The Probability of Lung Cancer in Patients With Incidentally Detected Pulmonary Nodules: Clinical Characteristics and Accuracy of Prediction Models.

BACKGROUND: The frequency of cancer and accuracy of prediction models have not been studied in large, population-based samples of patients with incidental pulmonary nodules measuring > 8 mm in diameter. RESEARCH QUESTIONS: How does the frequency of cancer vary by size and smoking history among patients with incidental nodules? How accurate are two widely used models for identifying cancer in these patients? STUDY DESIGN AND METHODS: We assembled a retrospective cohort of individuals with incidental nodules measuring > 8 mm in diameter identified by chest CT imaging between 2006 and 2016. We used a validated natural language processing algorithm to identify nodules and their characteristics by scanning the text of dictated radiology reports. We reported patient and nodule characteristics stratified by the presence or absence of a lung cancer diagnosis within 27 months of nodule identification and estimated the area under the receiver operating characteristic curve (AUC) to compare the accuracy of the Mayo Clinic and Brock models for identifying cancer. RESULTS: The sample included 23,780 individuals with a nodule measuring > 8 mm, including 2,356 patients (9.9%) with a lung cancer diagnosis within 27 months of nodule identification. Cancer was diagnosed in 5.4% of never smokers, 12.2% of former smokers, and 17.7% of current smokers. Cancer was diagnosed in 5.7% of patients with nodules measuring 9 to 15 mm, 12.1% of patients with nodules > 15 to 20 mm, and 18.4% of patients with nodules > 20 to 30 mm. In the full sample, the Mayo Clinic model (AUC, 0.747; 95% CI, 0.737-0.757) was more accurate than the Brock model (AUC, 0.713; 95% CI, 0.702-0.724; P < .0001). When restricted to ever smokers, the Mayo Clinic model was still more accurate. Both models overestimated the probability of cancer. INTERPRETATION: Almost 10% of patients with an incidental pulmonary nodule measuring > 8 mm in diameter will receive a lung cancer diagnosis. Existing prediction models have only fair accuracy and overestimate the probability of cancer.

Trends in Influenza Vaccine Uptake and Severe Influenza-Related Outcomes at Kaiser Permanente Southern California, 2007-2017.

INTRODUCTION: Major efforts to increase influenza vaccine uptake among Kaiser Permanente Southern California (KPSC) members have been undertaken in recent years. However, whether these improvements translate to a decline in severe influenza-related outcomes has not been examined. We aimed to understand the impact of the influenza vaccination program at KPSC by examining influenza vaccine uptake and 3 severe influenza-related outcomes. METHODS: We conducted an ecologic trend analysis to understand influenza vaccine uptake and influenza-related hospitalization, intensive care unit (ICU) admission, and mortality for each influenza season (2007-2017). The same cohort was followed from the influenza season to the noninfluenza season immediately afterward while using the noninfluenza season as the comparison group. We also assessed the within-season correlation between influenza vaccine uptake and influenza-related outcomes. RESULTS: Influenza vaccine uptake rose from 23.9% to 45.5%, and all 3 influenza-related outcome rates declined (hospitalization: 35.4-26.8/10,000 patients; ICU: 5.9-5.2/10,000 patients; and mortality: 3.4-2.3/10,000 patients). Influenza vaccine uptake was negatively correlated with hospitalization (-0.32, p < 0.001) and mortality (-0.29, p = 0.001). However, once we adjusted for the noninfluenza season, the results of the correlation analysis were no longer statistically significant. CONCLUSION: Although we could not establish a statistically significant inverse relationship between influenza vaccination and severe influenza-related outcomes over the study period, our findings indicate an overall decline in influenza-related outcomes over the study period, suggesting improvements in both preventive and acute care quality at KPSC.

Twelve-year outcomes of prostate cancer after radical prostatectomy for T3 and/or positive margins managed with surveillance or salvage radiation therapy, based on risk groups.

BACKGROUND: To assess 12-year outcomes on radical prostatectomy with T3/positive margins, while categorizing patients into risk groups. METHODS: From 2004 to 2007, 862 radical prostatectomy patients had T3/positive margins. Management included surveillance (54.8%), salvage radiation therapy (SRT) (36.8%), and primary androgen deprivation therapy (ADT) (8.5%). Freedom from biochemical failure, metastasis-free-survival (MFS), prostate cancer-specific survival (PCSS) were estimated using Kaplan-Meier. Multivariable analysis established prognostic factors that affected PCSS, which were used to form risk groups. Subanalysis was performed on SRT patients. RESULTS: Median follow-up was 12.1 years. T3b, Gleason score (GS), and detectable postoperative PSA independently lowered PCSS. Very-low-risk (VLR) were GS 6. Low-risk (LR) were GS 3 + 4 with T3a or positive margins, but undetectable postoperative PSA <0.1. High-risk (HR) were T3b with GS 7-10, or any GS 7-10 with T3a/b and positive margins, but undetectable PSA. Ultra-high-risk (UHR) were detectable PSA with GS 7-10. Median time to first salvage treatment for VLR, LR, HR, and UHR were 11.1, 10.8, 5.3, and 0.6 years, p < 0.001. The 12-year freedom from biochemical failure for VLR, LR, HR, UHR were 60.2%, 52.9%, 28.4%, and 0%, p < 0.001. For 12-year MFS, 99.1%, 97.8%, 88.6%, and 63.6%, p < 0.001. For 12-year PCSS, 99.5%, 99.4%, 93.5%, and 78.9%, p < 0.001. For subanalysis of 317 SRT patients, 10-year MFS were 100.0%, 97.0%, 88.2%, and 84.6%, p = 0.008. CONCLUSIONS: Outcomes of VLR/LR yields excellent results using surveillance or SRT as initial management, in which adjuvant radiation therapy or ADT plus SRT can be avoided. For HR, early SRT or adjuvant radiation therapy can be considered reasonable, and UHR patients may benefit from ADT plus immediate SRT.

Close or positive margins after mastectomy for DCIS: pattern of relapse and potential indications for radiotherapy.

PURPOSE: Mastectomies result in very high local control rates for pure ductal carcinoma in situ; however, close or involved tumor margins are occasionally encountered. Data regarding the patterns of relapse in this setting are limited. METHODS AND MATERIALS: Between 1994 and 2002, the pathology reports of 574 patients who had undergone mastectomy at our institution for pure ductal carcinoma in situ were retrospectively reviewed. Of the 574 patients, 84 were found to have margins of <10 mm. Of the 84 patients, 4 underwent postoperative radiotherapy and were excluded, leaving 80 patients for this analysis. Of the 80 patients, 31 had margins <2 mm and 49 had margins of 2.1-10 mm. High-grade disease was observed in 47 patients; 45 patients had comedonecrosis; and 30 had multifocal disease. Of the 80 patients, 51 were <60 years of age. RESULTS: With a median follow-up of 61 months, 6 (7.5%) of the 80 patients developed local recurrence. Of the 31 patients with a margin of