Netflix series – Cyrus’s pick-of-the-week
4. Uptime /  Downtime – The Kleptones – Paul’s pick-of-the-week

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

References

1. Cruickshank A, Stieler G, Ameer F. Evaluation of the solitary pulmonary nodule. Intern Med J. 2019;49(3):306-315.
2. Horeweg N, Van rosmalen J, Heuvelmans MA, et al. Lung cancer probability in patients with CT-detected pulmonary nodules: a prespecified analysis of data from the NELSON trial of low-dose CT screening. Lancet Oncol. 2014;15(12):1332-41.
3. Macmahon H, Naidich DP, Goo JM, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. 2017;284(1):228-243.
4. Fintelmann FJ, Gottumukkala RV, Mcdermott S, Gilman MD, Lennes IT, Shepard JO. Lung Cancer Screening: Why, When, and How?. Radiol Clin North Am. 2017;55(6):1163-1181.
5. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e93S-e120S.
6. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409.
7. Brenner AT, Malo TL, Margolis M, et al. Evaluating Shared Decision Making for Lung Cancer Screening. JAMA Intern Med. 2018;178(10):1311-1316.

Disclosures

Dr. Blagev has received research grants from Astra Zeneca, Zebra Medical and GSK through grants to Intermountain Healthcare and joint publications. We did not discuss any of these products or services during this recording. The Curbsiders have no relevant financial disclosures.

Citation

Askin C, Witt L, Blagev D, Williams PN, Watto MF. “#197 Pulmonary Nodules and Lung Cancer Screening with Denitza Blagev MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. March 2, 2020.