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Background In 2013, the United States Preventive Services Taskforce instituted recommendations for annual lung cancer screening (LCS) with low-dose chest CT imaging for high-risk individuals. LCS reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. Although racial disparities in lung cancer mortality have been well documented, less is known about disparities in LCS participation and adherence to follow-up in clinical practice. Research Question What is the association between race and adherence to LCS follow-up? Study Design and Methods A systematic review was conducted through a search of published studies in MEDLINE, PubMed, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature Database from database inception through October 2020. We included studies that examined rates of adherence to LCS follow-up and compared rates by race. Studies were pooled using random-effects meta-analysis. Results We screened 18,300 titles and abstracts, and 229 studies were selected for full-text review. Nine studies met inclusion criteria; seven were included in the meta-analysis. Median adherent follow-up rate was 37% (range, 16%-82%). Notable differences among the studies included the proportion of the Black population (range, 4%-47%) and the structure of the LCS programs. The meta-analyses showed lower adherence to LCS follow-up in the Black population (OR, 0.67; 95% CI, 0.55-0.80). This disparity persisted across all malignancy risk levels determined by initial screening results. Interpretation Lower adherence to LCS follow-up in Black compared with White patients occurs despite the higher potential lung cancer mortality benefit. Literature specifically addressing race-related barriers to LCS adherence remains limited. To ensure equity in LCS benefits, greater outreach to eligible Black patients should be implemented through increased physician education and use of screening program coordinators to focus on this patient population. Trial Registry PROSPERO; No.: CRD42020214213; URL: http://www.crd.york.ac.uk/PROSPERO

BACKGROUND: Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, stereotactic body radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making. METHODS: A PubMed systematic review from 2000–2021 of outcomes after lobectomy, segmentectomy and wedge resection in generally healthy patients is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved. RESULTS: In healthy patients there is no short-term benefit to sublobar resection vs. lobectomy in randomized and non-randomized comparisons. A detriment in long-term outcomes is demonstrated by adjusted non-randomized comparisons, more marked for wedge than segmentectomy. Quality-of-life data is confounded by the use of video-assisted approaches; evidence suggests the approach has more impact than the resection extent. Differences in pulmonary function tests by resection extent are not clinically meaningful in healthy patients, especially for multi-segmentectomy vs. lobectomy. The margin distance is associated with the risk of recurrence. CONCLUSIONS: A systematic, comprehensive summary of evidence regarding resection extent in healthy patients with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation on which to build a framework for individualized clinical decision-making.

The importance of vaccinations for COPD patients has been previously described. However, there is still a gap between guideline recommendations and the implementation of preventive care delivery for these patients. Specially, the rise of SARS-CoV-2 pandemic has made the significance of vaccination adherence more critical to address. Our study showed that referral to pulmonary clinic is associated with increased odds of receiving influenza (OR = 1.97, [95% CI 1.07, 3.65]) and pneumococcal vaccinations (PCV13 OR = 3.55, [1.47, 8.54]; PPSV23 OR = 4.92, [1.51, 16.02]). These data suggest that partnerships between primary care physicians and pulmonologists can potentially improve the vaccination rates for patients with COPD.

Two randomized trials have shown that lung cancer screening (LCS) with low dose computed tomography (LDCT) reduces lung cancer mortality in patients at high-risk for lung malignancy by identifying early-stage cancers, when local cure and control is achievable. The implementation of LCS in the United States has revealed multiple barriers to preventive cancer care. Rates of LCS are disappointingly low with estimates between 5%-18% of eligible patients screened. Equally concerning, follow-up after baseline screening is far lower than that of clinical trials (44-66% v90%). To optimize the benefits of LCS, programs must identify and address factors related to LCS participation and follow-up while concurrently recognizing and mitigating barriers. As a relatively new screening test, the most effective processes for LCS are uncertain. Therefore, LCS programs have adopted a wide range of approaches without clearly established best practices to guide them, particularly in rural and resource-limited settings. In this narrative review, we identify barriers and facilitators to LCS, focusing on those studies in non-clinical trial settings - reflecting "real world" challenges. Our goal is to identify effective and scalable LCS practices that will increase LCS participation, improve adherence to follow-up, inform strategies for quality improvement, and support new research approaches.

