Guidelines such as those put forth by the Fleischner Society and the American College of Radiology are useful tools for the initial triage of patients with pulmonary nodules.1,2 However, nodule management in actual practice is often nuanced. As with any medical condition, individual patients’ health, values, and preferences need to be taken into consideration when formulating a management plan. But more importantly, how we communicate nodule findings to our patients can influence their perception and whether they agree with and adhere to recommendations.
See related article, page 475
ACKNOWLEDGING PATIENT DISTRESS
Although most pulmonary nodules are benign, they generate a disproportionate amount of distress for patients (and clinicians). Studies have shown that a majority of patients overestimate their risk of cancer.3 Many patients report experiencing varying degrees of anxiety throughout their surveillance period.4 Even in patients who have completed guideline-based follow-up (and have been reassured that their findings are benign), there are those who report ongoing anxiety about their nodule findings.3,5 As clinicians, it is important to recognize and acknowledge patients’ emotional distress and to always avoid coming across as dismissive of their concerns.
EDUCATING PATIENTS AND ENGAGING THEM IN DECISION-MAKING PROCESS
Educating patients about their nodule findings will better help them understand the rationale behind subsequent managements steps.
Seeing is learning. Sharing images with the patient (either during an office visit or over a telehealth platform) is the best way to engage the patient and to ensure that they have a visual understanding of the size and location of their nodule(s). If there are old imaging studies for comparison, having images from both current and previous studies side by side will help give the patient a visual reference as to what is stable and what is not.
Several validated risk models (some with online calculator tools) help estimate cancer risk.6–8 We find it helpful to walk patients through their risk stratification using these models as a part of their office visit. Doing so keeps patients engaged during their visit, and in turn, patients come out of their visit with a better understanding of their risks. For patients whose stratification shows low risk, this can serve as an additional point of reassurance that surveillance with follow-up imaging is the best approach. On the other hand, for patients whose risk is intermediate or high, it helps drive the need to adhere to follow-up or referral to experts.
COMMUNICATION PREFERENCES
Factors such as how information is delivered (in person, over telephone, or in writing) and timeliness in delivering the information can affect how the patient perceives that information. For patients undergoing surveillance scans for their nodule findings, it is good practice to ask them specifically about their preferred style of communication ahead of time and ensure that results are communicated as soon as they become available. Patients should ideally be offered a visit to review their images and given a chance to ask questions about their findings.
ADDRESSING COMPLIANCE WITH FOLLOW-UP
Noncompliance with follow-up can have a significant impact on timely detection of cancer. One study showed that less than half of incidentally detected lung nodules receive appropriate follow-up.9 While dedicated lung nodule programs and patient management platforms have been shown to improve follow-up compliance, these often require resources that may not be available to all institutions.10 Manual tracking of patients is unfeasible in settings with any degree of patient volume (especially in a busy primary care practice). For this reason, we should insist that patients make their follow-up imaging appointment and subsequent office appointments before they leave the office. This way, a missed office appointment can be used as a cue to provide additional outreach.
FORBEARANCE WITH PET IMAGING
While positron emission tomography (PET) imaging has been given a role in current pulmonary nodule management guidelines, it is to be used with caution given the many mechanisms that can lead to false-negative and false-positive results.11 A meta-analysis showed poor specificity (approximately 61%) of PET imaging in regions where fungal and other infectious lung diseases are endemic.12 Caution should be exercised when using PET imaging in such areas given the increased risk of false-positive PET results leading to invasive procedures on benign findings. For these reasons, we recommend referring the patient for pulmonary consultation if PET imaging is being considered.
WHEN TO SEEK EXPERT OPINION
Pulmonary consultation should be sought any time a decision about biopsy is being made. Most guidelines specifically exclude patients with previous history of malignancy and those who are immunosuppressed (eg, transplant patients or patients on long-term immunosuppression). Patients with certain types of interstitial lung diseases can present with multiple pulmonary nodules. For these patients, referral for pulmonary consultation should also be considered.
DISCLOSURES
Dr. Lam reports no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
- Copyright © 2026 The Cleveland Clinic Foundation. All Rights Reserved.
REFERENCES
- 1↵MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology 2017; 284(1):228–243. doi:10.1148/radiol.2017161659
- 2↵American College of Radiology. Lung-RADS® v2022. November 2022. edge.sitecorecloud.io/americancoldf5f-acrorgf92a-produc-tioncb02-3650/media/ACR/Files/RADS/Lung-RADS/Lung-RADS-2022.pdf. Accessed July 17, 2026.
- 3↵Freiman MR, Clark JA, Slatore CG, et al. Patients’ knowledge, beliefs, and distress associated with detection and evaluation of incidental pulmonary nodules for cancer: results from a multicenter survey. J Thorac Oncol 2016; 11(5):700–708. doi:10.1016/j.jtho.2016.01.018
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- 5↵Slatore CG, Wiener RS, Golden SE, Au DH, Ganzini L. Longitudinal assessment of distress among veterans with incidental pulmonary nodules. Ann Am Thorac Soc 2016; 13(11):1983–1991. doi:10.1513/AnnalsATS.201607-555OC
- 6↵Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med 1997; 157(8):849–855. pmid:9129544
- 7Herder GJ, van Tinteren H, Golding RP, et al. Clinical prediction model to characterize pulmonary nodules: validation and added value of 18F-fluorodeoxyglucose positron emission tomography. Chest 2005; 128(4):2490–2496. doi:10.1378/chest.128.4.2490
- 8↵McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med 2013; 369(10):910–919. doi:10.1056/NEJMoa1214726
- 9↵Kattih Z, Moore JA, Wilson B, et al. Rate of incidental lung nodule follow-up: a cohort study evaluating adherence to guideline recommendations. Am J Med Open 2025; 13:100091. doi:10.1016/j.ajmo.2025.100091
- 10↵Aunger J, Yip KP, Dosanjh K, et al. Interventions to improve adherence to clinical guidelines for the management and follow-up of pulmonary nodules: a systematic review. Chest 2025; 168(1): 248–268. doi:10.1016/j.chest.2025.02.031
- 11↵Chang JM, Lee HJ, Goo JM, et al. False positive and false negative FDG-PET scans in various thoracic diseases. Korean J Radiol 2006; 7(1):57–69. doi:10.3348/kjr.2006.7.1.57
- 12↵Deppen SA, Blume JD, Kensinger CD, et al. Accuracy of FDG-PET to diagnose lung cancer in areas with infectious lung disease: a meta-analysis. JAMA 2014; 312(12):1227–1236. doi:10.1001/jama.2014.11488
