Contemporary Pulmonary Nodule Evaluation and Management in the U.S.: A Mixed Methods Study.

Abstract

Effective pulmonary nodule (PN) evaluation and management is essential to diagnosing early-stage lung cancers while avoiding unnecessary invasive procedures. Key knowledge gaps exist regarding how clinicians manage PNs and which opportunities for improvement should be prioritized. Which factors contribute to clinicians' PN evaluation and management practices, and what are perceived barriers to optimal clinical care? From August 2024 to December 2025, we performed an exploratory sequential mixed methods study of clinicians who care for patients with PNs. First, we conducted semi-structured qualitative interviews with 40 clinicians across multiple specialties before thematically analyzing interview transcripts to develop and administer a quantitative online survey nationwide. We descriptively analyzed survey data, triangulated results with representative interview quotes, and performed exploratory analyses assessing factors associated with survey responses, selected by a priori study objectives and qualitative findings. Of 3,588 U.S. clinicians e-mailed to participate in the survey, 192 (5.4%) across general pulmonology, interventional pulmonology, thoracic surgery, and other specialties completed it. Most clinicians (70.8%) reported using risk assessment tools to evaluate PN cancer risk, with clinical risk prediction models (70.3%) more commonly used than commercial biomarkers (18.8%). Most participants (63.5%) believed that an ideal risk assessment tool should prioritize not missing a lung cancer diagnosis rather than avoiding unnecessary invasive procedures. Clinicians generally agreed that PN evaluation is challenging (71.4%) and requires shared decision-making (95.8%), multidisciplinary collaboration (91.1%), and improvement (85.9%). Only 50.5% reported having the clinical resources necessary to provide optimal PN care. Participants ranked PN tracking and risk assessment tools as the top priorities for improving PN clinical care. Clinicians find PN evaluation challenging, requiring multidisciplinary collaboration, shared decision-making, and improvement, but many lack adequate resources to provide optimal care. Future efforts should focus on improving system-level PN tracking and cancer risk assessment.