Rationale: As chronic obstructive pulmonary disease (COPD) prevalence in women has outpaced that in men, COPD-related hospitalization and mortality are now higher in women. Presentation, evaluation, and treatment of COPD differ between women and men. Despite higher smoking rates in Veterans, little work has characterized differences in Veterans with COPD by sex. Objectives: To determine risk factors for 30-day readmission among Veterans hospitalized for COPD exacerbations and how they differed by sex. Methods: We performed a retrospective observational analysis of Veterans receiving primary care in Veterans Health Affairs facilities. We included Veterans Administration–based hospitalizations for Veterans with a COPD exacerbation (identified by International Classification of Disease, Ninth Revision codes) who survived to discharge between fiscal years 2012 and 2015. Primary outcome was 30-day readmission. Predictors ascertained before hospitalization included smoking status (current, former, never), pulmonary function testing, pulmonary medication prescriptions, and medical and psychiatric comorbidities (identified by International Classification of Disease, ninth revision codes). We created combined and sex-stratified multivariate logistic regression models to identify associations with 30-day readmission. Results: Our sample included 48,888 Veterans (4% women). Compared with men, women Veterans were younger, more likely to be nonwhite, and differed in smoking status. Women were more likely to have asthma, drug use, and several psychiatric comorbidities. Before hospitalization, women were less likely to have pulmonary function testing (76% vs. 78%; P = 0.01) or be treated with antimuscarinic (43% vs. 48%) or combined long-acting bronchodilator/inhaled corticosteroid (61% vs. 64%) inhalers. Women were more likely to receive nicotine-replacement therapy (all P

Immune checkpoint inhibitor (ICI) therapy represents a paradigm shift in the treatment of patients with locally advanced and metastatic lung cancer. Although immunotherapy generally has a more favorable safety profile when compared with chemotherapy, immune-related adverse events represent important, but incompletely understood, treatment-limiting complications associated with significant morbidity and mortality risk. Current guidelines for diagnosis and management are derived from consensus experience, highlighting that further prospective investigation in this area is needed. As ICI-related pneumonitis is a clinically and radiographically diverse toxidrome, clinical vigilance is important while treating patients with lung cancer.

Lung cancer screening with annual low-dose computed tomography (CT) decreases lung cancer mortality in high-risk patients, as defined by smoking history (> 30 pack-years) and age (55-74 years). Risks to screening include overdiagnosis, anxiety about indeterminate nodules, and radiation exposure. To be effective, lung cancer screening must combine individualized risk assessment, shared decision-making, smoking cessation, structured reporting, high quality and multi-specialty cancer care, and reliable follow-up; a multidisciplinary approach is crucial. Specialty organizations have outlined both the components of high quality lung cancer screening programs and the proposed metrics that programs should track. Long-term outcomes of lung cancer screening in the general population, further refinement of who to screen, and use of biomarkers for early cancer detection are ongoing research questions.

Palliative care (PC) focuses on improving the quality of life and minimizing suffering in patients with chronic, symptomatic, and life-threatening disease. Because of severe and progressive symptoms, coexisting lung disease, anxiety, and depression, lung cancer (LC) patients derive robust benefit fr

Despite advances in our understanding of risk, development, immunologic control, and treatment options for lung cancer, it remains the leading cause of cancer death. Tobacco smoking remains the predominant risk factor for lung cancer development. Nontobacco risk factors include environmental and occupational exposures, chronic lung disease, lung infections, and lifestyle factors. Because tobacco remains the leading risk factor for lung cancer, disease prevention is focused on smoking avoidance and cessation. Other prevention measures include healthy diet choices and maintaining a physically active lifestyle. Future work should focus on smoking cessation campaigns and better understanding disease development and treatment strategies in nonsmokers.

