Effect of a pulmonary nodule fact sheet on patient anxiety and knowledge: a quality improvement initiative

Pulmonary nodules and the psychological harm they can cause: A scoping review

More than 1.6 million pulmonary nodules are diagnosed in the United States each year. Although the majority of nodules are found to be benign, nodule detection and the process of ruling out malignancy can cause patients psychological harm to varying degrees. The present study undertakes a scoping review of the literature investigating pulmonary nodule-related psychological harm as a primary or secondary outcome. Online databases were systematically searched to identify papers published through June 30, 2023, from which 19 publications were reviewed. We examined prevalence by type, measurement, associated factors, and behavioral or clinical consequences. Of the 19 studies reviewed, 11 studies investigated distress, anxiety (n = 6), and anxiety and depression (n = 4). Prevalence of distress was 24.0 %-56.7 %; anxiety 9.9 %-42.1 %, and 14.6 %-27.0 % for depression. A wide range of demographic and social characteristics and clinical factors were associated with nodule-related psychological harm. Outcomes of nodule-related harms included experiencing conflict when deciding about treatment or surveillance, decreased adherence to surveillance, adoption of more aggressive treatment, and lower health-related quality of life. Our scoping review demonstrates that nodule-related psychological harm is common. Findings provide evidence that nodule-related psychological harm can influence clinical decisions and adherence to treatment recommendations. Future research should focus on discerning between nodule-related distress and anxiety; identifying patients at risk; ascertaining the extent of psychological harm on patient behavior and clinical decisions; and developing interventions to assist patients in managing psychological harm for better health-related quality of life and treatment outcomes.

Evaluating Efficiency and Adherence in Asian Lung Cancer Screening: Comparing Self-paid and Clinical Study Approaches in Taiwan

RATIONALE AND OBJECTIVES

This study aimed to assess how different screening methods, specifically self-paid screening versus participation in clinical studies, affect screening efficiency and adherence in a real-world Asian lung cancer screening population.

MATERIALS AND METHODS

This study collected 4166 participants from our hospital imaging database who underwent baseline low-dose computed tomography (LDCT) between January 2014 and August 2021. Adherence status was determined by counting CT scans, with one check indicating non-adherence and two or more checks indicating adherence. The primary objective was to investigate adherence to LDCT follow-up schedules among individuals with baseline pure ground-glass nodules (GGNs) based on different screening settings and to evaluate adherence status and CT follow-up clinical profiles.

RESULTS

Of the 4166 participants in the study, 3619 in the self-paid group and 547 in the clinical study group were men, with an average follow-up period of 4.5 years. Significant differences were observed in the proportions of Lung-RADS 4 lesions, subsolid nodules, and pure GGN lesions between the self-paid and clinical trial groups. A significant difference was found in adherence rates between the self-paid screening group (60.5%) and the clinical study group (84.8%) (p < 0.001). Adherence status rates significantly increased with larger GGN sizes across categories (p < 0.001). Multivariate logistic regression revealed that age (odds ratio [OR], 1.025; p = 0.012), smoking habits (OR, 1.744; p = 0.036), and clinical study screening type (OR, 3.097; p < 0.001) significantly influenced the adherence status.

CONCLUSION

The disparities in Asian lung cancer screening emphasize the need for increased efficacy, public awareness, and culturally sensitive approaches to mitigate overdiagnosis and enhance adherence among self-paying groups.

Investigation on sleep quality and psychological distress in patients with pulmonary nodules

BACKGROUND

Patients with pulmonary nodules (PNs) often suffer from the psychological burden of their disease and trap in sleep problems. This is insufficiently identified and addressed in clinical practice. The aim of this study was to investigate the psychological distress and sleep quality among PN patients and identify potential risk or protective factors for sleep quality.

METHODS

We conducted a cross-sectional study, which included 731 PN patients who visited the thoracic clinic of Guangdong Provincial People's Hospital. Each participant completed a structured questionnaire consisting of demographic characteristics, clinical characteristics, the Hospital Anxiety and Depression Scale (HADS) and the Pittsburgh Sleep Quality Index (PSQI). The reliability of the HADS (Cronbach's α = 0.944) and PSQI (Cronbach's α = 0. 0.757) in this study was satisfactory.

