title: Facility-level analysis of PET scanning for staging among US veterans with non-small cell lung cancer.
abstract: BACKGROUND
  PET scanning has been shown in randomized trials to reduce the frequency of surgery without cure among patients with potentially resectable non-small cell lung cancer (NSCLC). We examined whether more frequent use of PET scanning at the facility level improves survival among patients with NSCLC in real-world practice.
  
  
  METHODS
  In this prospective cohort study of 622 US veterans with newly diagnosed NSCLC, we compared groups defined by the frequency of PET scan use measured at the facility level and categorized as low (<25%), medium (25%-60%), or high (>60%).
  
  
  RESULTS
  The median age of the sample was 69 years. Ninety-eight percent were men, 36% were Hispanic or nonwhite, and 54% had moderate or severe comorbidities. At low-, medium-, and high-use facilities, PET scan was performed in 13%, 40%, and 72% of patients, respectively (P<.0001). Baseline characteristics were similar across groups, including clinical stage based on CT scanning. More frequent use of PET scanning was associated with more frequent invasive staging (P<.001) and nonsignificant improvements in downstaging (P=.13) and surgery without cure (P=.12). After a median of 352 days of follow-up, 22% of the sample was still alive, including 22% at low- and medium-use facilities and 20% at high-use facilities. After adjustment and compared with patients at low-use facilities, the hazard of death was greater for patients at high-use facilities (adjusted hazard ratio [HR], 1.35; 95% CI, 1.05-1.74) but not different for patients at medium-use facilities (adjusted HR, 1.14; 95% CI, 0.88-1.46).
  
  
  CONCLUSIONS
  In this study of veterans with NSCLC, markedly greater use of PET scanning at the facility level was associated with more frequent use of invasive staging and possible improvements in downstaging and surgery without cure, but greater use of PET scanning was not associated with better survival.
authors.affiliation: Department of Veterans Affairs, Palo Alto, CA. Electronic address: michael.k.gould@kp.org.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
authors.affiliation: VA Health Economics Research Center, Menlo Park, CA.
authors.forename: Todd H
authors.initials: TH
authors.lastname: Wagner
authors.affiliation: Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA.
authors.forename: Ellen M
authors.initials: EM
authors.lastname: Schultz
authors.affiliation: Palo Alto Institute for Research and Education, Palo Alto, CA.
authors.forename: Xiangyan
authors.initials: X
authors.lastname: Xu
authors.affiliation: VA Palo Alto Health Care System, Palo Alto, CA.
authors.forename: Sharfun J
authors.initials: SJ
authors.lastname: Ghaus
authors.affiliation: Durham Epidemiologic Research and Information Center, Durham VA Medical Center, Durham, NC; Duke University, Durham, NC.
authors.forename: Dawn
authors.initials: D
authors.lastname: Provenzale
authors.affiliation: Health Services Research and Development Service, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA.
authors.forename: David H
authors.initials: DH
authors.lastname: Au
mesh_terms: D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging* / Q000473:pathology*; D005260:Female; D006268:Health Facilities; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods; D049268:Positron-Emission Tomography; D011446:Prospective Studies; D014481:United States; D058014:Veterans Health