Less Versus More Intensive Surveillance of Pulmonary Nodules Detected Incidentally or by Screening: A Survey of Radiologist Beliefs About Guidelines Implemented in the Watch the Spot Trial.

Abstract

To examine radiologists' beliefs about protocols for less versus more intensive surveillance imaging in patients with small pulmonary nodules. We developed a self-administered survey to measure familiarity, adherence, and satisfaction with assigned protocols for surveillance as implemented in an unblinded, cluster-randomized, pragmatic trial of pulmonary nodule evaluation. Protocols were modeled on recommendations from the Fleischner Society (for incidental nodules) and the ACR's Lung CT Screening Reporting and Data System (for screening-detected nodules). We compared responses by study arm using multivariable logistic regression. The survey was completed by 153 of 514 invited radiologists (29.8%), including 76 responders in the less intensive study arm and 77 in the more intensive arm. For incidentally detected nodules, large majorities of responders in both study arms reported at least moderate familiarity (>88%) and at least very frequent adherence (>94%) with assigned protocols for surveillance, and over 70% agreed that benefits of adherence outweigh the harms. Responders in the less intensive arm were more likely to agree that their preferred guideline was in use during the study (78.9% versus 45.5%; adjusted odds ratio [aOR] 13.9, 95% confidence interval [CI] 4.2-45.7), were more likely to believe that the supporting evidence for the assigned guideline was strong or very strong (76.3% versus 54.6%; aOR 2.40, 95% CI 1.13-5.07), and were less likely to believe that follow-up recommendations were too frequent (25.0% versus 41.6%; aOR 0.46, 95% CI 0.22-0.96). For screening-detected nodules, responders in both study arms reported high levels of protocol familiarity, adherence, and agreement that benefits of adherence outweigh the harms. In this pragmatic clinical trial, practicing radiologists reported high levels of familiarity, adherence, and agreement with assigned guidelines for pulmonary nodule evaluation. Perceptions of the supporting evidence and beliefs about the frequency of surveillance were more favorable in the less intensive study arm, likely reflecting radiologists' preference for and comfort with guidelines currently in use.