title: Impact of the introduction of EBUS on time to management decision, complications, and invasive modalities used to diagnose and stage lung cancer: a pragmatic pre-post study.
abstract: BACKGROUND
  Utilisation of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and guide sheath (EBUS-GS) for diagnosis and staging of lung cancer is gaining popularity, however, its impact on clinical practice is unclear. This study aimed to determine the impact of the introduction of endobronchial ultrasound-guided procedures (EBUS) on time to management decision for lung cancer patients, and on the utilisation of other invasive diagnostic modalities, including CT-guided trans-thoracic needle aspiration (CT-TTNA), bronchoscopy, and mediastinoscopy.
  
  
  METHODS
  Hospital records of new primary lung cancer patients presenting in 2007 and 2008 (Pre-EBUS cohort) and in 2010 and 2011 (Post-EBUS cohort) were reviewed retrospectively.
  
  
  RESULTS
  The Pre-EBUS cohort included 234 patients. Of the 326 patients in the Post-EBUS cohort, 90 had an EBUS procedure (EBUS-TBNA for 19.0% and EBUS-GS for 10.4% of cases). The number of CT-TTNAs and bronchoscopies decreased following the introduction of EBUS (p = 0.015 and p < 0.001 respectively). Of 162 CT-TTNAs, 59 (36%) resulted in complications compared to 1 complication each for bronchoscopy and EBUS-GS, and no complications from EBUS-TBNA. Fewer complications occurred overall in the Post-EBUS cohort compared to the Pre-EBUS cohort (p = 0.0264). The median time to management decision was 17 days (IQR 24) for the Pre-EBUS and 13 days (IQR 21) for the Post-EBUS cohort (p = 0.07). Within the Post-EBUS cohort, median time to management decision was longer for the EBUS group (n = 90) than the Non-EBUS group (17 days (IQR 29) vs. 10 days (IQR 10), p < 0.001). For half of EBUS-TBNA patients (n = 28, 50.0%) and EBUS-GS patients (n = 14, 50.0 %), EBUS alone provided sufficient diagnostic and/or staging information; these patients had median time to management decision of 10 days. Regression analysis revealed that the number of imaging events, inpatient, and outpatient visits were significant predictors of time to management decision of >28 days; EBUS was not a predictor of time to management decision.
  
  
  CONCLUSIONS
  The introduction of EBUS led to fewer CT-TTNAs and bronchoscopies and did not impact on the time to management decision. EBUS-TBNA or EBUS-GS alone provided sufficient information for diagnosis and/or regional staging in half of the lung cancer patients referred for this investigation.
authors.affiliation: Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), School of Surgery, The University of Western Australia, Perth, 6009, WA, Australia. neli.slavova-azmanova@uwa.edu.au.
authors.forename: Neli S
authors.initials: NS
authors.lastname: Slavova-Azmanova
authors.affiliation: Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), School of Surgery, The University of Western Australia, Perth, 6009, WA, Australia.
authors.forename: Catalina
authors.initials: C
authors.lastname: Lizama
authors.affiliation: Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), School of Surgery, The University of Western Australia, Perth, 6009, WA, Australia.
authors.forename: Claire E
authors.initials: CE
authors.lastname: Johnson
authors.affiliation: Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), School of Surgery, The University of Western Australia, Perth, 6009, WA, Australia.
authors.forename: Herbert P
authors.initials: HP
authors.lastname: Ludewick
authors.affiliation: Health Promotion Evaluation Unit, School of Sport Science, Exercise and Health, The University of Western Australia, Perth, 6009, WA, Australia.
authors.forename: Leanne
authors.initials: L
authors.lastname: Lester
authors.affiliation: Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, 6009, WA, Australia.
authors.forename: Shanka
authors.initials: S
authors.lastname: Karunarathne
authors.affiliation: Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, 6009, WA, Australia.
authors.forename: Martin
authors.initials: M
authors.lastname: Phillips
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D044963:Biopsy, Fine-Needle; D001999:Bronchoscopy; D061765:Endoscopic Ultrasound-Guided Fine Needle Aspiration; D005260:Female; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging / Q000473:pathology*; D008175:Lung Neoplasms / Q000175:diagnosis* / Q000473:pathology; D008198:Lymph Nodes / Q000000981:diagnostic imaging / Q000473:pathology; D008207:Lymphatic Metastasis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D008297:Male; D008481:Mediastinoscopy; D008875:Middle Aged; D009367:Neoplasm Staging; D014057:Tomography, X-Ray Computed
references.citation: J Thorac Oncol. 2011 Feb;6(2):239-40
references.pmid: 21252714
references.citation: JAMA. 2010 Nov 24;304(20):2245-52
references.pmid: 21098770
references.citation: Respir Med. 2011 Nov;105(11):1704-11
references.pmid: 21875783
references.citation: Respirology. 2011 Oct;16(7):1144-9
references.pmid: 21801276
references.citation: Am J Respir Crit Care Med. 2012 Aug 1;186(3):255-60
references.pmid: 22652031
references.citation: Clin Lung Cancer. 2012 Nov;13(6):475-81
references.pmid: 22498114
references.citation: Chest. 2013 May;143(5 Suppl):e211S-50S
references.pmid: 23649440
references.citation: Gen Thorac Cardiovasc Surg. 2013 Sep;61(9):522-7
references.pmid: 23749650
references.citation: Am J Manag Care. 2013 Dec;19(19 Suppl):s398-404
references.pmid: 24494721
references.citation: QJM. 2014 Mar;107(3):201-6
references.pmid: 24259720
references.citation: Lancet Respir Med. 2015 Apr;3(4):282-9
references.pmid: 25660225
references.citation: Am J Clin Oncol. 1982 Dec;5(6):649-55
references.pmid: 7165009
references.citation: J Chronic Dis. 1987;40(5):373-83
references.pmid: 3558716
references.citation: Anticancer Res. 1996 Mar-Apr;16(2):995-9
references.pmid: 8687166
references.citation: Chest. 1997 Jul;112(1):251-3
references.pmid: 9228384
references.citation: Thorax. 1998 Jun;53 Suppl 1:S1-8
references.pmid: 9713437
references.citation: Cancer Epidemiol Biomarkers Prev. 2005 Mar;14(3):576-81
references.pmid: 15767332
references.citation: Ann Thorac Surg. 2005 Dec;80(6):2051-6; discussion 2056
references.pmid: 16305843
references.citation: Chest. 2006 Sep;130(3):710-8
references.pmid: 16963667
references.citation: Chest. 2007 Sep;132(3 Suppl):178S-201S
references.pmid: 17873168
references.citation: BMC Pulm Med. 2008;8:2
references.pmid: 18221551
references.citation: Thorac Surg Clin. 2008 Nov;18(4):363-79
references.pmid: 19086606
references.citation: J Thorac Oncol. 2011 Feb;6(2):244-85
references.pmid: 21252716