Pulmonary function testing (PFT) is required to diagnose chronic obstructive pulmonary disease (COPD) but is completed for only 30-50% of patients with the disease. We determined patient factors associated with

Precision medicine targets prevention and treatments based on phenotypic, biochemical, genetic, and psychosocial characteristics that determine individual variability. Personalized treatment has been a long-standing paradigm for lung cancer. Advances in our understanding of lung cancer biology over the past two decades have dramatically changed our approaches to evaluation and management. This chapter highlights three “lessons” that inform an increasingly precise approach to lung cancer and are applicable to other diseases. The lessons discuss how advances in disease understanding facilitate individualized treatment tools, use of these tools in personalized assessments, and the importance of a holistic approach to the individual patient.

Lung cancer patients are at high risk of suffering due to severe and refractory symptoms, concomitant respiratory comorbidity, frequent disease progression, and treatment that can worsen and compromise quality of life. Palliative care (PC) has shown multiple benefits to cancer patients such as better quality of life, higher patient and family satisfaction, improved disease understanding, less symptom burden, fewer depressive symptoms, less aggressive end of life care, and even improved survival with early implementation. For these reasons, multiple societies have recognized PC as an essential component of lung cancer care, and early PC is recommended for patients with metastatic disease or refractory symptoms. Unfortunately, utilization of PC is both low and often near the end of life, increasing risk for suffering. Misconceptions about PC often underlie delayed referral to PC. This review summarizes the literature for utilization of PC in lung cancer and focuses on patient benefits, misconceptions, barriers, and implementation.

Incidental radiographic abnormalities are commonly identified on computed tomographic (CT) imaging studies. In the chest, the finding of incidental lung nodules often raises the possibility of lung cancer. Published lung nodule evaluation and management guidelines rely on the determination of the pretest probability of malignancy. This chapter focuses on intermediate- and high-risk lung nodules. In situations where suspicion for malignancy is high enough to warrant further evaluation, clinicians should use a multimodality approach to perform the most efficient evaluation. Essentially, all patients with suspicious lung nodules undergo chest CT, and many will warrant PET/CT imaging. Evaluation should include history and physical examination (focusing on potential sites of metastasis) and pulmonary function testing. Brain MRI is recommended if focal neurologic signs or advanced stage disease is suspected. Laboratory testing should be guided by the clinical situation. Tissue acquisition may be obtained via surgical or nonsurgical techniques (e.g., bronchoscopy or CT-guided biopsy). The ideal site for biopsy should have high diagnostic accuracy and should be chosen for the most efficient approach to establishing both diagnosis and stage. With minimally invasive biopsy techniques, a nondiagnostic result does not definitively exclude cancer, and continued surveillance or additional diagnostic procedures may be necessary. With rare exceptions, histologic confirmation of cancer should be established before treatment is initiated; however, in some cases, diagnostic and therapeutic results can be achieved during a single surgical procedure. Because of the complexity of lung nodule management and the potential for patient distress and procedural harms, shared decision-making to enhance patient understanding and enable patient input into management decisions is recommended. Difficult cases may benefit from a multidisciplinary approach to evaluation and management.

The findings of the NLST (National Lung Screening Trial) are the basis for screening high-risk individuals according to age and smoking history. Although screening is covered for eligible Medicare beneficiaries, the generalizability of the NLST in the elderly population has been questioned.Compare outcomes of patients diagnosed with stage 1 non-small cell lung cancer in the NLST to a nationally representative cohort of elderly patients Methods: Analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare and NLST datasets for patients with stage 1 disease aged 65 to 74 years.Lung cancer-specific mortality, all-cause mortality, and 30-, 60-, and 90-day treatment mortality were measured. When compared with the NLST group undergoing surgery for stage 1 non-small cell lung cancer, those in the SEER-Medicare NLST eligible cohort had no difference in adjusted odds ratios for 30-, 60-, and 90-day surgical mortality (P values = 0.97, 0.65, and 0.46, respectively). Although the 5-year cancer-specific survival did not differ between cohorts (hazard ratio [HR], 0.84 NLST vs. SEER-Medicare NLST eligible; P = 0.21), the adjusted HR estimate for all-cause mortality was better in the NLST cohort (HR, 0.71; P 0.01). For patients who did not receive surgery for early-stage disease (presumably for curative intent), the outcomes were far worse (13.1, 18.9, 23.9%, for 30-, 60-, and 90-day treatment mortality, respectively).Elderly patients with minimal comorbid conditions meeting the inclusion criteria of the NLST who underwent surgery had excellent postoperative outcomes and similar lung cancer-specific 5-year survivorship. In those with significant comorbidities or those not undergoing surgery, competing causes of death may diminish the benefit, and there is no evidence to recommend screening in this group.

