Melanie Cole, MS (Host): Welcome to GW Hospital DocPod, a peer-to-peer podcast for medical professionals with the George Washington University Hospital. I'm Melanie Cole. And joining me today is Dr. Sora Ely. She's an Assistant Professor in the Division of Thoracic Surgery at the George Washington University School of Medicine and Health Sciences, and she's affiliated with the George Washington University Hospital.

She's here today to highlight pulmonary nodules and the new GW Hospital Incidental Lung Nodule Program. Dr. Ely, it's a pleasure to have you join us today. I'd like you to start by giving us a little overview of the prevalence of incidental lung nodules. How often are they found? Are they generally cancerous? Give us a little overview.

Dr Sora Ely: Thank you so much for having me and the opportunity to talk about our exciting new program. To answer your question about how prevalent are these nodules, they're really everywhere. We find them all the time and, frankly, we keep finding them more and more often. The last really good estimates that we have from the U.S. population are a little old now, 2010. And that found that just under a third of CT scans of the chest identified a nodule, translating to more than 1.5 million nodules discovered annually.

Keep in mind that the amount of CT scans we do has increased greatly in the last decade since that study was published. And so, this also doesn't consider nodules that were discovered in other types of imaging. It was only CT chest. So, we discover them frequently on other types of imaging. So really, the 30% of scans and 1.6 million nodules per year is probably a severe underestimate of what we're finding today. I would guess that every single provider listening to this podcast has personally diagnosed at least one incidental lung nodule in their career so far.

As for whether these nodules are cancerous, thankfully, the majority of these nodules are benign or not cancerous. However, a small percentage do represent lung cancer. Probably that's about 5% nationwide, although it varies a bit depending on the region of the country. That 5% may seem like a low number, it's absolutely critical that we don't miss this 5% as this is one opportunity to catch lung cancer early when it has the best chance of cure.

Melanie Cole, MS: Well, thank you for that. So, tell us about the Incidental Lung Nodule Program at the George Washington University Hospital, its primary objectives. How did this program come about?

Dr Sora Ely: Well, as we talked about 5% of those nodules will be cancer. Unfortunately, studies have also shown that up to two-thirds of patients don't get adequate followup for those nodules. So, that was the main impetus to develop this nodule program. We basically wanted to make sure that we weren't missing cancers. And there's a number of reasons that these nodules may not get appropriate follow up and cancers may get missed.

From a provider perspective, if you think about it, these incidental nodules that are discovered on scans ordered for a different purpose oftentimes may occur in the ED. It may be that the formal read is not fully available before the patient even leaves the emergency department, and then the nodule comes on the read later after the patient's already gone. It may be that the provider doesn't notice the nodule in the read, if it's not included in the impression. It may be, you know, the usual reasons that patients don't follow up for any kinds of things that they're supposed to be doing. So, there's a lot of room for error in these nodules. And because they're so common, it happens commonly that these patients don't get followed.

So, our primary intention here was to make sure that we're not missing those patients. And right now, we're doing this on a referral basis. So basically, providers can refer patients when they find these nodules so that they don't have to consider and review all the current guidelines. They can just send the patient in. And eventually, we're also hoping to be able to catch patients who may not even have been noticed by the provider and, as a true quality assurance, make sure that those patients are caught.

Interestingly, studies have also shown that nodule programs can actually result in more cancer detection than lung cancer screening programs, simply because of how common lung nodules are. So even though the risk of someone for lung cancer in a lung cancer screening program is much higher than the average person who comes into a lung nodule program, we just find so many of these nodules that that 5% ends up being a much bigger number in most programs than from the screening program.

They've also shown that there's improved survival after a lung cancer diagnosis for patients who came in through a nodule program compared to coming in the usual way through no program at all. This means that we probably should be developing nodule programs alongside our screening programs. So, a lot of people consider these somewhat complementary to screening. One of the issues with screening is that there's no way that we can capture every person with screening. No screening test does that. But there's a lot of known issues with lung cancer screening since it's basically entirely based on your risk related to smoking history.

But there's a lot of other risk factors for lung cancer that we don't understand as well and are not yet incorporated into the screening eligibility guidelines. So, some patients may still be able to come into the program if they were patients that were at elevated risk for lung cancer, but didn't qualify for screening, because those patients also tend to be at a higher risk for finding a nodule.

For all these reasons, GW Hospital now offers both our lung cancer screening program and now our new incidental lung nodule program.

Melanie Cole, MS: So, based on that, and this is so interesting in the statistics that you've been citing, what criteria do you use to utilize and identify and assess these incidental lung nodules?

Dr Sora Ely: Well, the foundation of our management is a well-established evidence-based guideline published by the Fleischner Society for these types of nodules. Most providers will probably at least have heard of this guideline, if not know the details of it. It is a fairly detailed guideline. It takes into account all kinds of risk factors like the nodule characteristics, how it changes over time on subsequent scans, and even patient risk factors like smoking history.

One of the most important characteristics when we assess a nodule is size. Fleischner and other studies have all shown that size is very predictive of risk of cancer. But even with all these factors taken into account by the guideline, guidelines can just never account for every detail of a presentation. So, this is why we also discuss all of our patients in a multidisciplinary nodule board. For providers who are familiar with a tumor board, it's a similar idea. Basically, we bring together multiple interested specialties. So in this case, thoracic surgery, pulmonology, and interventional pulmonology, as well as chest radiology. We'll review all of these nodule cases together and decide whether we think that the guideline fits. And if so, we follow the guideline for management. If there are reasons that we think the guideline is not a perfect fit for that case, then we may make adjustments and that will be reflected in our final recommendation to the referring provider.

