During the COVID-19 crisis, what’s a lung-screening program to do with a patient referred for surveillance chest CT after a pure ground glass nodule incidentally turned up in his or her lung?
Delay that patient’s surveillance scan for approximately three to six weeks.
That’s one of 12 general yet scenario-specific guidelines issued by a panel of 24 chest-care experts the ACR convened by teleconference. The group’s aim is to help patients as well as directors of lung-imaging programs make good decisions while COVID-19 continues to spread widely.
The panel included 17 pulmonologists and two thoracic surgeons along with five radiologists. Its report posted online in several journals, including JACR, Radiology: Imaging Cancer and Chest, April 23.
Lead author Peter Mazzone, MD, MPH, of Cleveland Clinic, senior author Gerard Silvestri, MD, MS, of the Medical University of South Carolina and colleagues introduce their consensus recommendations with an overview statement.
During the present public-health crisis, they write, “it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation.”
Emphasizing that their recommendations should not be received as one-size-fits-all instructions, the panel notes: “[W]hat is appropriate now will change over time. Application of a general assessment to an individual patient requires the clinical judgment of the management team.”
Here are the panel’s general consensus statements on each of the 12 scenarios as divided into three categories.
Please note: The full document expounds on each statement with essential annotations covering local, regional and patient-related factors that may, in clinical practice, warrant modifying the guidance.
BASELINE AND ANNUAL LUNG CANCER SCREENING
Scenario 1. An individual who meets eligibility criteria is referred to your lung cancer screening program. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer non-urgent care, it is suggested that the initiation of screening be delayed.”
Scenario 2. An individual who meets eligibility criteria is due for their repeat annual chest CT screening exam (Lung-RADS category 1 or 2 on their prior screening exam). Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer non-urgent care, it is suggested that the annual screening exam be delayed.”
SURVEILLANCE OF A PREVIOUSLY DETECTED LUNG NODULE
Scenario 3. A patient is due now for a surveillance CT scan of the chest for an incidentally detected solid nodule, < 8 mm in average diameter. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer non-urgent care, it is acceptable to delay the surveillance CT scan for approximately 3 to 6 months”
Scenario 4. A patient is due now for a surveillance chest CT scan for evaluation of a screening-detected lung nodule, Lung-RADS category 3. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer non-urgent care, it is acceptable to delay surveillance for approximately 3 to 6 months.”
Scenario 5. A patient is due now for a surveillance chest CT scan for an incidentally detected pure ground glass nodule. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer non-urgent care, it is acceptable to delay surveillance of any size pure ground glass nodule for approximately 3 to 6 months.”
Scenario 6. A patient is due now for a surveillance chest CT scan for an incidentally (or screening) detected part-solid lung nodule with the solid component 6 mm to 8 mm in diameter. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer non-urgent care, it is acceptable to delay surveillance for approximately 3 to 6 months.”
Scenario 7. A patient is due now for a 3-month surveillance CT scan of the chest for an incidentally detected solid nodule, ≥ 8 mm in average diameter (or a Lung-RADS category 4 screening-detected lung nodule). You estimate the probability of malignancy to be < 10%. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer non-urgent care, it is acceptable to delay the surveillance CT scan for approximately 3 to 6 months.”
EVALUATION OF INTERMEDIATE- AND HIGH-RISK LUNG NODULES
Scenario 8. A patient presents for evaluation of an incidentally detected solid nodule ≥ 8 mm in diameter (or a Lung-RADS category 4 screening-detected lung nodule). You estimate the probability of malignancy to be 10 to 25%. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer non-urgent care, it is acceptable to re-evaluate the patient with a chest CT scan in approximately 3 to 6 months.”
Scenario 9. A patient presents for evaluation of an incidentally (or screening-) detected part-solid lung nodule with the solid component ≥ 8 mm in diameter. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer non-urgent care, it is acceptable to monitor the nodule with a chest CT scan in approximately 3 to 6 months.”
Scenario 10. A patient presents for evaluation of an incidentally detected solid nodule ≥ 8 mm in diameter (or a Lung-RADS category 4 screening-detected lung nodule). You estimate the probability of malignancy to be 65 to 85%. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to defer procedures and surgery when reasonable, it is acceptable to evaluate the patient with a PET scan and/or non-surgical biopsy to ensure there is a need to proceed to treatment (surgical resection or stereotactic radiotherapy).”
Scenario 11. A patient presents for evaluation of an incidentally detected solid nodule ≥ 8 mm in diameter (or a Lung-RADS category 4 screening-detected lung nodule). You estimate the probability of malignancy to be > 85%. Consensus statement: “During the COVID pandemic, consistent with CDC guidance to minimize exposure to the healthcare environment, it is acceptable to avoid further diagnostic testing and proceed to an empiric treatment decision (i.e. surgical resection or stereotactic radiotherapy).”
Scenario 12. A patient has been diagnosed with a clinical stage I non-small cell lung cancer. Consensus statement: “Treatment of clinical stage I non-small cell lung cancer may be delayed, consistent with CDC guidance to defer surgery when reasonable, after taking into consideration an assessment of the size of the cancer, growth rate of the cancer (if serial imaging is available), FDG/PET avidity of the primary tumor, patient values, and the general health and fitness of the patient.”
In their discussion, panel members underscore that local factors must be considered when making individual decisions around lung imaging while the pandemic continues to confound nearly all providers of non-urgent healthcare.
The factors they name include the prevalence of COVID and the availability of rapid COVID testing in the community, the readiness of resources (capable personnel, imaging equipment and PPE supplies), local policies and the availability of less-affected care sites nearby.
“As much as possible, patient management should be based on evidence and reflect a balance of benefits and harms of particular management approaches,” Mazzone et al. write. “Given the limited information available to clinicians, we encourage providers and patients to consider guidance from this document and those of other professional societies. … We hope these statements are helpful and provide some reassurance and direction to individuals who are eligible for lung cancer screening, patients with lung nodules and the clinicians who care for them during this challenging time.”
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.