As part of the Choosing Wisely® campaign, the Society of Thoracic Surgeons developed a list of tests and procedures that they consider to be ordered more often than necessary. Included in this list is the use of brain imaging in patients with Stage 1 non-small cell lung cancer (NSCLC) who have no neurological symptoms. Yet, in a study published in Chest, researchers found that 12% of participants with stage IA NSCLC in the National Lung Screening Trial underwent at least one brain-imaging test.
Imaging of the brain is often done in NSCLC patients to ascertain whether cancer has spread. But pooled clinical data from retrospective studies demonstrated that only 3% of patients who have a negative neurological evaluation present with intracranial metastasis. One additional study limited to patients with Stage 1 NSCLC reported a prevalence of just 1.3%, indicating that the test offers little clinical benefit.
In total, 643 clinical Stage IA patients were identified as having received computed tomography (CT) or magnetic resonance (MR) brain imaging within 60 days after diagnosis., Of these patients, 77 (12%) received at least one brain imaging study, and all of these patients subsequently underwent curative surgery for their lung cancer, indicating that no brain metastases were found upon imaging. Age (between 65 years and 69 years) and the size of the tumor (larger than 20 mm) were found to be highly associated with the use of brain imaging.
The Society of Thoracic Surgeons recommends against the use of brain imaging in NSCLC patient because it has not ben evaluated by a randomized clinical trial and may not be cost-effective or medically necessary. Still, imaging frequency varied widely across cancer centers, ranging from 0% to 80%. The authors of the study, led by Alex A. Balekian, MD, MSHS (Keck School of Medicine of the University of Southern California, Los Angeles, CA), suggest that this variation may be due to a lack of awareness of or disagreement with the Choosing Wisely recommendations.
