Reply: Lung Cancer Diagnosis and Staging Centers
Authors: Neal Navani, Sam M. Janes
Journal: American Journal of Respiratory and Critical Care Medicine (2013)

From the Authors:

We thank Drs. Maturu, Agarwal, and Rossi for their interest in our article (1). Drs. Maturu and Agarwal question the cost effectiveness of endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) compared with standard bronchoscopy in the diagnosis of lung cancer. None of the patients included in our study had endobronchial disease, and we cannot agree with their statement that the vast majority of patients with lung cancer have abnormal endobronchial findings. Drs. Maturu and Agarwal also miss an important point regarding the utility of EBUS-TBNA in patients with lung cancer. Not only can EBUS-TBNA provide a lung cancer phenotype and genotype, but it also provides a highly accurate nodal stage, critical to determining the treatment options. EBUS-TBNA, therefore, provides considerable information in addition to that provided by bronchoscopy and may prevent the need for further investigations such as integrated positron emission tomography–computed tomography, endoscopic ultrasound–guided fine needle aspiration, and mediastinoscopy. We are currently investigating the clinical efficacy and cost effectiveness of EBUS-TBNA as an initial investigation after staging computed tomography scan in patients with suspected lung cancer (2).

We agree with Dr. Rossi that the personalization of advanced non–small cell lung cancer (NSCLC) management has adjusted the spotlight onto tissue acquisition techniques and their interpretation. A paradox currently exists whereby patients with metastatic disease (in whom cancer phenotyping and genotyping is mandatory for best outcomes) have the smallest biopsies, whereas patients with considerably larger surgically resected specimens currently do not have systemic treatment tailored to their tumor. Dr. Rossi highlights the key role that the pathologist plays in deciding treatment options for patients with advanced NSCLC as well as the demands now placed on small biopsy samples.

As well as the pathologist requiring more dedicated lung cancer expertise, the same may apply to pulmonologists. Evidence already exists that the presence of dedicated thoracic surgeons may result in better lung cancer outcomes (3). The number of centers using EBUS-TBNA as a diagnostic and staging tool continues to increase internationally. Although the learning curve to reach competency in the procedure may be short (4), the focus has been on procedure sensitivity, whereas the assessment of quality of samples generated has not yet been built into competency assessment.

The centers included in our study are recognized for their expertise in lung cancer management, and it is unclear whether the results seen in our study may be generalizable to centers without specific expertise in lung cancer. Dr. Rossi calls for pathologists dedicated to lung cancer in each laboratory that receives lung cancer samples. However, given current progress and the prospect of further genetic targets in NSCLC reaching clinical utility in the very near future, perhaps the time has come to consider centers dedicated to lung cancer imaging and tissue acquisition as well as pathological diagnostics. This model may optimize the patient experience for lung cancer diagnosis and staging, raise standards of diagnostics to a more uniform level, be cost effective, and facilitate recruitment to clinical trials.