Lung (2019) 197:249–255 https://doi.org/10.1007/s00408-019-00207-6 LUNG CANCER Using a Dedicated Interventional Pulmonology Practice Decreases Wait Time Before Treatment Initiation for New Lung Cancer Diagnoses Bryan S. Benn1 · Mihir Parikh2 · Pei H. Tsau3 · Eric Seeley4 · Ganesh Krishna4,5 Received: 19 December 2018 / Accepted: 7 February 2019 / Published online: 19 February 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Purpose While there is significant mortality and morbidity with lung cancer, early stage diagnoses carry a better prognosis. As lung cancer screening programs increase with more pulmonary nodules detected, expediting definitive treatment initia- tion for newly diagnosed patients is imperative. The objective of our analysis was to determine if the use of a dedicated interventional pulmonology practice decreases time delay from new diagnosis of lung cancer or metastatic disease to the chest to treatment initiation. Methods Retrospective chart analysis was done of 87 consecutive patients with a new diagnosis of primary lung cancer or metastatic cancer to the chest from our interventional pulmonology procedures. Demographic information and time intervals from abnormal imaging to procedure and to treatment initiation were recorded. Results Patients were older (mean age 69) and former or current smokers (72%). A median of 27 days (1–127 days) passed from our diagnostic biopsy to treatment initiation. A median of 53 total days (2–449 days) passed from abnormal imaging to definitive treatment. Endobronchial ultrasound-guided transbronchial needle aspiration was the most commonly used diagnostic procedure (59%), with non-small cell lung cancer the majority diagnosis (64%). For surgical patients, all biopsy- negative lymph nodes from our procedures were cancer-free at surgical excision. Conclusions Compared to prior reports from international and United States cohorts, obtaining a tissue biopsy diagnosis through a gatekeeper interventional pulmonology practice decreases median delay from abnormal imaging to treatment initiation. This finding has the potential to positively impact patient outcomes and requires further evaluation. Keywords Interventional pulmonology · Bronchoscopy · Lung cancer · Chest imaging · Wait time Abbreviations Cryo Flexible cryoprobe biopsy and tissue extraction EBUS-TBNA Endobronchial ultrasound-guided biopsy transbronchial needle aspiration * Bryan S. Benn ECH El Camino Hospital [email protected] EMN Electromagnetic navigation-guided biopsy 1 Division of Pulmonary and Critical Care Medicine, IP Interventional pulmonology University of California, Los Angeles, 10833 LeConte NSCLC Non-small cell lung cancer Avenue, Los Angeles, CA 90095, USA PAMF Palo Alto Medical Foundation 2 Division of Thoracic Surgery and Interventional SHN Sutter Health Network Pulmonology, Beth Israel Deaconess Medical Center, Boston, MA, USA 3 Division of Thoracic Surgery, Palo Alto Medical Foundation, Introduction Palo Alto, CA, USA 4 Division of Pulmonary and Critical Care Medicine, Lung cancer is the second-most commonly diagnosed University of California, San Francisco, San Francisco, CA, cancer in the United States and third in the world as well USA as a leading cause of cancer-related deaths [1]. Five-year 5 Division of Pulmonary and Critical Care Medicine, Palo Alto survival rate at diagnosis for all stages of lung cancer is Medical Foundation, Palo Alto, CA, USA Vol.:(0123456789)1 3 250 Lung (2019) 197:249–255 17.7% [1], worse compared to other common cancers. Methods However, early stage, or localized disease, carries a much better 5-year survival of 55.2% [1]. Thus, it is imperative Practice Pattern to identify opportunities for early detection. The National Lung Screening Trial demonstrated that All patients were seen at our Mountain View, California screening high-risk patients with annual low-dose CT IP clinic of the Palo Alto Medical Foundation (PAMF), chest scans significantly reduced lung cancer mortality which is one of five medical foundations comprising the [2] and increased early-stage lung cancer detection with Sutter Health Network (SHN). A Northern Californian- a decrease in advanced stage lung cancer incidence [3, based not-for-profit comprehensive healthcare system, 4]. As a result, significant efforts are underway to imple- SHN includes physician organizations, acute care hos- ment lung cancer screening protocols with low-dose CT pitals, surgery centers, medical research facilities, and scans [5]. While lung cancer screening remains a complex training programs. SHN partners with more than 12,000 process, recent estimates place the number of Americans doctors to care for more than 3 million people in its health- eligible for screening between seven to nine