RESULTS

A total of 328 patients (44.9%) had PSQI global scores > 5, indicating poor quality of sleep. Age ≥ 50 years (OR 1.88, 95% CI 1.35-2.58; P < 0.001), female (OR 1.56, 95% CI 1.05-2.33; P = 0.028), detection of nodule for 7-12 months (vs for more than 24 months, OR 2.14, 95%CI 1.18-3.89, P = 0.013), anxiety (OR 1.78, 95% CI 1.17-2.71; P = 0.007) and depression (OR 1.84, 95% CI 1.16-2.92; P = 0.010) were independent risk factors for impaired sleep quality. A significant correlation revealed that sleep quality was positively correlated with both anxiety and depression (Spearman r = 0.342, P < 0.001 and Spearman r = 0.314, P < 0.001, respectively). All dimensions of the PSQI scale were significantly decreased in both anxiety group and depression group compared to the psychologically normal group (P < 0.05).

CONCLUSIONS

Impaired sleep quality is highly prevalent among patients with PNs and associated with age, gender, time from the date of detection, anxiety and depression. Based on the finding of impaired sleep quality and psychological health, screening for psychological and sleep problems in PN patients will be of great clinical benefit.

Exploring the psychological profile: a cross-sectional study of 1,185 patients with pulmonary nodules in an outpatient clinic

BACKGROUND

The purpose of this study was to identify the potential risk and protective factors of psychological burden in patients with pulmonary nodules (PNs) and to explore how the psychological status of the patients affects their treatment preferences.

METHODS

In this questionnaire-based study, 1,185 outpatients were evaluated using the Hospital Anxiety and Depression Scale (HADS), and the correlations between psychological burden and patients' sociodemographic and clinical characteristics were assessed.

RESULTS

Prevalence of anxiety and depression was 42.1% and 27.0%, respectively, among patients with PNs. Binary logistic regression analysis revealed that age over 60 years old [odds ratio (OR) =0.57; 95% confidence interval (CI): 0.36-0.89], computed tomography (CT) scan due to physical discomfort (OR =1.58; 95% CI: 1.11-2.24), multiple PNs (OR =1.52; 95% CI: 1.20-1.94), family history of malignancy (OR =1.28; 95% CI: 1.01-1.64), and subjective symptoms (OR =1.70; 95% CI: 1.32-2.19) were independently associated with anxiety, while multiple PNs (OR =1.51; 95% CI: 1.15-1.98), subjective symptoms (OR =1.65; 95% CI: 1.23-2.20), and indeterminate nodules (OR =1.91; 95% CI: 1.08-3.40) were independently associated with depression. There was a tendency for patients with anxiety and depression to choose more aggressive management strategies (P<0.001 and P=0.001, respectively). Univariate analysis showed that symptomatic patients (χ²=9.696; P=0.021) and those with progressive nodules (χ²=18.198, P=0.033) chose more aggressive treatment strategies.

CONCLUSIONS

Anxiety and depression are common in patients with PNs, which might result in nonnegligible overtreatment. Presence of subjective symptoms can significantly exacerbate psychological burden and influence treatment preference. Taking psychological factors into consideration in the outpatient clinic may facilitate patient-centered communication and promote judicious decision-making.

A cross-sectional study of psychological burden in Chinese patients with pulmonary nodules: Prevalence and impact on the management of nodules

Background

Uncertainty after the detection of pulmonary nodules (PNs) can cause psychological burden. We designed this study to quantitatively evaluate the prevalence, severity and possible impact of this burden on the preference of patients for management of nodules.

Methods

The Hospital Anxiety and Depression Scale (HADS) was used to evaluate psychological burden in patients. An independent t‐test and a Mann–Whitney U test were used to determine the significance of differences between groups in continuous variables. A chi‐square test was used to determine the significance of difference between groups in categorical variables.

Results

A total of 334 inpatients diagnosed with PNs were included in the study. A total of 17.96% of the participates screened positive for anxiety and 14.67% for depression. Female patients had significantly higher positive rates of both anxiety and depression screenings than male patients (21.57% vs. 12.31%, p = 0.032 and 18.05% vs. 9.30%, p = 0.028, respectively). Among patients screened positive for anxiety, the proportion of those who chose more aggressive management was significantly higher (34/60 vs. 113/274, p = 0.029). The rate of benign or precursor disease resected was significantly higher in patients with more aggressive management (46.94% vs. 9.63%, p < 0.01).

Conclusions

Anxiety and depression are common in Chinese patients with PNs. Patients with positive HADS anxiety screening results are more likely to adopt more aggressive management that leads to a higher rate of benign or precursor disease resected/biopsied. This study alerts clinicians to the need to assess and possibly treat emotional responses.

Can dynamic imaging, using 18F-FDG PET/CT and CT perfusion differentiate between benign and malignant pulmonary nodules?

BACKGROUND

The aim of the study was to derive and compare metabolic parameters relating to benign and malignant pulmonary nodules using dynamic 2-deoxy-2-[fluorine-18]fluoro-D-glucose (¹⁸F-FDG) PET/CT, and nodule perfusion parameters derived through perfusion computed tomography (CT).

