The following is a summary of “Differences in VA and Non-VA Pulmonary Nodules: All Evaluations Are not Created Equal,” published in the July 2023 issue of the Clinical Lung Cancer by New et al.
Clinicians who must recommend surveillance or intervention based on the risk of malignancy posed by indeterminate pulmonary nodules face a common obstacle. In this cohort study, centers participating in the Colorado SPORE in Lung Cancer enrolled patients presenting for evaluation of indeterminate pulmonary nodules. If they had a definitive malignant diagnosis, benign diagnosis, or radiographic resolution or stability of their nodule for >2 years, they were followed prospectively and included in the analysis. Patients evaluated at Veterans Affairs (VA) and non-VA sites had the same likelihood of receiving a malignant diagnosis (48%).
The VA cohort posed a greater risk for smoking history and chronic obstructive pulmonary disease (COPD) than the non-VA cohort. More VA malignant nodules were diagnosed with squamous cell carcinoma (25% vs. 10%) and at a later stage in VA patients. When comparing risk score calculators and VA/non-VA cohorts, discrimination and calibration of risk calculators yielded widely varied and distinct estimates. Applying the American College of Chest Physicians guidelines to their groups could have led to the inappropriate resection of 12% of benign nodules. Significant distinctions exist between VA and non-VA patients in terms of underlying risk, histology of malignant nodules, and stage of diagnosis.
This study demonstrates the difficulty of deploying risk calculators in a clinical setting, as model discrimination and calibration varied between calculators and their higher-risk VA and lower-risk non-VA groups. Risk stratification and managing indeterminate pulmonary nodules (IPNs) is a prevalent clinical issue. Researchers found differences in patient and nodule characteristics, histology and diagnostic stage, and risk calculator performance in this prospective cohort study of 282 patients with IPNs from Veterans Affairs (VA) and non-VA sites. Their findings emphasize the difficulties and deficiencies of the current IPN management guidelines and tools.