Respiratory Institute Outcomes
Thoracic Oncology (Lung Cancer)
Lung Nodule Management Program
Lung nodules are the most common incidental findings on routine medical imaging. It is estimated that an approximate 1.6 million patients per year in the US are identified to have lung nodules.1 Internal data from Cleveland Clinic actionable findings team shows more than 21,000 incidental lung nodule findings reported between January 2022 to August 2023.
Most incidental lung nodules are benign and only a small percentage of nodules represent precancerous or early cancerous lesions. Regardless, incidental lung nodule findings can create a great deal of anxiety and distress for patients. As leaders in the field of pulmonary medicine, the medical team’s aim is to provide patients with accurate risk stratification and appropriate counseling for their lung nodule findings.
The overarching goal of any lung nodule program is to maximize capturing early lung cancers, while minimizing unnecessary follow-up scans and invasive procedures on benign findings.
Patient Referral & Enrollment
2022 - 2023
The lung nodule program at Cleveland Clinic works in close collaboration with the Imaging Institute’s actionable findings team. The team’s goal is to expedite referral and enrollment of high-risk nodule findings into the program. Each week, advanced practice providers review patient charts that have been flagged by the actionable findings Team for any high-risk lung nodule findings. The team then provides outreach to these patients either through phone, MyChart message, or mail and offers them an appointment with one of our lung nodule providers.
In addition to internal referrals for incidental lung nodule findings, the program receives referrals from outside providers along with patient self-referrals for a second opinion. As the program expands and grows, the team must ensure sufficient clinic capacity to allow ease of access for all its patients.
One metric that the team monitors closely is the number of days between consultation request to consultation completion (the target is less is less than 30 days). Our administrative team routinely reviews providers’ clinic slot utilization and diverts clinical resources to where they are needed to ensure expedited patient access.
Review of Historic Imaging
Lung Nodule Patient Has Prior Image
Internal data from the program shows that nearly half of lung nodule patients who come for a new incidental lung nodule have had some form of historic imaging.
| Prior Lung Nodule Image | % |
|---|---|
| Has Prior Image | 47% |
| No Prior Image | 53% |
| Percentage of Total Count | 100% |
Lung Nodule Seen on Prior Image
| Seen on Prior Image | % |
|---|---|
| Lung Nodule Seen on Prior Image | 58% |
| Not Seen in Prior Image | 42% |
| Percentage of Total Count | 100% |
Having historic imaging for comparison is critically important in accurate risk stratification of lung nodule findings.² It is vitally important that all attempts are made to obtain old imaging records for comparison whether they were performed at Cleveland Clinic or at an outside healthcare facility.
The lung nodule program at Cleveland Clinic has dedicated nursing and administrative team members who help retrieve prior imaging studies (regardless of location). This is done ahead of the patient’s clinic visit to save time and allow lung nodule providers to accurately formulate a follow-up plan at the first meeting with the patient.
Guidelines Based Care Paths
To ensure consistent, high-quality practice across all sites and providers, physicians and advanced practice providers receive up-to-date care paths for lung nodule management. Care paths are reviewed and updated annually by Cleveland Clinic program leadership. They are based on expert consensus and the most current recommendations from the Fleischner Society, American Thoracic Society, American College of Radiology, and the American College of Chest Physicians.
Physician and Advanced Practice Provider Training
As with all things in medicine, the management and care of lung nodules is ever evolving. In addition to providing team members with up-to-date care paths, providers have access to monthly didactic lectures, journal article reviews, and case conference, all of which are digitally recorded and available through the Cleveland Clinic Thoracic Oncology Education Portal. The goal is continuous learning and improvement of care delivered to patients.
Multidisciplinary Lung Nodule Tumor Board
Lung nodule management can often be nuanced and not all cases fall within the confines of guidelines. Use of multidisciplinary tumor boards has been shown to reduce radiation exposure and procedure-related complications, as well as lower healthcare expenditure.3 The lung nodule program at Cleveland Clinic has long been utilizing a multidisciplinary tumor board for review of difficult or challenging lung nodule scenarios and in instances where invasive diagnostic testing or surgery may be needed. One of the metrics that is currently being monitored is the rate of invasive testing on benign procedures (ideally this is kept to a minimum to minimize any potential harm to patients). The program’s tumor board takes place on a weekly basis such that treatment plans can be delivered with little delay.
Future Metrics
The lung nodule program at Cleveland Clinic is in a constant state of self-evaluation. Team members work closely with data scientists to explore and capture important metrics, including patient adherence to a follow-up plan, incidence of lung cancer, staging of lung cancer at the time of diagnosis, and rate of invasive procedures being performed on benign findings..
