An Aggressive Approach to Lung Cancer Decreases Mortality

In the primary healthcare continuum, the incidence of pulmonary masses continues to be a critical concern, where management may be hastily referred to CVT surgery. Such cases are frequently encountered, and they demand swift and precise diagnostic efforts to discern the characteristics of the mass and to strategize effective treatment modalities. The necessity of timely intervention is particularly evident in the context of untreated lung malignancies, with general survival estimates being alarmingly limited to approximately two years. This time frame is further compressed to about 7.5 months in the case of non-small cell lung cancer (NSCLC).  This stark prognosis underscores the urgency for immediate and judicious clinical judgment.    

Present is a proposed algorithm that advocates for a proactive stance, which diverges from traditional paradigms, but is supported by our clinical successes. Our institution is a referral site for 11 counties in Missouri and Iowa, situated at least 2.5 hours away from any major metropolitan area. Our methodology yielded exceptional outcomes when surgery was performed, achieving a survival rate of 100% for patients with Stage 1 lung cancer, a significant elevation from the 80% national average. In instances of Stage 2 lung cancer, our surgical survival rate (lobectomy and pneumonectomy) stands at 98%, in stark contrast to the 60-65% national average.

At the macro level, lung cancer remains a formidable opponent in the oncological arena, recognized as the primary cause of cancer-related mortality among both sexes in the United States and globally. The year 2020 marked the diagnosis of over 2.2 million new lung cancer cases worldwide, with a disproportionately higher incidence among males. The death toll from lung cancer is similarly significant, reinforcing its status as a leading cause of cancer death on a worldwide scale. In primary healthcare settings, it is vital to acknowledge the gender-specific impact of lung cancer. Historical patterns have shown men to be at a higher risk, a fact largely attributed to smoking patterns. Nevertheless, genetic factors and hormonal variances make women distinctly vulnerable to lung cancer, underscoring the importance of gender-tailored prevention and treatment modalities. Lung cancer is the chief cause of cancer-related mortality among women. Projections indicate an unsettling trend: the number of lung cancer-related deaths among women in the United States is anticipated to eclipse those from breast cancer by a considerable margin of over 50%. This forecast is a grim indicator of the pressing need for enhanced healthcare strategies and the importance of continuous innovation in diagnostic and therapeutic practices within primary care. The goal is to streamline the management of pulmonary nodules that are revealed through imaging for settings that do not have readily accessible CVT surgeons.

Methods or Case Description:

This flowchart directs the primary healthcare providers and serves as the basis for this clinical decision process. This flowchart includes some of the critical issues like existing imaging, progression of mass, and use of imaging techniques like CT scans or PET scans. Moreover, it describes the procedure that is based on biopsy results.

Outcomes:

Evaluate to determine the availability of prior imaging records:

If Previous Imaging is Available: If no change in size is observed and the imaging is older than two years, no additional evaluation is required. This is due to evidence that the untreated non-small cell lung cancer (NSCLC) mortality rate is very high, in fact these patients live  7.15 months on average. When including small cell carcinoma, 2-year survivability for untreated stage 4 is less than 5%. These findings highlight the validity of our 2-year surveillance approach.

In cases where growth is detected in the mass: For masses smaller than 4 mm, schedule a follow-up CT after 3 months. If larger at that time, get a PET CT. For masses measuring 4-8 mm, arrange a follow-up CT after 6 weeks. If larger at that time, get a PET CT. For masses larger than 8 mm, a PET scan is recommended. If PET scan is positive, biopsy the mass. It should be noted the accuracy of PET is diminished when the mass is < 8mm. If there is no growth seen after the first follow up CT, it is best to recommend repeat evaluation at 3 months and 6-month intervals thereafter until negative growth for 2 years.

Absence of Previous Imaging: In the absence of prior imaging records, order a CT scan to facilitate further evaluation. If the initial mass is less than 8 mm, continue with a structured follow-up regimen involving 6-week, 3-month, and 6-month CT scans over 2 years. If any growth is observed during these follow-ups, a PET scan is advised. If mass is initially  >8 mm, recommend a PET CT.

PET Scan Protocol and Biopsy: If the PET scan yields positive results, proceed with a biopsy. If the PET scan is negative, continue monitoring with periodic imaging at 6 weeks, 3 months, and every 6 months until there is no indication of growth for 2 years.  If mass continues to increase in size and is irregularly shaped (stellate), even if PET is negative, recommend CT-guided needle biopsy. If the biopsy results are negative, persist with imaging follow-ups as above. If the biopsy results are positive, surgical intervention is indicated. However, if mass is irregular, spiculated, and has the characteristics of malignant process, an aggressive approach with thoracic wedge resection or lobectomy (pending pathology results).   


Conclusion:

The strategic blueprint for clinical decision-making is a cornerstone for primary care practitioners addressing pulmonary masses. From monitoring the mass to the employment of intricate imaging modalities and even surgical intervention, this tool is multifaceted. Yet, it's imperative to emphasize that the application of these clinical pathways is as diverse as the patient population itself, necessitating individualization based on each patient's unique presentation and within the bounds of the physician's expert judgment.

 Comprehensive care delivery is a balance requiring the collaboration of thoracic surgeons, radiologists, and oncologists. While this framework provides a foundation, the individual narrative of each patient should ultimately guide care.

 Addressing potential reservations, our proposed course may tread a more assertive path than some traditional stances. We fully recognize and empathize with the challenges faced by primary healthcare professionals in less urbanized areas, particularly with the logistical hurdles in referring cases to specialized thoracic surgeons. The disparity in the distribution of resources was a guiding consideration in our design of these practical guidelines.