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J Thorac Cardiovasc Surg 2009;137:33-35
© 2009 The American Association for Thoracic Surgery
Invited Commentary |
Dr Veeramachaneni, it was a very good presentation, providing a lot of very useful information. Perhaps I can summarize, as you did, and add a little bit more.
Why does a surgeon want to get involved with ditzels, with little nodules? As you pointed out, it certainly is a way of alleviating anxiety on the part of the patient and providing a service to the patient and the primary physician, both of whom have received letters from the radiologist saying, "You have a nodule. It could be lung cancer. You should be followed up." And who better to follow it up than a surgeon, ideally a conservative surgeon, who is in the best position to make a judgment as to what should be watched and what should be excised? By the way, I think it does promulgate the interest of thoracic surgeons in all things relating to lung cancer. I have often been quoted as saying nothing is too small, in my opinion, for a thoracic surgeon to be involved in.
I think it also fosters research into the early diagnosis: how to tell which nodules are cancer or not. It not only maintains the radiologic skills of the thoracic surgeons, but also encourages other investigators to use this as a population base to figure out some tag, some marker, some immunologic way of determining if a nodule is malignant. Here you have a database, a group of patients who are being followed up. I think that is another potential environment.
I think it supports the minimally invasive treatment of early cancers, whether by ablative techniques or excisional techniques. Again, I think it is not bad for the thoracic surgeon to be involved.
We started a clinic in Philadelphia. We talked to the HMO that did not send their patients to our institution for CT scans. I said, "I will not take the responsibility of following the patients and saving you a lot of money and unnecessary surgery unless you agree to allow us out of network to do the CT scans," and they said yes.
My final question concerns the loss of follow-up of patients. Have you any idea as to whether it was because of the patient or because of insurance issues, and do you have any follow-up on those patients to know what the ultimate outcome was?
Dr Veeramachaneni. We lost 45% of our patients to follow-up, and we were not able to contact all of them individually to determine why they did not follow up. All that we do have is a clinic note that indicates that they were scheduled for follow-up and they did not show up. A small subset of patients showed up for their first clinic visit where the surgeon as well as the nurse practitioner evaluated them. They were subsequently scheduled for follow-up. About 20-odd patients in that group failed to show up for their first follow-up. Those patients we have contacted. Approximately half of them chose to continue follow-up with their referring physician and the other half just chose to discontinue follow-up entirely. I do not have a good sense of whether it was an insurance or financial-driven thing, but given the large catchment area of Washington University, I think travel distance might have been partially responsible.
Dr Cooper. I noticed that you had a very low incidence in the use of PET scans, which I greatly applaud. I think their value is uncertain for the 3-, 4-, 5-, and 6-mm nodule. The standard seems to be that everybody gets a PET scan, and if they have a positive one, they are told they have cancer. I certainly think that your limited use of PET scan saved a lot of money for the system. Do you have any comment as to what you believe the importance of PET scan is in monitoring these patients?
Dr Veeramachaneni. For this presentation, I did not actually include that information, but we had 42 patients out of the entire cohort, or approximately 10%, who underwent PET imaging. It suggested malignancy in 8 patients, but its accuracy was not 100%, because most of these lesions were in the 1-cm or perhaps even smaller category.
Dr Cooper. Actually, we have only gotten started. We are following up about 130 patients. Six people came in with lung cancers that were pretty obvious. It is surprising how many patients are out there who have been followed up for lesions that even the conservative individual would not normally follow. Maybe that is a secondary benefit.
My last question is this: You mentioned 2 patients who either had widespread metastases or N2 disease when they were finally discovered to have cancer. That is somewhat different from Claudia Henschke's experience. I know she has been subject to a lot of criticism, but what she did demonstrate is that careful follow-up using different types of tools for early nodules can lead to a resection of those that are cancer, an extremely high cure rate, and a very low incidence of unnecessary operative interventions. Have you any messages for us on how to avoid following up patients and subsequently finding out that they have N2 or widespread disease? Do you think in retrospect there is anything different that you would have done?
Dr Veeramachaneni. In 1 of those 2 patients the nodule in question was in the setting of an apical scar. The patient was followed up for a number of years, and there was some controversy as to whether there was any radiographic change. In fact, this case was actually presented at a multidisciplinary conference and the decision was made to offer the patient just another follow-up imaging study in a 6-month interval. In the meantime, however, bone metastasis developed. In the other patient, who presented with T1 N2 disease, the PET scan was also negative. I apologize that we do not have standardized uptake value measurements of that patient because none were reported at that time, but micrometastatic disease was noted at the time of thoracotomy.
Dr Cooper. Thank you very much, Dr Veeramachaneni. It was a great paper.
Dr Ross M. Bremner (Phoenix, Ariz). I think one of the benefits of having a clinic like this is to allow for easy referral for physicians who do not know what to do with a pulmonary nodule. It may be very obvious to us that it is a lung cancer. To allow that ease is a great benefit of having such a clinic.
I have two quick questions. Do you have any information on the cost-efficacy per patient who ended up being treated for cancer for those 1000-plus scans that you did? Second, how did you address the malpractice issues involved with this, the patients who do not get followed up and then the patients whom you stop following up after 2 years, who may have an indolent cancer or bronchioloalveolar carcinoma lesion.
