Data from: Physician assessment of pretest probability of malignancy and adherence with guidelines for pulmonary nodule evaluation

The annual incidence of pulmonary nodules is estimated at 1.57 million. Guidelines recommend using an initial assessment of nodule probability of malignancy (pCA). A previous study found that despite this recommendation, physicians did not follow guidelines.
METHODS:

Physician assessments (N = 337) and two previously validated risk model assessments of pretest probability of cancer were evaluated for performance in 337 patients with pulmonary nodules based on final diagnosis and compared. Physician-assessed pCA was categorized into low, intermediate, and high risk, and the next test ordered was evaluated.
RESULTS:

The prevalence of malignancy was 47% (n = 158) at 1 year. Physician-assessed pCA performed better than nodule prediction calculators (area under the curve, 0.85 vs 0.75; P < .001 and .78; P = .0001). Physicians did not follow indicated guidelines when selecting the next test in 61% of cases (n = 205). Despite recommendations for serial CT imaging in those with low pCA, 52% (n = 13) were managed more aggressively with PET imaging or biopsy; 12% (n = 3) underwent biopsy procedures for benign disease. Alternatively, in the high-risk category, the majority (n = 103 [75%]) were managed more conservatively. Stratified by diagnosis, 92% (n = 22) with benign disease underwent more conservative management with CT imaging (20%), PET scanning (15%), or biopsy (8%), although three had surgery (8%).
CONCLUSIONS:

Physician assessment as a means for predicting malignancy in pulmonary nodules is more accurate than previously validated nodule prediction calculators. Despite the accuracy of clinical intuition, physicians did not follow guideline-based recommendations when selecting the next diagnostic test. To provide optimal patient care, focus in the areas of guideline refinement, implementation, and dissemination is needed.

肺结节的年发病率预估为157万例。临床指南推荐采用肺结节恶性概率（pCA，probability of malignancy）的初始评估方案。既往研究表明，即便有该指南推荐，临床医师仍未严格遵循指南规范。
方法：
本研究纳入337例肺结节患者，基于最终诊断结果，对医师评估结果（N=337）以及两种已验证的癌症预测试概率风险模型的评估性能进行评估与对比。将医师评估的pCA划分为低、中、高风险三级，并对后续开具的检查项目进行分析。
结果：
随访1年时，恶性病变的患病率为47%（n=158）。医师评估的pCA性能优于肺结节预测计算器（曲线下面积分别为0.85与0.75；P<0.001 与 P=0.0001）。61%的病例（n=205）中，医师在选择后续检查项目时未遵循指南推荐。尽管指南推荐对pCA较低的患者采用连续CT成像随访，但其中52%（n=13）的患者接受了更具侵入性的正电子发射断层显像（PET，Positron Emission Tomography）检查或活检；另有12%（n=3）的良性病变患者接受了活检操作。与之相反，高风险等级患者中多数（n=103[75%]）接受了更为保守的诊疗方案。按诊断分层分析显示，良性病变患者中92%（n=22）接受了保守管理，包括CT成像（20%）、PET扫描（15%）或活检（8%），另有3例（8%）接受了手术治疗。
结论：
相较于已验证的肺结节预测计算器，医师评估用于预测肺结节恶性病变的准确性更高。尽管临床直觉具备一定准确性，但医师在选择后续诊断检查时仍未遵循基于指南的推荐方案。为给患者提供最优诊疗服务，亟需在指南优化、落地实施与推广普及三个领域加强工作。