Lung cancer continues to be a difficult disease frequently diagnosed in late stages with a high mortality and symptom burden. In part because of frequent lung comorbidity, even lung cancer survivors often remain symptomatic and functionally limited. Though targeted therapy continues to increase treatment options for advanced-stage disease, symptom burden remains high with few therapeutic options. In the last several decades, exercise and physical activity have arisen as therapeutic options for obstructive lung disease and lung cancer. To date, exercise has been shown to reduce symptoms, increase exercise tolerance, improve quality of life, and potentially reduce length of stay and postoperative complications. Multiple small trials have been performed in perioperative non–small-cell lung cancer patients, although fewer studies are available for patients with advanced-stage disease. Despite the increased interest in this subject over the last few years, a validated exercise regimen has not been established for perioperative or advanced-stage disease. Clinicians underutilize exercise and pulmonary rehabilitation as a therapy, in part because of the lack of evidence-based consensus as to how and when to implement increasing physical activity. This review summarizes the existing evidence on exercise in lung cancer patients.

Convex probe endobronchial ultrasound (EBUS) is a minimally invasive diagnostic technique that allows real-time sampling of mediastinal and hilar lymph nodes and central pulmonary lesions. Its utility in diagnosing both malignant and nonmalignant diseases has led to an increased uptake and use by pulmonologists over the past decade. Because of the robust evidence supporting its safety and diagnostic yield, EBUS is now the first guideline recommended test for staging in non-small cell lung cancer (NSCLC). It has also a role in providing tissue for molecular analysis, thereby guiding in the selection of agents in the new era of personalized chemotherapies in the treatment of NSCLC. The following review highlights the evidence for EBUS in diagnosing mediastinal pathology and addresses technique, training, and competency and future directions for this technology.

Background Obstructive sleep apnea syndrome (OSAS) may be associated with cognitive impairment (CI). The goal of this study was to evaluate the impact of risk factors and continuous positive airway pressure (CPAP) on a screening tool for cognitive function. Methods The Mail-In Cognitive Function Screening Instrument (MCFSI) is a self-administered test designed to identify CI in the Alzheimer's Disease Cooperative Study. It was administered to 88 consecutive patients with OSAS attending the Medical University of South Carolina Sleep Clinic. An MCFSI score ≥ 5 was considered abnormal. Results Data were analyzed on 61 patients after excluding missing and duplicate data. The MCFSI score was abnormal in 15 patients (25%). African Americans were more likely to be CPAP-noncompliant. Female gender and smoking were associated with abnormal MCFSI scores. CPAP-compliant patients were more likely to have normal MCFSI scores, although the difference was not statistically significant ( P = 0.06). Conclusions CPAP-compliant patients showed a trend toward lower MCFSI scores. There may be gender and racial differences in CI related to OSAS, predisposing certain groups to worse morbidity. Appropriate treatment and compliance with CPAP could improve CI in OSAS. Larger studies with multivariate analyses are needed to identify relationships between individual OSAS and CI risk factors.

Introduction. The link between obstructive sleep apnea (OSA) and venous thromboembolism (VTE) remains unclear. We sought to study a possible association between VTE and OSA. Methods. We retrospectively collected data on patients with VTE between 1999 and 2009. Data on demographics and comorbidities were recorded as well as body mass index was calculated. Primary outcome was prevalence of OSA defined as an apnea−hypopnea index (AHI) ≥5. The study was registered at clinicaltrials.gov (NCT01051297). Results. We identified 840 patients with VTE. Obstructive sleep apnea was confirmed in 130 (15.5% [13%-17.9%]). Compared to the control group (no OSA), those who had OSA were more obese (83.8% vs 43.8%) and had statistically higher prevalence of diabetes, coronary artery disease, and congestive heart failure. Conclusions. The prevalence of OSA 15.5% (13%-17.9%) appears to be higher than that of the general population among patients with VTE. Our findings suggest a possible link between OSA and VTE.