Dr Veeramachaneni. I cannot comment on cost analysis. I do not know the exact data as to how much revenue was generated or the cost. That is somewhat of a soft number, as I have discovered in terms of trying to figure out the exact cost of anything.
As to your second question, at the time that each patient is seen in clinic, we recommend follow-up and we also schedule their follow-up for their next visit. In addition, we inform the referring primary care physician of the need for follow-up and what our findings were in the form of a letter. However, we have not tried to track down those patients who do not show up subsequently.
Dr Scott J. Swanson (New York, NY). I enjoyed this. I think it is a great addition to what we do as thoracic surgeons.
It seems to me you may want to rethink the 2-year strategy, since over half of your patients presented after 2 years. What is your current recommendation about how long to follow up patients? Did you try to recontact the people that you dismissed after 2 years to see how they are doing?
Dr Veeramachaneni. I completely agree with you that the 2-year benchmark was established in an era before high-resolution CT scans and finding patients with these small nodules. Just as the ELCAP trial demonstrated, we might be diagnosing these patients at an earlier stage of cancer, but it is still a matter of debate as to whether we are accomplishing improved morbidity or mortality by acting on these data. Once we have identified patients with a nodule, I think we are somewhat obligated to continue to counsel these patients and follow them. We do not have a specific end point.
As to the question of what do we do about the patients who were dismissed from our clinic, all of these patients did have radiographic stability and they did not have new nodules that would have mandated further testing. If these individuals are considered at high risk, their physicians might want to enroll them in a screening trial. However, right now I do not think there are any data to support enrolling high-risk patients routinely into screening programs outside of a clinical trial.
Dr Frank C. Detterbeck (New Haven, Conn). The spectrum of disease that we are seeing is changing dramatically. I recently did a review of this. Tumor doubling time for normal, routine-care–detected patients is 136 days on average, and in CT screening studies it is 485 days, dramatically different. That is why the whole 2-year mark is changing. It is clear that we are seeing indolent tumors in a different spectrum of disease.
My question is really something to work on. I think that you would be in an ideal situation to look at patients who were discovered as part of a CT screening trial and those patients who happened to be walking down the street within 100 yards of an emergency room and somehow ended up with a scan and see if those are similar populations. I suspect they are, but it would be very useful.
Dr Veeramachaneni. Thank you.
Dr Walter Klepetko (Vienna, Austria). How many of your patients had a history of any other malignant disease? Did you exclude those patients from such a study? Would it have any impact on your follow-up strategy?
Dr Veeramachaneni. We did not exclude any patients who were referred to our clinic. The 2 patients who received a diagnosis of metastatic lesions in fact had a known history of nonlung primary tumors. One patient had sarcoma and the other patient had colorectal cancer. In terms of clinical management and follow-up of those nodules, it was left to the discretion of the surgeon evaluating that patient whether it should be 6-month interval follow-up or 1-year follow-up.
Dr Klepetko. My second question concerns your judgment of changes in the size of the nodules. Was it done with the naked eye of the radiologist or did you apply volumetric assessment?
Dr Veeramachaneni. I do not know the specific technique used by our radiologists, but from my recent exposure to our radiologists, I do not believe they use an automated volumetric assessment. They rely on the measurements that they routinely take. I should stress that it is the same group of radiologists, the same CT scanner, and, no doubt, the same technique.
Dr Cerfolio. How many people in the audience are using volumetric measurements for these ditzelomas with thin-cut CTs as opposed to just linear?
[A show of hands.]
Dr Cerfolio. That is what we have gone to at the University of Alabama at Birmingham. I think that is a more accurate way. If they have only one nodule, you can get them in and they get a thin slice, they get less radiation, and they do not need intravenous contrast.
Dr Klepetko. It is extremely helpful and provides very objective data.
Dr Cerfolio. And it is more accurate.
Dr John R. Benfield (Los Angeles, Calif). A number of years ago I reviewed a paper that was subsequently published in the Annals of Thoracic Surgery, which indicated that there is perhaps little need, if any, for surgeons to follow up their patients postoperatively long term. I wrote an invited, or perhaps not so invited, commentary speaking against that and in favor of surgeons following up their patients. What is your posture toward following up patients postoperatively long term? Do you agree or disagree with the thesis that long-term postoperative follow-up can simply be relegated to primary physicians or referring physicians?
Dr Veeramachaneni. I think as surgical oncologists and thoracic oncologists, we have an obligation to continue to follow up these patients, and that is certainly the practice at Washington University.
Dr Erino Angelo Rendina (Rome, Italy). My question echoes that of Dr Benfield. As a matter of fact, I think your paper is of extreme interest from a speculative point of view. However, from the standpoint of manpower, is it really indispensable that thoracic surgeons be involved in such a clinic, considering that in the time span of 2 years, only 5 patients were operated on out of more than 400?
Dr Veeramachaneni. In the interest of full disclosure, I should state that this clinic is formally disbanded owing to lack of nurse practitioner personnel. This happened within the past year, but these patients continue to be seen in the regular clinic. The way the clinic was designed, a nurse practitioner who was following up these solitary pulmonary nodule patients would show up at the same time as the regular clinic. These patients would be scheduled at the same time as the regular clinic, but most of the patient education follow-up would be done by the nurse practitioner. The surgeon would be able to come in and say hello or provide additional counseling, but the whole idea was to unburden the surgeon from routine follow-up while at the same time providing high-quality care.
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