The Initial Chest X-ray at Certain Intervals in Patients with the First Presentation of Suspected Lung Cancer

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1 Evidence Summary A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO) The Initial Chest X-ray at Certain Intervals in Patients with the First Presentation of Suspected Lung Cancer X. Yao, A. Donohue, and D. E. Maziak Report Date: July 30, 2010 The full Evidence Summary is available on the CCO website (http://www.cancercare.on.ca) For information about the PEBC and the most current version of all reports, please visit the CCO website at or contact the PEBC office at: Phone: , ext Fax: Evidence Summary Citation (Vancouver Style): Yao X, Donohue A, Maziak DE. The initial chest x-ray at certain intervals in patients with the first presentation of suspected lung cancer. Toronto (ON): Cancer Care Ontario; 2010 Jul 30. Program in Evidence-based Care Evidence Summary No.:

2 Evidence Summary A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO) The Initial Chest X-ray at Certain Intervals in Patients with the First Presentation of Suspected Lung Cancer X. Yao, A. Donohue, and D. E. Maziak Report Date: July 30, 2010 QUESTION Lung Cancer Pathway Map - Second Priority Question: In patients with a first presentation of suspected lung cancer, do the different time intervals between the suspicion of lung cancer and the initial chest x-ray influence the outcomes (e.g., survival and/or quality of life)? TARGET POPULATION Patients with a first presentation of suspected lung cancer. INTENDED USERS Family physicians responsible for referring patients to specialists such as radiologists, respirologists, and surgeons involved in the further diagnosis and treatment for patients with suspected lung cancer. INTRODUCTION As part of an ongoing quality improvement initiative at Cancer Care Ontario (CCO), a project to map the diagnostic pathway for lung cancer was conducted by CCO s program for Disease Pathway Management (DPM). The development process is outlined below: An initial draft pathway was mapped on the basis of existing public information, Clinical co-chairs of the DPM lung cancer team edited the draft pathway, A multidisciplinary DPM lung cancer diagnosis team reviewed the draft and provided feedback that was incorporated into subsequent drafts, The DPM lung cancer diagnosis team identified several points in the pathway where an evidence search could be useful in developing guidance for clinicians. In collaboration with the Program in Evidence-based Care (PEBC), four questions were developed to produce evidence summaries that will inform the diagnostic pathway. The four research questions are: Q1: a) What are the diagnostic values (sensitivity, specificity, likelihood ratio, and accuracy) for fine-needle aspiration biopsy (FNAB) versus core-needle biopsy Evidence Summary Page 1

3 (CNB) to diagnose lung cancer in patients with an undiagnosed chest nodule or mass demonstrated on imaging? b) Compared with core needle biopsy, do fine needle aspiration biopsy samples have sufficient diagnostic yield for molecular predictive marker studies by mutation analysis and fluorescent in situ hybridization in patients with a clear mass on the CT scan? Q2: In patients with a first presentation of suspected lung cancer, do the different time intervals between the suspicion of lung cancer and the initial chest x-ray influence the outcomes (e.g., survival and/or quality of life)? Q3: If the initial chest x-ray is negative in patients with a first presentation of suspected lung cancer, should a CT scan or any other examinations be performed? Q4: Is whole-body positron emission tomography (PET) (or whole-body PET-CT) more accurate than conventional staging tests (e.g., chest and abdominal CT plus bone scan) in the identification of newly diagnosed non-small cell lung cancer (NSCLC) patients who are at stage IIIB or greater, in order to avoid unnecessary surgical treatments? The pathways were reviewed by the Lung Cancer Disease Site Group, and this feedback was incorporated into subsequent drafts of the pathway. This evidence summary addresses the second priority question posed above, regarding whether the initial chest x-ray at certain intervals influences outcomes in patients with a first presentation of suspected lung cancer. In collaboration with clinical experts from the DPM lung cancer diagnosis team, the PEBC conducted a systematic review to answer this question. This systematic review will advise the DPM on the development of their pathway and other project considerations rather than serve as a foundation for a practice guideline, as would be typical of the PEBC reports. METHODS This evidence-based report was developed by CCO s DPM team in collaboration with the PEBC. For this project, the core methodology used to develop the evidentiary base was the systematic review. Evidence was selected by one methodologist and reviewed independently by four members of the DPM lung cancer diagnosis team. Search Strategy A literature search was performed using MEDLINE and EMBASE through Ovid (January 1, 1990 to March 3, 2010). The search strategies are reported in Appendices 1 and 2. The following resources were checked for existing systematic reviews and practical guidelines: The Cochrane Library (to Issue 1, 2010); New Zealand Guidelines Group (to February 3, 2010); National Institute for Health and Clinical Excellence and Scottish Intercollegiate Guidelines Network (to February 11, 2010); and National Health and Medical Research Council (Australia), American Society of Clinical Oncology guidelines, National Guideline Clearing House, and Canadian Medical Association Infobase (to February 12, 2010). Study Selection Criteria Inclusion Criteria Articles were eligible for inclusion in this systematic review if they met all the following criteria: 1. Were published in full text from Jan 1, 1990 to March 3, Were systematic reviews, meta-analyses, clinical practice guidelines, randomized trials, or cohort studies. Evidence Summary Page 2

