Pretreatment Invasive Nodal Staging in Lung Cancer: Knowledge, Attitudes, and Beliefs among Academic and Community Physicians

Published:November 18, 2021DOI:
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      Pretreatment invasive nodal staging is paramount for appropriate treatment decisions in non-small cell lung cancer. Despite guidelines recommending when to perform staging, many studies suggest that invasive nodal staging is underutilized. Attitudes and barriers to guideline-recommended staging are unclear. The National Lung Cancer Roundtable initiated this study to better understand factors associated with guideline-adherent nodal staging.

      Research Question

      What are the knowledge gaps, attitudes, and beliefs of thoracic surgeons and pulmonologists about invasive nodal staging? What are the barriers to guideline-recommended staging?

      Study Design and Methods

      A web-based survey to a random sample of pulmonologists and thoracic surgeons identified as members of CHEST in 2019. Survey domains included knowledge of invasive nodal staging guidelines, attitudes and beliefs towards implementation, and perceived barriers to guideline adherence.


      Among 453 responding physicians, 29% were unaware that invasive nodal staging guidelines exist. Among the 320 physicians who knew guidelines exist, attitudes towards the guidelines were favorable, with 91% agreeing guidelines are generalizable and 90% agreeing that recommendations improved their staging and treatment decisions. Approximately 80% responded that guideline recommendations are based on satisfactory levels of scientific evidence, and 50% stated a lack of evidence linking adherence to guidelines to changes in management or better patient outcomes. Nearly 9 in 10 physicians reported at least one barrier to guideline adherence. The most common barriers included patient anxiety associated with treatment delays (62%), difficulty implementing guidelines into routine practice (52%), and time delays of additional testing (51%).


      Among physicians who responded to our survey, more than a quarter were unaware of invasive nodal staging guidelines. Attitudes towards guideline recommendations were positive although 20% reported insufficient evidence to support staging algorithms. Most physicians reported barriers to implementing guidelines. Multi-level interventions are likely needed to increase rates of guideline-recommended invasive nodal staging.



      EBUS (Endobronchial ultrasound-guided needle aspirate), NSCLC (Non-small cell lung cancer), CT (Computed tomography), PET (Positron emission tomography), NLCRT (National Lung Cancer Round Table), SBRT (Stereotactic body radiation therapy), NCCN (National Comprehensive Cancer Network), ACCP (American College of Chest Physicians), MUSC (Medical University of South Carolina)
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