Brain Imaging for Staging of Patients With Clinical Stage IA Non-small Cell Lung Cancer in the National Lung Screening Trial Adherence With Recommendations From the Choosing Wisely Campaign

BACKGROUND: The Choosing Wisely recommendations from the Society of Thoracic Surgeons include avoiding brain imaging in asymptomatic patients with early-stage non-small cell lung cancer (NSCLC). We aimed to describe use of brain imaging among National Lung Screening Trial participants with stage IA NSCLC and to identify factors associated with receipt of brain imaging. METHODS: We identified patients with clinical stage IA NSCLC who received CT scans or magnetic resonance brain imaging within 60 days after diagnosis, but before definitive surgical staging. Using multivariate logistic regression, we identified variables associated with undergoing brain imaging. RESULTS: Among 643 patients with clinical stage IA NSCLC, 77 patients (12%) received at least one brain imaging study. Of seven patients (1.1%) who were upstaged to stage IV, only two underwent brain imaging and neither had documentation of brain metastasis. Brain imaging frequency by enrollment center varied from 0% to 80%. All patients who underwent brain imaging subsequently underwent surgery with curative intent, suggesting strongly that imaging revealed no evidence of intracranial metastases. In multivariate analyses, primary tumor size > 20 mm (OR, 2.50; 95% CI, 1.50-4.16; P<.001) and age 65 to 69 (OR, 2.78; 95% CI, 1.38-5.57; P<.01) were independently associated with greater use of brain imaging. CONCLUSIONS: Among National Lung Screening Trial patients with stage IA NSCLC, one in eight underwent brain imaging, but none ultimately had intracranial metastases. Larger tumor size and older age were associated with greater use of brain imaging. Wide variation in use between centers suggests either lack of awareness or disagreement about this Choosing Wisely recommendation.