Title:Quality Assessment of Diagnostic Methods Employed for Suspected Lung Cancer
VOLUME: 12 ISSUE: 2
Author(s):Akash Verma, Chee K. Phua, Wen Y. Sim, Albert Y.H. Lim, Dessmon Y.H. Tai, Soon K. Goh, Ai C. Kor, Benjamin Ho and John Abisheganaden
Affiliation:Tan Tock Seng Hospital, Department of Respiratory and Critical Care Medicine, 11 Jalan Tan Tock Seng, 308433, Singapore.
Keywords:Bronchoscopy, quality, lung cancer, TTNA, EBUS-TBNA.
Abstract:Background: In diagnosing lung cancer, evidence-based guidelines
recommend choosing the procedure that is safe, least invasive, and provides
information about stage of the cancer together with the diagnosis. This study was
done to assess the quality of practice patterns for diagnosing lung cancer.
Methods: Retrospective review of patients diagnosed with lung cancer from
January 2011 - December 2013.
Results: Intra-parenchymal mass & mediastinal abnormality (discrete lymph node
and mediastinal infiltration) were the common intra-thoracic radiological
abnormality seen in 80 (64.5%) and 71 (57.2%) of patients respectively. TTNA
was the most commonly performed procedure. No radiological difference in size & location of the
mass was found in TTNA or bronchoscopy group. The yield of TTNA was higher than bronchoscopy
(95% vs 68%, p=0.001) and the cost per patient was lower (S$581 vs S$1122, p=0.001). However
TTNA correlated with missed opportunity of nodal staging in (52.5%) of patients, greater
complication rate (48%), and delayed diagnosis by 14 (1-337) days. In bronchoscopy, the delay was
shorter, and complication rate was lower. However 72.7% of patients missed opportunity of nodal
staging, and the number of procedures needed per patient for diagnosis was higher (1.34 vs 1.05,
p=0.02).
Conclusion: Bronchoscopy was timely and safer technique than TTNA, but fraught with need for
repeat procedures, and higher cost. TTNA on the other hand was more diagnostic and inexpensive
than bronchoscopy but had high rate of complication, and delayed diagnosis. Both procedures had
high rate of discordance with the guidelines & missed information regarding stage. Reserving TTNA
for small peripheral lesions without mediastinal abnormality or bronchus sign, greater adoption of
convex probe EBUS-TBNA, and availability of daily TTNA were the factors identified to improve
quality.
