Comparing modalities for risk assessment in patients with pulmonary lesions and nondiagnostic bronchoscopy for suspected lung cancer.
Diana H Yu, Majid Shafiq, Hitesh Batra, Marla Johnson, Bailey Griscom, Janna Chamberlin, Lori R Lofaro, Jing Huang, William A Bulman, Giulia C Kennedy, Lonny B Yarmus, Hans J Lee, David Feller-Kopman
Author Information
Diana H Yu: Department of Medicine, Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco, USA, CA. diana.yu@ucsf.edu.
Majid Shafiq: Brigham and Women's Hospital, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Boston, MA, USA.
Hitesh Batra: Department of Medicine, Division of Pulmonary and Critical Care Medicine Birmingham, University of Alabama at Birmingham, Birmingham, AL, USA.
Marla Johnson: Veracyte, Inc., South San Francisco, CA, USA.
Bailey Griscom: Veracyte, Inc., South San Francisco, CA, USA.
Janna Chamberlin: Veracyte, Inc., South San Francisco, CA, USA.
Lori R Lofaro: Veracyte, Inc., South San Francisco, CA, USA.
Jing Huang: Veracyte, Inc., South San Francisco, CA, USA.
William A Bulman: Veracyte, Inc., South San Francisco, CA, USA.
Giulia C Kennedy: Veracyte, Inc., South San Francisco, CA, USA.
Lonny B Yarmus: Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Hans J Lee: Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
David Feller-Kopman: Department of Medicine, Division of Pulmonary and Critical Care Medicine, Dartmouth College, Hanover, NH, USA.
BACKGROUND: Bronchoscopy is commonly utilized for non-surgical sampling of indeterminant pulmonary lesions, but nondiagnostic procedures are common. Accurate assessment of the risk of malignancy is essential for decision making in these patients, yet we lack tools that perform well across this heterogeneous group of patients. We sought to evaluate the accuracy of three previously validated risk models and physician-assessed risk (PAR) in patients with a newly identified lung lesion undergoing bronchoscopy for suspected lung cancer where the result is nondiagnostic. METHODS: We performed an analysis of prospective data collected for the Percepta Bronchial Genomic Classifier Multicenter Registry. PAR and three previously validated risk models (Mayo Clinic, Veteran's Affairs, and Brock) were used to determine the probability of lung cancer (low, intermediate, or high) in 375 patients with pulmonary lesions who underwent bronchoscopy for possible lung cancer with nondiagnostic pathology. Results were compared to the actual adjudicated prevalence of malignancy in each pre-test risk group, determined with a minimum of 12 months follow up after bronchoscopy. RESULTS: PAR and the risk models performed poorly overall in the assessment of risk in this patient population. PAR most closely matched the observed prevalence of malignancy in patients at 12 months after bronchoscopy, but all modalities had a low area under the curve, and in all clinical models more than half of all the lesions labeled as high risk were truly or likely benign. The studied risk model calculators overestimate the risk of malignancy compared to PAR, particularly in the subset in older patients, irregularly bordered nodules, and masses > 3 cm. Overall, the risk models perform only slightly better when confined to lung nodules < 3 cm in this population. CONCLUSION: The currently available tools for the assessment of risk of malignancy perform suboptimally in patients with nondiagnostic findings following a bronchoscopic evaluation for lung cancer. More accurate and objective tools for risk assessment are needed. TRIAL REGISTRATION: not applicable.
