Choosing Wisely:

Don’t perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines.

Rationale and Comments: Clinical practice guidelines for pulmonary nodule evaluation (such as those issued by the Fleischner Society or the American College of Chest Physicians) suggest that intensity of surveillance should be guided by the likelihood of malignancy. In patients with no prior history of cancer, solid nodules that have not grown over a two-year period have an extremely low risk of malignancy (although longer follow-up is suggested for ground-glass nodules). Similarly, intensive surveillance (e.g., repeating CT scans every three months for two years or more) has not been shown to improve outcomes such as lung cancer mortality. Meanwhile, extended or intensive surveillance exposes patients to increased radiation and prolonged uncertainty.
Sponsoring Organizations:
  • American College of Chest Physicians/American Thoracic Society
  • Sources:
  • American College of Chest Physicians guidelines
  • Disciplines:
  • Pulmonary medicine
  • References: • MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP, Patz EF Jr, Swensen SJ; Fleischner Society. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400.
    • Gould MK, Donington J, Lynch WR, Mazzone, Midthun DE, Naidich DP, Wiener RS. Evaluation of patients with pulmonary nodules: When is it lung cancer?: ACCP evidence-based clinical practice guidelines (3rd edition). Chest. 2013 May;143(5):e93.
    • Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, Berrington de González A, Miglioretti DL. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009;169(22):2078-86.
    • Wiener RS, Gould MK, Woloshin S, Schwartz LM, Clark JA. What do you mean, a spot? A qualitative analysis of patients’ reactions to discussions with their doctors about pulmonary nodules. Chest. 2012 Jul 17. doi: 10.1378/chest.12–1095. [Epub ahead of print].

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