Diagnostic Error in Patients With Pulmonary Symptoms: More Challenging Cases

Alan Fein, MD; Joaquin E. Morante, MD; Aashir M. Shah, MBBS


December 19, 2017

'What's My Lung Cancer Risk?'

A 65-year-old smoker (50 pack-years) presented for a routine visit. He asked the physician for an assessment of his lung cancer risk, because one of his friends was recently diagnosed with lung cancer. The physician ordered a chest x-ray, which showed hyperinflation but was otherwise normal.

Figure 4. Hyperinflation on chest x-ray.

The patient was reassured that his chest x-ray was negative and sent home.

Why was this a diagnostic error?

Lung Cancer Screening

In December 2013, the US Preventive Services Task Force recommended low-dose CT for lung cancer screening in patients at high risk for lung cancer. The currently accepted US guidelines include the following screening criteria:

  • Age 55-77 years;

  • No signs of lung cancer;

  • Current smokers or those who quit in the past 15 years; and

  • At least a 30–pack-year smoking history.

Although the USPSTF recommends screening adults up to the age of 80 years, Medicare will reimburse for screening only in those 55-77 years of age who meet other eligibility criteria. If these criteria are met, the physician should have a discussion with the patient about the risks and benefits of lung cancer screening. Assuming that the physician and patient agree that lung cancer screening should be done, the management of lung nodules should be consistent with one of the available guidelines, such as the Fleischner Society 2017 Guidelines for Management of Incidentally Detected Pulmonary Nodules in Adults (Table) or the Lung-RADS™ criteria.

Table. Fleischner Society 2017 Guidelines for Management of Incidentally Detected Pulmonary Nodules in Adults[4]

The National Lung Screening Trial[5] found that patients who received low-dose helical CT had a 15%-20% lower risk of dying of lung cancer than those who received a standard chest x-ray (Figure 5).

Figure 5. Key findings from the National Lung Screening Trial.

Low-dose CT has a high false-positive rate and can lead to unnecessary invasive workup. This risk should be discussed with the patient before ordering low-dose CT.


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