4 3. Included patients with the first presentation of suspected lung cancer. 4. Compared different intervals from the first suspicion of lung cancer to the initial x-ray and reported patient outcomes (survival and/or quality of life, for examples). Exclusion Criteria Articles were excluded if they met any of the following criteria: 1. Did not report patient outcome. 2. Reported single interval from the first suspicion of lung cancer to the initial x-ray and reported patient outcomes. 3. Were published in a language other than English. 4. Were non-systematic reviews, letters, editorials, case studies, historical articles, or commentaries. Data Abstraction One reviewer went through the guideline websites that were mentioned in the Search Strategy section The Cochrane Library, and the retrieved citation titles and abstracts from MEDLINE and EMBASE to identify potentially relevant guidelines and articles, which were then obtained as full texts, and checked all the related references from these texts. For each eligible study, one reviewer would extract all the study data (such as design features, patient population, time information of the initial chest x-ray examination, and patient outcomes reported to be impacted by different interval times of the initial chest x-ray examination). Data Analysis Meta-analyses, if appropriate for clinically homogenous studies, were to be conducted. STATA 9.0 was to be used as the statistical software. A two-sided significance level of α = 0.05 was assumed. RESULTS No existing systematic reviews or practice guidelines addressed how different intervals, from the first suspicion of lung cancer to the initial chest x-ray examination, influenced clinical outcomes in patients with a first presentation of suspected lung cancer. One thousand six hundred eighty (1,680) citations of primary studies were identified from the electronic searches (Appendix 3). One thousand six hundred sixty-two (1,662) articles were excluded after reviewing the titles and abstracts. Eighteen articles were potentially relevant or could not be judged as relevant by their titles (their abstracts were not available directly from the literature search), but their full-text reviews yielded nothing. Twenty-five additional references from the 18 articles were thought to be potentially relevant but did not meet our study selection criteria when reviewed in full. DISCUSSION AND CONCLUSION No evidence meeting the inclusion criteria was found in this systematic review to deal with the second priority question within the lung cancer pathway map, regarding whether the initial chest x-ray at a certain interval influences outcomes in patients with a first presentation of suspected lung cancer. Well-designed, good quality studies focused on this question are needed in the future. The next step is to obtain expert clinical consensus from all the members of the lung cancer DPM team for this particular question. CONFLICT OF INTEREST No authors have conflicts of interest for this project. Evidence Summary Page 3

