Are respiratory physicians adherent to guidelines when evaluating pulmonary nodules?

Although fewer than 1% of pulmonary nodules are malignant, appropriate evaluation is essential in optimising patient outcomes. The 2017 Fleischner Society Guidelines provide recommendations on management of incidentally detected nodules; however, studies to date have shown variable guideline adherence. Adherence to guidelines in Australian nodule clinics has not been reported.

A retrospective analysis of medical records was conducted for new patients evaluated in a pulmonary nodule clinic between 1 July 2017 and 1 July 2020. Patient demographics, past medical history, family history of malignancy, smoking history, baseline lung function tests, reasons for referral and lung nodule characteristics were analysed. Follow-up recommendations were evaluated to determine Guideline adherence. Final diagnoses, where available, were extracted from multidisciplinary meeting (MDM) data.

Three hundred sixty-one patients were included (mean age 68.2 years, female 44.3%). One hundred ten patients (30.5%) were never smokers, 106 (29.3%) current smokers, and 140 (38.8%) former smokers. Most lung nodules were identified incidentally (77.0%) with mean diameter (±SD) 12.1 ± 6.4 mm averaged from the long and short axes. Adherence to guidelines was 97.2%. Ninety-seven patients (26.9%) were diagnosed with malignancy. Among patients diagnosed with lung cancer, former smokers had a higher risk (48.1%, relative risk (RR) 1.8; 95% confidence interval (CI) 1.08-3.1; P = 0.02) of lung cancer than never smokers (20.3%), with current smokers being intermediate in risk (31.6%, RR 1.6; 95% CI 0.96-2.84; P = 0.07).

Our findings from this first-in-Australia study demonstrate appropriate lung nodule follow-up in accordance with Fleischner Society Guidelines in a dedicated respiratory physician-led nodule clinic.