Differences in VA and Non-VA Pulmonary Nodules: All Evaluations Are not Created Equal

Area of Science:

• Pulmonology
• Thoracic Oncology
• Medical Informatics

Background:

• Indeterminate pulmonary nodules (IPNs) require careful risk assessment for malignancy to guide management.
• Current risk stratification tools and guidelines face challenges in clinical application.

Purpose of the Study:

• To evaluate the performance of risk calculators and current guidelines in managing indeterminate pulmonary nodules.
• To compare patient and nodule characteristics between Veterans Affairs (VA) and non-VA cohorts.

Main Methods:

• A prospective cohort study of 282 patients with IPNs from VA and non-VA sites.
• Analysis included patients with definitive diagnoses or stable/resolved nodules over 2 years.
• Comparison of risk calculator discrimination and calibration between cohorts.

Main Results:

• Malignancy rates were similar (48%) between VA and non-VA patients, but VA patients had higher risk factors (smoking, COPD) and more squamous cell carcinoma.
• Risk calculators showed wide-ranging and variable performance between different tools and between VA/non-VA groups.
• Applying current guidelines could have led to unnecessary resection of 12% of benign nodules.

Conclusions:

• Significant differences exist in risk factors, histology, and stage at diagnosis between VA and non-VA patients with IPNs.
• Risk calculator performance is variable and may not be reliable across different patient populations.
• Current IPN management guidelines and tools require refinement to improve clinical accuracy and patient outcomes.