title: [18F]Fluorodeoxyglucose uptake by positron emission tomography for diagnosis of suspected lung cancer: impact of verification bias.
abstract: BACKGROUND
  Verification bias occurs when test findings influence the decision to perform a gold standard test. It adversely influences diagnostic test accuracy by inflating sensitivity and deflating specificity. We studied the impact of verification bias on the estimated accuracy of a test commonly used in suspected lung cancer.
  
  
  METHODS
  We studied 534 consecutive patients referred for [(18)F]fluorodeoxyglucose uptake by positron emission tomography (PET). Primary outcomes were tissue diagnoses of cancer and of mediastinal lymph node metastases. A secondary outcome was 3-year mortality. We accounted for verification bias using 2 validated methods.
  
  
  RESULTS
  The gold standard test, namely tissue acquisition, was performed in 419 patients (78%); mediastinal lymph node sampling occurred in 301 (56%). While the 410 patients with PET-diagnosed stage I cancer or higher were more likely than patients with negative PET scan findings to undergo tissue diagnosis testing (92% vs 34%) (P<.001), there was no association between PET findings and performance of mediastinal sampling. Without accounting for verification bias, the sensitivity and specificity of PET for diagnosis of cancer were 0.95 (95% confidence interval [CI], 0.92-0.97) and 0.31 (95% CI, 0.21-0.42), respectively. After adjustment, sensitivity fell to 0.85 (95% CI, 0.81-0.89), while specificity increased to 0.51 (95% CI, 0.40-0.60). For diagnosis of mediastinal disease, verification bias had slight effects on test accuracy. There were 224 deaths, with a strong gradient between PET stage and death (P<.001).
  
  
  CONCLUSIONS
  The diagnostic accuracy of PET for assessment of suspected lung cancer is substantially affected by verification bias.
authors.affiliation: Department of Cardiovascular Medicine, The Cleveland Clinic, Ohio 44122, USA. lauerm@ccf.org
authors.forename: Michael S
authors.initials: MS
authors.lastname: Lauer
authors.forename: Sudish C
authors.initials: SC
authors.lastname: Murthy
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
authors.forename: Ikenna C
authors.initials: IC
authors.lastname: Okereke
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Rice
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D005260:Female; D019788:Fluorodeoxyglucose F18 / Q000493:pharmacokinetics*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000000981:diagnostic imaging* / Q000378:metabolism / Q000401:mortality; D008207:Lymphatic Metastasis / Q000175:diagnosis* / Q000473:pathology; D008297:Male; D008482:Mediastinum; D008875:Middle Aged; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care; D049268:Positron-Emission Tomography; D019275:Radiopharmaceuticals / Q000493:pharmacokinetics*; D012680:Sensitivity and Specificity
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18