Effect of a Rule-in Biomarker Test on Pulmonary Nodule Management: A Survey of Pulmonologists and Thoracic Surgeons

Clin Lung Cancer. 2020 Mar;21(2):e89-e98. doi: 10.1016/j.cllc.2019.05.004. Epub 2019 Jun 13.


Introduction: The field of biomarker development is evolving to assist in determining benign from malignant pulmonary nodules. Although a prospective clinical utility would best to show how a biomarker affects patient treatment and outcomes, we sought to begin to understand how the results might alter management by determining how physicians would use the results of a rule-in blood test to manage pulmonary nodules.

Materials and methods: Pulmonologists and thoracic surgeons in the American College of Chest Physicians clinician database were invited to participate in an online survey. The participant demographic data were collected. Four hypothetical clinical vignettes were presented. The participants accessed the pretest probability (probability of cancer [pCA]) for malignancy and chose the management strategies as the case progressed. The management strategies chosen before and after the result of a rule-in biomarker test were compared and assessed for guideline concordance.

Results: Of the 455 eligible participants who had opened the survey, 416 (92%) completed it: 332 pulmonologists and 84 thoracic surgeons. Although 91% of the participants were very comfortable managing nodules, depending on the case, 30% to 62% incorrectly assessed the pCA, with 22% to 62% overestimating the risk and 8% to 51% underestimating the risk. After a rule-in blood test result, the clinician change in management moved in the right direction in some cases but, in others, the physicians used the results incorrectly. Pulmonologists and thoracic surgeons differed in the management strategies, with surgeons recommending surgery more often.

Conclusions: Although the use of biomarker testing for pulmonary nodule evaluation is promising, without proper physician education, the potential for harm exists. Clinical utility studies are needed to appropriately inform the effect of biomarker use.

Keywords: Autoantibody; Malignant nodules; Nodule guidelines; Nodules; Risk stratification management.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Biomarkers, Tumor / metabolism*
  • Disease Management
  • Female
  • Humans
  • Lung Neoplasms / metabolism
  • Lung Neoplasms / pathology
  • Lung Neoplasms / therapy*
  • Male
  • Multiple Pulmonary Nodules / metabolism
  • Multiple Pulmonary Nodules / pathology
  • Multiple Pulmonary Nodules / therapy*
  • Practice Patterns, Physicians' / standards*
  • Pulmonologists / statistics & numerical data*
  • Risk Assessment
  • Solitary Pulmonary Nodule / metabolism
  • Solitary Pulmonary Nodule / pathology
  • Solitary Pulmonary Nodule / therapy*
  • Surgeons / statistics & numerical data*
  • Surveys and Questionnaires


  • Biomarkers, Tumor