PATIENTS AND METHODS

Twenty patients with 21 pulmonary nodules incidentally detected on CT underwent a dynamic ¹⁸F-FDG PET/CT and a perfusion CT. The maximum standardized uptake value (SUV_max) was measured on conventional ¹⁸F-FDG PET/CT images. The influx constant (K_i ) was calculated from the dynamic ¹⁸F-FDG PET/CT data using Patlak model. Arterial flow (AF) using the maximum slope model and blood volume (BV) using the Patlak plot method for each nodule were calculated from the perfusion CT data. All nodules were characterized as malignant or benign based on histopathology or 2 year follow up CT. All parameters were statistically compared between the two groups using the nonparametric Mann-Whitney test.

RESULTS

Twelve malignant and 9 benign lung nodules were analysed (median size 20.1 mm, 9-29 mm) in 21 patients (male/female = 11/9; mean age ± SD: 65.3 ± 7.4; age range: 50-76 years). The average SUV_max values ± SD of the benign and malignant nodules were 2.2 ± 1.7 vs. 7.0 ± 4.5, respectively (p = 0.0148). Average K_i values in benign and malignant nodules were 0.0057 ± 0.0071 and 0.0230 ± 0.0155 min^-1, respectively (p = 0.0311). Average BV for the benign and malignant nodules were 11.6857 ± 6.7347 and 28.3400 ± 15.9672 ml/100 ml, respectively (p = 0.0250). Average AF for the benign and malignant nodules were 74.4571 ± 89.0321 and 89.200 ± 49.8883 ml/100g/min, respectively (p = 0.1613).

CONCLUSIONS

Dynamic ¹⁸F-FDG PET/CT and perfusion CT derived blood volume had similar capability to differentiate benign from malignant lung nodules.

Patient vs Clinician Perspectives on Communication About Results of Lung Cancer Screening: A Qualitative Study

BACKGROUND

In the incidental pulmonary nodule and breast cancer screening settings, high-quality patient-centered communication can improve adherence to evaluation and mitigate patient distress. Although guidelines emphasize shared decision-making before lung cancer screening, little is known about patient-clinician communication after lung cancer screening.

RESEARCH QUESTION

How do patients and clinicians perceive communication and results notification after lung cancer screening, and are there approaches that may mitigate or exacerbate distress?

STUDY DESIGN AND METHODS

We conducted interviews and focus groups with 49 patients who underwent lung cancer screening in the prior year and 36 clinicians who communicate screening results (primary care providers, pulmonologists, nurses), recruited from lung cancer screening programs at 4 hospitals. We analyzed transcripts using conventional content analysis.

RESULTS

Clinicians and patients diverged in their impressions of the quality of communication after lung cancer screening. Clinicians recognized the potential for patient distress and tailored their approach to disclosure based on how clinically concerning they perceived results to be. Disclosure of normal or low-risk findings usually occurred by letter; clinicians believed this process was efficient and well received by patients. Yet many patients were dissatisfied: several could not recall receiving results at all, and others reported that receiving results by letter left them confused and concerned, with little opportunity to ask questions. By contrast, patients with larger nodules typically received results during an immediate phone call or clinic visit, and both patients and clinicians agreed that these conversations represented high-quality communication that met patient needs. Regardless of their cancer risk, patients who learned their results in a conversation appreciated the opportunity to discuss both the meaning of the nodule and the evaluation plan, and to have their concerns addressed, preempting distress.

INTERPRETATION

Tension exists between clinicians' interest in efficiency of results notification by letter in low-risk cases and patients' need to understand and be reassured about screening results, their implications, and the plan for subsequent screening or nodule evaluation-even when clinicians did not perceive results as concerning. Brief conversations to discuss lung cancer screening results may improve patient understanding and satisfaction while reducing distress.

Patient characteristics associated with adherence to pulmonary nodule guidelines

BACKGROUND

While pulmonary nodule guidelines provide follow-up recommendations based on nodule size and malignancy risk, these are inconsistently followed in clinical practice. In this study, we sought to identify patient characteristics associated with guideline-concordant nodule follow-up.

METHODS

We conducted a retrospective cohort study of patients diagnosed with a pulmonary nodule between 2011 and 2014 at Boston Medical Center. Appropriate nodule follow-up evaluation was based upon the 2005 Fleischner Society Guidelines. In primary analysis, we compared patients with guideline-concordant follow-up to those with delayed or absent follow-up. In secondary analysis, we compared those with any follow-up to those without follow-up as well as the rate of guideline-concordant follow-up in patients seen by a pulmonologist.

