Most Lung-Nodule Evaluation Can Be Delayed During COVID-19 Pandemic

By Reuters Staff

April 30, 2020

NEW YORK (Reuters Health) - Most lung-cancer screening and evaluation of incidentally detected lung nodules can be delayed for several months during the COVID-19 pandemic, according to an expert panel.

The added risk to patients and healthcare providers from exposure to the healthcare environment and the contact that occurs during testing have altered the balance of benefit and harm struck by current guideline recommendations for lung-cancer screening and the evaluation of lung nodules, Dr. Peter J. Mazzone of Cleveland Clinic's Respiratory Institute, in Cleveland, Ohio, and colleagues note in a report simultaneously appearing in the Journal of the American College of Radiology, CHEST and Radiology: Imaging Cancer.

The expert panel, comprising pulmonologists, thoracic radiologists and thoracic surgeons, reviewed the current evidence related to lung-cancer screening and lung-nodule evaluation. They then developed a dozen statements related to baseline and annual lung-cancer screening, surveillance of a previously detected lung nodule, evaluation of intermediate- and high-risk lung nodules and management of clinical stage I non-small cell lung cancer (NSCLC).

During the COVID-19 pandemic, initiation of lung-cancer screening of individuals who meet eligibility criteria, as well as chest CT of individuals due for their repeat annual screening, can be delayed, they advise.

Similarly, surveillance CT scans can be delayed for approximately three to six months for patients with an incidentally detected solid nodule <8 mm in average diameter, as well as patients with a screening-detected lung nodule, Lung-RADS category 3; patients with an incidentally detected pure-ground-glass nodule; patients with an incidentally (or screening-) detected part-solid lung nodule whose solid component is 6-8 mm in diameter; patients with a larger (8 mm or greater average diameter) incidentally detected solid nodule (or a Lung-RADS category 4 screening-detected lung nodule) where the probability of malignancy is estimated to be as high as 25%; and patients with a part-solid lung nodule whose solid component is 8 mm or more in diameter.

For patients with an incidentally detected solid nodule 8 mm or more in diameter (or a Lung-RADS category 4 screening-detected lung nodule) with an estimated probability of malignancy of 65% to 85%, it is acceptable to evaluate them with a PET scan and/or nonsurgical biopsy to ensure there is a need to proceed to treatment with surgical resection or stereotactic radiotherapy.

For similar patients whose estimated probability of malignancy exceeds 85%, it is acceptable to avoid further diagnostic testing and proceed to an empiric treatment decision.

Finally, for patients diagnosed with a clinical-stage-I NSCLC, treatment may be delayed after taking into consideration an assessment of the size of the cancer, its growth rate, FDG/PET avidity of the primary tumor, patient values, and the general health and fitness of the patient.

Patient preferences should be taken into account in all of these scenarios, because individual patients may differ in how they perceive the potential benefits and harms associated with delayed or modified evaluation and management.

The authors "recognize that our statements should not be interpreted as one-size-fits-all, and that what is appropriate now will change over time. Application of a general assessment to an individual patient requires the clinical judgment of the management team."

"Local factors, such as the prevalence of COVID in the community, the availability of rapid COVID testing, the adequacy of resources (personnel, imaging equipment, personal protective equipment), local policies, and the presence of other care delivery sites that are less impacted by COVID, should be considered when making individual decisions," they add.

The recommendations are endorsed by the American College of Radiology.

Dr. Mazzone did not respond to a request for comments.

SOURCE: Journal of the American College of Radiology, online April 23, 2020.