Stage I lung cancer patients still getting needlessly imaged for brain metastases

A new study supports the Choosing Wisely position that neuroimaging does not give worthwhile benefit to patients with screening-detected stage I non-small-cell lung cancer (NSCLC) but no symptoms of metastasis to the brain. However, the same study shows that many patients are receiving the imaging anyway.

This latter finding, along with the wide variation the researchers observed in imaging utilization between centers, suggests “either lack of awareness or disagreement about this Choosing Wisely recommendation,” conclude the authors, led by Alex Balekian, MD, of the University of Southern California.

The study is running in the April edition of Chest.

Balekian and colleagues identified National Lung Screening Trial patients with clinical stage IA NSCLC who received CT scans or MR brain imaging within 60 days after diagnosis but before definitive surgical staging.

After adjusting for variables, they found that, among 643 patients with clinical stage IA NSCLC, 77 patients (12 percent) received at least one brain imaging study—and none came back with evidence of intracranial metastasis.

The team further found that brain imaging frequency by enrollment center varied from 0 percent to 80 percent, and larger tumor size and older age were associated with greater use of brain imaging.

Meanwhile, all patients who underwent brain imaging subsequently underwent surgery with curative intent, “suggesting strongly that imaging revealed no evidence of intracranial metastases,” Balekian et al. write in their discussion.

Noting that their findings echo those published 15 years earlier, the authors conclude:

“The Choosing Wisely recommendation for avoiding brain imaging in asymptomatic patients with stage IA NSCLC is supported by this study, and efforts should be made to monitor and improve adherence.”

In accompanying commentary, David Ost, MD, MPH, of the University of Texas MD Anderson Cancer Center in Houston, says the Balekian study buttresses the belief that brain imaging in asymptomatic patients with screen-detected clinical stage I NSCLC is unwarranted.

He adds that the finding, consonant as it is with national recommendations, should inform future evidence-based guidelines.

“To improve outcomes and quality of care for patients with lung cancer, the wisest path would be to focus on developing high-quality evidence to inform physicians and patients about the best available options,” Ost writes. “Once the evidence base is strong, standardization will be more effective.”

Ost says that, without a strong evidence base, “unwarranted monitoring for adherence to weak guidelines would be counterproductive, wasteful of resources and unwise.”