Inconclusive: The Pulmonary Nodules You Need to Follow

Pulmonary nodules may be identified through calcium CT scoring scans, radiographs for surgery clearance, abdominal CT scans, or secondary to an accident to the thorax requiring radiographs. The cardiologist, general surgeon, or emergency physician may refer the patient back to the PCP rather than to a pulmonologist. But will this land on the top of the referral pile? Are PCPs aware of the standards for 2-year follow-up? An inconclusive pulmonary nodule program can navigate patients whose nodule is not identified within the continuum of cancer care to either benign disease or an early diagnosis of cancer, based on Fleischner criteria.¹

Programs that identify pulmonary nodules in high-risk patients is a priority with the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI), as evidenced by the changes in clinical research grants from CCOP to NCORP with an emphasis on prevention studies. But how should health care systems manage those patients whose nodules were identified on radiographs or scans in cases where a primary care physician (PCP) or pulmonologist was not involved? How many of these patients are missed at an early stage and are not picked up until the nodule is a cancer?

Many hospitals are creating lung-screening programs for high-risk persons, and some cancer programs are establishing lung nodule clinics to address this specific issue. This article reviews the program developed for the Main Line Health regional health system in Lankenau, Pennsylvania, area.

FROM A PILOT TO A SYSTEM-WIDE PROGRAM

Our Pulmonary Nodule Program started as a pilot project at Lankenau Medical Center, the teaching institution in a regional health system that consists of 4 acute-care hospitals. Therefore, physician awareness and education was crucial in that we needed to work with not only attending physicians, but residents and fellows in a multitude of specialty areas as well.

Creating a pilot program at 1 hospital was challenging; expanding it across an entire health care system required cooperation from multiple interdisciplinary teams. We found the keys to a successful program are to educate physician groups on appropriate referrals and follow-up, to keep tabs on patients’ follow-up needs, and to maintain communications with all involved. Issues of sharing information related to the patient with multiple electronic medical records (EMRs) or paper charts, however, are an ongoing work in process.

Multiple tumor board discussions regarding cancer cases with a notation of pulmonary nodules brought up the question of who was responsible for following up these nodules, regardless of the cancer diagnosis. For example, a patient with a known colorectal cancer is found to have a 4 mm nodule in the right upper lobe (RUL). GI knows about the nodule, but has someone put in for a pulmonary consult or called the nurse navigator to follow up the finding?

When these types of cases became increasingly evident, marketing tools were created to promote the Pulmonary Nodule Program to other clinical staffs. The tools were designed to remind all clinicians of the program and encourage referral when nodules were seen in the course of treating the patient.

Appropriate utilization of a nurse navigator who works with the care team reduces outward migration of care as well as early diagnosis of pulmonary cancers, which can lead to an improved quality of life for our patients. Oncology nurses are in a unique position to manage the nontraditional patient, from determining that a nodule exists to designation of a benign or malignant outcome.

The support of the Cancer Committee at each hospital, along with that of senior administration, made expanding the program from a pilot at 1 hospital to a full-fledge program across 4 acute-care hospitals within a regional health care system easier. Clinician education and identification of appropriate referrals is an ongoing need; however, the nurse navigator attends 1 to 2 tumor board meetings at each hospital each month, so knowledge of the program is continuing to grow and referrals are being made increasingly quicker.

HOW THE PROGRAM SHOULD WORK

A key element of ensuring early diagnosis of lung cancer is timely access to care; specifically, reducing the time from abnormal finding to treatment, if necessary. Often lung nodules are identified during diagnostic CT scans conducted for an unrelated condition.

When completing a report for a referring physician, the radiologist sends a copy of the report of abnormal findings to the nurse navigator, who reviews the report with a pulmonary physician. The appropriate follow-up is then recommended. The nurse navigator then contacts the patient’s primary care physician and offers to follow up the patient within the pulmonary nodule program, if the physician wishes.

Unless the primary care physician indicates a preference for a specific pulmonologist or other hospital/system, the patient will be seen as soon as possible (in 1 to 2 weeks). A pulmonologist runs the program, with a multidisciplinary team that evaluates patients, referring all patients with a malignancy to the lung cancer program. This process significantly reduces time from nodule identification to appropriate treatment while also driving patient volume to the cancer program.