5 ACKNOWLEDGEMENTS The authors would like to thank Dr. Dan Mozeg and Dr. Chris Allen for their participation and rewording of the research question at the beginning of this project. Updating This document will be reviewed in three years to determine if it is still relevant to current practice and to ensure that the recommendations are based on the best available evidence. The outcome of the review will be posted on the CCO website. If new evidence that will result in changes to these recommendations becomes available before three years have elapsed, an update will be initiated as soon as possible. Funding The PEBC is a provincial initiative of Cancer Care Ontario supported by the Ontario Ministry of Health and Long-Term Care through Cancer Care Ontario. All work produced by the PEBC is editorially independent from its funding source. Copyright This report is copyrighted by Cancer Care Ontario; the report and the illustrations herein may not be reproduced without the express written permission of Cancer Care Ontario. Cancer Care Ontario reserves the right at any time, and at its sole discretion, to change or revoke this authorization. Disclaimer Care has been taken in the preparation of the information contained in this report. Nonetheless, any person seeking to apply or consult the report is expected to use independent medical judgment in the context of individual clinical circumstances or seek out the supervision of a qualified clinician. Cancer Care Ontario makes no representation or guarantees of any kind whatsoever regarding the report content or use or application and disclaims any responsibility for its application or use in any way. For information about the PEBC and the most current version of all reports, please visit the CCO website at or contact the PEBC office at: Phone: , ext Fax: Evidence Summary Page 4

6 Appendix 1. Searching strategies from MEDLINE Ovid (March 3, 2010) (n=381). Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1950 to Present # Searches Results 1 ((chest or pulmonary or thora$ or bronch$) adj4 (x-ray$ or (x adj1 ray$) or radiogra$ or roentgenog$)).mp. 2 (((chest or pulmonary or thora$ or bronch$) adj4 XR$) or CXR$).mp or (delay$ or detain$ or late or belated or postpon$ or defer$ or wait$ or earl$).mp exp Lung Neoplasms/ exp Bronchial Neoplasms/ or exp Carcinoma, Non-Small-Cell Lung/ or exp Carcinoma, Squamous Cell/ or exp Carcinoma, Bronchogenic/ or Carcinoma, Small Cell/ ((lung or pulmonary or chest or thora$ or bronch$) adj4 (lesion$ or cancer$ or neoplasm$ or carcinom$ or maligan$ or tumo?r$)).mp (NSCLC or SCLC).mp or/ and 4 and (case report$ or letter$ or editorial$ or historical article$ or comment$).pt screen$.ti not 11 not limit 13 to (English language and humans and yr="1990 -Current") 381 Evidence Summary Page 5

7 Appendix 2. Searching strategies from EMBASE Ovid (March 3, 2010) (n=1299). EMBASE 1988 to 2010 Week 08 # Searches Results 1 ((chest or pulmonary or thora$ or bronch$) adj4 (x-ray$ or (x adj1 ray$) or radiogra$ or roentgenog$)).mp. 2 (((chest or pulmonary or thora$ or bronch$) adj4 XR$) or CXR$).mp or (delay$ or detain$ or late or belated or postpon$ or defer$ or wait$ or earl$).mp lung cancer.mp. or exp lung cancer/ exp Bronchial Neoplasms/ or exp Carcinoma, Non-Small-Cell Lung/ or exp Carcinoma, Squamous Cell/ or exp Carcinoma, Bronchogenic/ or Carcinoma, Small Cell/ ((lung or pulmonary or chest or thora$ or bronch$) adj4 (lesion$ or cancer$ or neoplasm$ or carcinom$ or maligan$ or tumo?r$)).mp (NSCLC or SCLC).mp or/ and 4 and (case report$ or letter$ or editorial$ or historical article$ or comment$).pt not limit 12 to (human and English language and yr="1990 -Current") screen$.ti not Evidence Summary Page 6

8 Appendix 3. Flow of studies considered for this systematic review Initial search results 1662 excluded after title and abstract review 18 potentially relevant studies identified for full-text review 25 additional references from 18 potentially relevant studies found or ordered for full-text reviews 0 included in systematic review Evidence Summary Page 7

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