million [6, 7]. care system. Approximately, 700,000 patients are seen at While historical incidence rates for pulmonary nod- PAMF, which cares for patients focused in Alameda, San ules in the US remained steady for many decades at Mateo, Santa Clara, and Santa Cruz counties of North- 150,000 per year [8], a more recent evaluation using ern California. As the only IP clinic in SHN, our practice electronic health records and natural language processing received referrals from physicians within SHN and from increased the incidence tenfold to over 1.5 million nodules others outside this healthcare system. detected per year [9]. With so many new nodules found, All IP procedures were performed by IP fellows (BSB, healthcare providers are challenged by how to appropri- MP, ES) from the joint University of California, San Fran- ately triage these results. Standardized protocols stratify- cisco-PAMF fellowship under direct attending supervision ing risk for cancer based on nodule characteristics exist (GK) at El Camino Hospital (ECH) in Mountain View, [10], yet physician adherence to them varies substantially California. ECH is a non-profit hospital with 300 beds and [11]. approximately 20,000 inpatient visits and 150,000 outpa- A significant number of these newly found nodules tient visits in 2017. Procedures were performed in our two will ultimately undergo a diagnostic biopsy. The clinical dedicated, fully equipped IP suites. importance of quickly obtaining a tissue diagnosis has been shown as patients with delay from imaging to diag- nosis of more than four months have significantly worse Study Cohort survival [12] and may miss the opportunity to undergo a curative procedure [13]. Unfortunately, the time interval Retrospective chart review was performed of all patients between initial presentation, tissue diagnosis, and treat- consecutively presenting to our IP clinic for evaluation of ment initiation varies quite widely, with prospective stud- a new imaging abnormality from July 1, 2015 to Decem- ies reporting a median time from onset of first symptoms ber 31, 2016 who underwent a diagnostic IP procedure until treatment initiation between 138 and 189 days [14, resulting in a new primary lung cancer or metastatic can- 15]. Furthermore, a recent review of wait times for cancer cer to the thorax diagnosis. All patients seen and referred surgery in the US showed an increase in the median time directly for surgery, transthoracic needle aspiration biopsy, from diagnosis to treatment [16]. or followed with surveillance imaging were excluded. 90 Interventional pulmonologists are often the first sub-spe- patients were identified with three patients subsequently cialty physicians to evaluate patients with imaging findings excluded who were lost to follow-up, leaving 87 patients concerning for lung cancer and may be able to utilize differ- for further analysis. ent modalities to expedite diagnosis and treatment initiation. Demographic data, including age, sex, race/ethnicity, To address this possibility, we retrospectively reviewed all and smoking status were obtained. Additionally, charts patients seen in our interventional pulmonology (IP) clinic were reviewed for the following event dates: initial abnor- which we diagnosed with primary lung cancer or meta- mal imaging study, initial evaluation in IP clinic, IP proce- static cancer to the thorax. We examined the time from our dure, post-procedure presentation to consultative physician diagnostic procedure until definitive treatment initiation. (thoracic surgery, medical or radiation oncology, or pal- We hypothesized that obtaining a tissue biopsy diagnosis liative care), and definitive treatment initiation (surgery, through a gatekeeper IP practice would facilitate referral for treatment with chemotherapy, radiation, biological, hor- definitive treatment by decreasing wait time between these monal, or immunological therapy, or initiation of pallia- two time points, with potentially positive implications for tive/hospice care). The types of interventional procedure patient staging and survival. 1 3 Lung (2019) 197:249–255 251 performed were also recorded. All pathological diagno- Age‑Adjusted Median Wait Times ses from interventional procedures, subsequent surgeries where applicable, and discussion with all consultative phy- Median time from initial abnormal chest imaging to IP pro- sicians were also recorded. cedure was 17 days (1–322 days) (Table 2), with patients The study protocol was reviewed and approved by the eventually undergoing surgery waiting longest. After our institutional review boards of both PAMF and ECH. diagnostic procedure, a median of 8 days (1–68 days) elapsed before further evaluation with a consultative physi- Statistical Analysis cian.