Melanie Cole, MS: Tell us about some of the exciting advanced imaging technologies and techniques that have helped you to improve the detection. We talked about CT screening, and there are imaging modalities there, but tell us about some of the characterization of lung nodules within the program and some of the advanced technology.

Dr Sora Ely: Within the healthcare field as a whole, there have been incredible advances in imaging and particularly CT scanning, as well as a drastically increased use of CT scan imaging already that has partially led to the ever rising detection rate of these incidental nodules. In terms of special technologies that we bring to bear in this program here at GW Hospital, we offer the ability to do robot bronchoscopy, which is a relatively new technique that combines live imaging as well as prior imaging mapping, so that basically it allows us to get out to very small nodules in the periphery of the lung that were previously not accessible by bronchoscopic biopsy. So, this is something that a lot of major centers are starting to offer and we do offer it here. And it's a great technique because it allows us to sample the nodule itself as well as, if we need to, to sample the lymph nodes or other sites in the lung, all in the same procedure.

Melanie Cole, MS: Dr. Ely, what protocols do you follow for surveillance and management of them, particularly concerning risk stratification followup intervals?

Dr Sora Ely: Well, as I mentioned, we base our management on the Fleischner criteria. But the basic principle for surveillance and management is that the more concerning a nodule is, it will get re-imaged sooner or potentially, if really concerning, biopsied or even taken to surgery. Less concerning nodules may not need to be re imaged until a full year later or, in some cases, may not need any follow up imaging at all. That'll just depend on the full assessment.

Melanie Cole, MS: I'd like to ask you about the patients in that case. If you're doing this watchful waiting or no followup scans, how do you help them to navigate that anxiety, to deal with all of this navigation that they've got?

Dr Sora Ely: That's one of the advantages of having a somewhat centralized program like this. In the past, if a single provider, let's say a primary care doc or a pulmonologist found one of these nodules and tried to manage it solo, first of all, keeping track of a number of studies and ensuring that those timelines were happening appropriately, even after they made the initial appropriate assessment of the nodule. And in between, the patient's getting shuttled around to a bunch of different services. They have to talk to radiology. If they're having a procedure, they need to talk to those people. So, the nodule program really helps hold the hand of the patients, where they have a steady contact throughout the whole process that they can call at any time or message and get in touch with a provider that knows their case and can help them get in touch with any one of those services.

Melanie Cole, MS: That's a very comprehensive approach. And you mentioned before briefly when you were talking about your nodule board, tell us a little bit about the multidisciplinary communication and the multidisciplinary approach that's so important for these patients as they're going through that navigation.

Dr Sora Ely: So, just like we do with cancer tumor boards, we have our multidisciplinary nodule board that I mentioned. This is really a key component of how we facilitate communication between the different specialties. Additionally, as I mentioned, since we serve as kind of the point contact for both patients and providers, it makes it easier for them to get in touch at any time and for them to communicate about the same patient, because they always have a stable contact, even on the provider side. But really, the nodule board, I think, is one of the key factors. And first of all, regularly bringing all of us together to discuss live each patient's case, but additionally to form relationships so that we always know how to get in touch with each other, and we stay in touch about these patients cases as they progress.

Melanie Cole, MS: This is such a great program, Dr. Ely. And I hope that you'll join us again and update us as this program develops and evolves. And can you speak to any future directions of areas of expansion for the program, your vision as you see it, what you'd like to see happen, including potential enhancements, refinements? Tell us where you see this going.

Dr Sora Ely: So actually, I alluded to this briefly before, but one of the most exciting things that we're working on and hope to have live later this year is that we're going to be incorporating a software detection component to our program.

So as I said, right now, patients are getting referred into our program by their providers. So, this requires that the provider has to notice the nodule and address it appropriately, either themselves or to send it to our program. But I mentioned that, for many human reasons, there are times where providers may not notice the nodule to send it or to address it themselves. So, this will address that aspect. The software will look at language from all the imaging within the GW system and find scans that mention a lung nodule. All of those scans will get funneled into our program list. And basically, we'll review those to make sure that all of those incidental nodules got appropriate followup. So if they did, we don't have to do anything. We just make sure, first of all, that the patient's got appropriate followup or that nodule was addressed. If not, then we take that opportunity to contact the patient and the provider both, and let them know about the finding and make sure that they do address it. And it's also an opportunity that if they were unaware or they feel unable or unwilling to address that nodule in their clinic, they can refer the patients at that time.

Additionally, if patients don't have a provider, let's say they got an emergency department scan and they don't have a primary care doc, this is also a way that we can bring the patients in and make sure that they don't get lost. So, this is really an exciting aspect that we're hoping to have added later this year, and we hope that this will really contribute to preventing the loss to followup of these patients.

Melanie Cole, MS: Thank you so much, Dr. Ely, for joining us today and telling us about the program. To refer your patient, please call 1-855-GW-LUNGS, option 2, or you can call 1-888-4GW-DOCS.

That concludes this episode of GW Hospital DocPod, a peer-to-peer podcast for medical professionals with the George Washington University Hospital. I'm Melanie Cole. Thanks so much for tuning in today.

Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Please speak with your physician about these risks to find out if this procedure is right for you.