RESULTS

Of 3916 patients diagnosed with a pulmonary nodule, 1117 were included for analysis. Overall, 598 (53.5%) patients received guideline-concordant follow-up. Lower rates of guideline concordance were seen in patients of Hispanic ethnicity (OR 0.60, 95% CI 0.36-1.00), while higher rates were seen for nodules 7-8 mm (OR 1.55, 95% CI 1.02-2.35) and nodules >8 mm (OR 1.49, 95% CI 1.01-2.20). Having a history of COPD (OR 1.75, 95% CI 1.26-2.43), and being seen by a pulmonologist (OR 1.97, 95% CI 1.51-2.58) were also associated with guideline concordance. Among patients seen by a pulmonologist, 62.2% received guideline-concordant follow-up.

CONCLUSION

Overall rates of pulmonary nodule follow-up are low. Patient ethnicity, COPD history, nodule size and involvement of a pulmonologist may impact follow-up rates and are potential targets for implementation interventions to improve pulmonary nodule follow-up.

Assessment of anxiety and depression in patients with incidental pulmonary nodules and analysis of its related impact factors

Objectives

To assess anxiety and depression in patients with incidental pulmonary nodules and analyze the related impact factors.

Methods

All patients were assessed by questionnaires for their anxiety and depression after incidentally found pulmonary nodules. Hospital anxiety and depression scale (HAD), generalized anxiety disorder scale‐7 (GAD‐7), and multidimensional scale of perceived social support (MSPSS) were used to evaluate their anxiety and depression in order to understand the basic information and social support, and to analyze the related factors.

Results

The HAD scale was used in 201 patients with pulmonary nodules. Univariate analysis showed the frequency of visits and social support had significant effects on anxiety (χ² = 9.604, 20.912, P < 0.05). Regression analysis showed that social support (OR = 4.042, 95% CI: 2.1617.558, P < 0.05) was an independent influencing factor of anxiety. Univariate analysis showed that marital status, exposure history and social support had significant effects on depression (χ² = 10.626, 6.005, 3.984, P < 0.05). Regression analysis showed that marital status (OR = 0.375, 95% CI: 0.186–0.754, P < 0.05) and social support (OR = 2.206, 95% CI: 1.016–4.789, P < 0.05) were independent influencing factors of depression. The results of GAD‐7 showed the incidence of anxiety in patients with pulmonary nodules was 59.3% (108/182). Univariate analysis showed that anxiety was correlated with a history of chronic disease, psychological disease and social support (χ² = 9.949, 8.356, 11.872, P < 0.05). Further regression analysis showed that a previous history of psychological disease (OR = 5.088, 95% CI: 1.804–14.339) and social support (OR = 2.768, 95% CI: 1.505–5.094), were independent influencing factors of anxiety.

Conclusions

The results of the study concluded that anxiety was affected by social support and previous psychological factors, while depression was affected by marital status and social support. Doctors should therefore strengthen communication with patients, and alleviate the negative emotions of patients as far as possible.

Patient-Centered, Guideline-Concordant Discussion and Management of Pulmonary Nodules

Providing guideline-concordant management of pulmonary nodules can present challenges when a patient's anxiety about cancer or fear of invasive procedures colors judgment. The way in which providers discuss and make decisions about how to evaluate a pulmonary nodule can affect patient satisfaction, distress, and adherence to evaluation. This article discusses the complexity of tailoring patient-provider communication, decision-making, and implementation of guidelines for pulmonary nodule evaluation to the individual patient, emphasizing the importance of how information is conveyed and the value of listening to and addressing patients' concerns. We summarize the relevant guideline recommendations and literature, and provide two case scenarios to illustrate a patient-centered approach to discussing and managing pulmonary nodules from our perspectives as a pulmonologist and thoracic surgeon.

THE HIGH COST OF LOW VALUE CARE

The main focus of this study is bridging the "evidence gap" between frontline decision-making in health care and the actual evidence, with the hope of reducing unnecessary diagnostic testing and treatments. From our work in pulmonary embolism (PE) and over ordering of computed tomography pulmonary angiography, we integrated the highly validated Wells' criteria into the electronic health record at two of our major academic tertiary hospitals. The Wells' clinical decision support tool triggered for patients being evaluated for PE and therefore determined a patients' pretest probability for having a PE. There were 12,759 patient visits representing 11,836 patients, 51% had no D-dimer, 41% had a negative D-dimer, and 9% had a positive D-dimer. Our study gave us an opportunity to determine which patients were very low probabilities for PE, with no need for further testing.