Original Abstract
BACKGROUND: 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. RESEARCH QUESTION: Which factors contribute to clinicians' PN evaluation and management practices, and what are perceived barriers to optimal clinical care? STUDY DESIGN AND METHODS: 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. RESULTS: 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. INTERPRETATION: 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.