IPBronch.com | Interventional Pulmonology

🎯 Background & Rationale

Effective pulmonary nodule (PN) evaluation and management is the linchpin of early lung cancer diagnosis. However, managing PNs requires balancing the detection of early malignancy against the non-trivial harms of invasive diagnostic procedures. While numerous risk prediction models, commercial biomarkers, and technological advancements (such as advanced bronchoscopic imaging) have emerged, the degree to which contemporary clinicians actually integrate these tools into routine practice remains largely unknown. This study addresses key knowledge gaps regarding current clinical decision-making practices, specialty variability, and perceived system-level barriers to optimal PN care.

👥 Study Design & Population

This was an exploratory sequential mixed-methods study conducted in the U.S. and Canada, comprising two sequential phases:

Qualitative Phase: Semi-structured interviews with 40 clinicians across general pulmonology, interventional pulmonology (IP), and thoracic surgery to identify emergent themes.
Quantitative Phase: A national, cross-sectional online survey of 192 clinical participants across 34 U.S. states and Washington D.C., recruited via the American Association for Bronchology and Interventional Pulmonology (AABIP) and targeted outreach. Survey participants spanned general pulmonology (29.7%), IP (47.9%), thoracic surgery (6.3%), and other specialties (16.1%), including attending physicians (72.9%), trainees (13.5%), and advanced practice providers (13.5%).

📈 Methodology & Rigor

Qualitative interview transcripts were analyzed thematically using inductive and deductive approaches to develop the quantitative survey. The national online survey utilized convenience sampling (with a 5.4% invitation completion rate, yielding 192 completed responses) and evaluated clinician attitudes, risk assessment tool utilization, and management pathways. Quantitative data were analyzed using descriptive statistics, weighted scoring methods for ranking clinical care priorities, and Chi-squared bivariate analyses to explore differences across clinical specialties, years of experience, and the availability of patient navigators. Qualitative quotes were triangulated with survey results.

🔬 Key Findings

Risk Assessment Tools: Most clinicians (70.8%) used risk assessment tools, utilizing clinical risk prediction models (70.3%) far more frequently than commercial biomarkers (18.8%). The Mayo Clinic model (87.4%) and Brock model (60.7%) were most common. However, among users, less than 12% reported that these tools significantly influenced their actual management decisions.
Sensitivity vs. Specificity: Overall, 63.5% of clinicians believed ideal risk assessment tools should prioritize missing no lung cancer diagnoses (sensitivity) over avoiding unnecessary procedures (specificity). This preference was significantly more pronounced among clinicians with ≤10 years of experience compared to those with >10 years (73.4% vs. 45.6%; P<0.001).
Management & Specialty Heterogeneity: There was limited consensus on when to biopsy, with practices varying significantly by specialty. Bronchoscopy was overwhelmingly reported as the first-choice biopsy modality (90.1% overall).
Shared Decision-Making & Resources: 89.6% of clinicians reported that shared decision-making occurs most of the time or always. However, only 50.5% agreed they had the necessary clinical resources to provide optimal care, though those with patient navigation were more likely to feel adequately resourced (58.4% vs. 41.8%; P=0.02). Clinicians ranked better PN tracking tools first and more accurate cancer risk assessment tools second among priorities for improvement.

⚖️ Critical Appraisal

The study successfully combines qualitative depth with national quantitative breadth to capture modern practice patterns following the widespread adoption of advanced navigational bronchoscopy and newer biomarkers. Limitations include a low survey response rate (5.4%), which is common in contemporary clinician surveys and may limit broad generalizability, as well as potential social desirability bias regarding reported rates of shared decision-making. Nevertheless, the strong concordance between the qualitative and quantitative phases supports external validity.

💡 The Clinical Bottom Line

Contemporary PN management is heavily reliant on clinical gestalt rather than commercial biomarkers, and is characterized by a strong shift toward bronchoscopic approaches as the first-line diagnostic modality. Despite this technological progress, clinicians feel heavily burdened by administrative tracking and a lack of system-level resources. Clinicians prioritize investments in robust PN tracking systems and more actionable cancer risk assessment tools to mitigate diagnostic delays and reduce system-level friction.

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.