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Imaging for the Pretreatment Staging of Small Cell Lung Cancer
Comparative Effectiveness Reviews, No. 174
Investigators: Jonathan R Treadwell, PhD, Matthew D Mitchell, PhD, Amy Tsou, MD, MS, Drew Torigian, MD, Charu Aggarwal, MD, and Karen M Schoelles, MD, SM, FACP.
Author Information and AffiliationsStructured Abstract
Objectives:
For small cell lung cancer (SCLC), several imaging modalities can be used to determine cancer staging, which is important to ensure optimal management. Our aim was to synthesize the literature on whether some imaging modalities are better than others for the pretreatment staging of small cell lung cancer. We searched for evidence on comparative accuracy (sensitivity, specificity) as well as subsequent clinical outcomes (choice of treatment, survival, and quality of life).
Data sources:
We searched EMBASE, MEDLINE, PubMed, and the Cochrane Library from 2000 through June 15, 2015, for full-length articles on the use of multidetector computed tomography (MDCT), positron emission tomography/computed tomography (PET/CT), magnetic resonance imaging (MRI), combined PET/MRI, endobronchial ultrasound (EBUS), endoscopic ultrasound with fine-needle aspiration (EUS-FNA), and bone scintigraphy in the pretreatment staging of small cell lung cancer.
Review methods:
We included studies of pertinent imaging tests on SCLC patients before treatment that reported one or more of the outcomes of interest (studies did not have to directly compare two or more imaging modalities). We extracted data from the included studies and constructed evidence tables. Comparative outcomes of interest included test concordance, staging accuracy (sensitivity and specificity), choice of treatment, timeliness of treatment, tumor response, harms due to overtreatment or undertreatment, survival, and quality of life. For each pair of tests and each assessed aspect (e.g., determination of metastases), we determined whether the evidence was sufficient to permit a conclusion of a difference, a conclusion of similar accuracy, or neither (i.e., insufficient). We rated the risk of bias of individual studies using an internal validity instrument and graded the overall strength of evidence of conclusions using Evidence-Based Practice Center guidance.
Results:
The searches identified 2,880 citations; after screening against the inclusion criteria, we included seven primary studies that enrolled a total of 408 patients. Six of the seven studies were deemed moderate risk of bias (principally due to failure to report on patient selection, reader blinding to results of comparator tests, and possible spectrum bias), and one was deemed high risk of bias (due to failure to blind readers to results of comparator tests and presence of spectrum bias). One of the studies reported test concordance, three studies reported the comparative accuracy of two or more testing strategies (one of which had also reported test concordance), and four studies reported the accuracy of a single imaging modality. Staging determinations included limited versus extensive disease, osseous (bone or bone marrow) metastases, lymph node involvement, liver metastases, spleen metastases, adrenal metastases, brain metastases, and any distant metastases. The most frequently reported imaging tests were MDCT, [18F]-fluorodeoxyglucose (FDG) PET/CT, and bone scintigraphy. No studies were included for any other outcomes or for associations with patient comorbidity, body habitus, or tumor characteristics.
Conclusions:
Evidence is sparse on imaging modalities in the pretreatment staging of small cell lung cancer. Nevertheless, we drew three conclusions about comparative accuracy: (1) FDG PET/CT is more sensitive than MDCT for detecting osseous metastases; (2) FDG PET/CT is more sensitive than bone scintigraphy for detecting osseous metastases; (3) Standard staging plus FDG PET/CT is more sensitive than standard staging alone for detecting any distant metastases. We assigned a grade of low to the strength of evidence for these conclusions, mostly due to risk of bias and a small number of studies. Research gaps include the dearth of evidence on several tests of interest (particularly MRI, EBUS, EUS, and PET/MRI), a lack of study designs to compare tests on patient-oriented outcomes such as survival, and a lack of data on whether comparative accuracy or effectiveness are associated with patient factors.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Discussion
- References
- Abbreviations and Acronyms
- Appendix A Search Strategy
- Appendix B List of Excluded Full Articles
- Appendix C Evidence Tables
- Appendix D Risk of Bias Assessments
- Appendix E Appendix References
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2012-00011-I Prepared by: ECRI-Penn Evidence-based Practice Center, Plymouth Meeting, PA and Philadelphia, PA
Suggested citation:
Treadwell JR, Mitchell MD, Tsou A, Torigian DA, Aggarwal C, Schoelles KM. Imaging for the Pretreatment Staging of Small Cell Lung Cancer. Comparative Effectiveness Review No. 174. (Prepared by the ECRI Institute-Penn Medicine Evidence-based Practice Center under Contract No. 290-2012-00011-I.) AHRQ Publication No. 16-EHC015-EF. Rockville, MD: Agency forHealthcare Research and Quality, April 2016. ww.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the ECRI-Penn Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00011-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients).
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality-enhancement tools, or reimbursement or coverage policies may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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.ahrq.gov
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