Identification and management of incidental findings in a Veteran's lung cancer screening program

Abstract:Background: Incidental findings (IFs) are common on low dose CT obtained during lung cancer screening (LCS). The identification and management of clinically significant IFs is a challenging aspect of LCS programs and there is no standardized method of reporting IFs to primary care providers or patients. We explored the prevalence of incidental findings and radiologist use of the “S” modifier to identify clinically significant findings compared to what the LCS team identified as a clinically significant finding. We also presented a standardized reporting approach that provides suggested actions for providers and patients. Methods: We conducted a review of a sample of low-dose CT scans of the chest reported between August 17, 2023 and April 29, 2024 completed at VA Boston Healthcare System, omitting scans with findings concerning for lung cancer. We assessed the reporting of incidental findings by the radiologist, compared this to identification of clinically significant incidental findings by the lung cancer screening team, and evaluated factors associated with number and occurrence of incidental findings (via complete case regression). Results: Among 495 patients (Mean Age: 69.0 (6.6), 94.4% Male, 53.2% Current Smoker), 444 scans were retained for analysis. Scans had a median of seven incidental findings. The most common incidental finding was multiple pulmonary nodules (77.9%). There were 165 low-dose CT with findings the lung cancer screening team considered clinically important, however, radiologists only assigned the “S” modifier to 35 scans. Conclusions: All scans reviewed had incidental findings and nearly 40% had a finding that was clinically significant to the lung cancer screening team. There was inconsistent reporting between the radiologists and lung cancer screening team on clinical significance. Radiologists identified fewer clinically important findings than the lung cancer screening team and applied the “S” modifier inconsistently. There is no standardized method for reporting clinically significant low-dose CT results to primary care providers or patients. Our approach provides a structured approach, acknowledges multiple clinical opinions, and provides a framework for communication.