Challenges and current practices in the management of pulmonary nodules in China: a mixed methods study

Introduction

According to the Fleischner Society, pulmonary nodules (PNs) are small, rounded lesions found in the lungs that are typically smaller than 30 mm in diameter (1). PNs are common among the general population. A study from the United States reported an increase in nodule detection from 24% to 31% in computed tomography (CT) scans conducted from 2006 to 2012 (2). Another study conducted in China identified 2040 (26%) cases of PNs among 7,752 participants (3). PNs are predominantly benign and asymptomatic but can occasionally serve as early indicators of lung cancer (2,4). Data from the Pan-Canadian Early Detection of Lung Cancer (PanCan) study indicated that 5.5% of detected nodules are malignant (5). Among cancers, lung cancer still ranks the highest in mortality and accounts for the most cancer-related deaths in China and around the world (6). Research suggests that earlier-stage lung cancer is associated with a better prognosis and higher survival rate as compared to advanced-stage cancer; however, the majority of lung cancers are not detected until stage IV (7,8). Therefore, timely and accurate diagnosis, along with high-quality follow-up management, are essential to the effective care of these nodules, particularly within high-risk populations.

Management strategies for PNs vary across guidelines. However, they all generally emphasize the evaluation of the nodule’s characteristics, individual risk assessment, and structured follow-up (9,10). Regular CT scans play an important role in structured follow-up. These scans are crucial in the timely monitoring of the change in nodule size, shape, and characteristics over time, all of which can serve as indicators of malignancy, thereby eventually improving patient outcomes (11). Instead of regular CT, low-dose CT has been developed for not only detecting lung cancer but also reducing radiation exposure dose in United States and Japan (12,13). It was reported that the adherence rate was 22.3%, and predictors of poor adherence included current smoking status and Hispanic or Black race (14). The use of CT in the management of PN has shown clear benefits, but there remains a substantial issue in the adherence to follow-up recommendations. Previous studies indicate that only half of patients follow guideline-recommended follow-up (15,16). This low adherence may be the result of several factors, including poor communication between physician and patients, small nodule size, and demographic factors (15,16). Nonadherence may lead to a delayed diagnosis of serious conditions related to PNs, and thus there is a clear need for health care systems to improve adherence to follow-up CT scans among patients with PNs.

Solving the nonadherence problem requires a comprehensive approach. PN management programs implemented by hospitals may be a viable approach for enhancing adherence. Numerous hospitals in the United States have already established PN management programs and have employed a multidisciplinary approach to monitor and manage PNs in patients with high-risk disease (17,18). One study reported on a chronic disease management program (CDMP) implemented by the South Korean government which significantly improved the adherence of patients with hypertension and diabetes (19). A systematic review of 102 studies indicated that disease management programs improve the patient adherence, patient satisfaction, and disease control for multiple chronic diseases (20). However, there is currently no such management programs in China and therefore limited evidence regarding their feasibility in China. Moreover, few studies have investigated the potential barriers to implementing PN management, the service demands of patients, and physicians’ opinion on management programs in China. Therefore, our study aimed to evaluate the current practice of follow-up management for patients with PN in China and to identify the potential barriers and obstacles in PN management. A questionnaire among patients with PN was used to evaluate the follow-up routine of these patients and their preferences regarding the specific type of follow-up service. Additionally, to identify barriers to establishing an effective management program, another survey was implemented that queried physicians’ real-life experiences in treating PNs.

Additionally, to identify the obstacles in establishing an effective management program, we conducted semistructured interviews aimed at understanding physicians’ real-life experiences in managing PNs and their perspectives on the feasibility of such programs in China. By identifying and understanding these needs and issues, we hope to establish a theoretical foundation, based on real-world experience and data, for patient service programs and to address deficiencies in the research on PN management in China. We present this article in accordance with the COREQ reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-610/rc).

Methods

Overall study design

We used a mixed methods explanatory sequential approach to investigate the service demands of patients and physicians’ opinion on the management programs in China. In the first phase, we collected and analyzed quantitative survey data to explore potential factors associated with follow-up adherence and patients’ preferences for specific types of services. Subsequently, in the second phase, we examined the barriers to PN management through semistructured interviews of physicians from the relevant fields. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Ethics Committee of Zhongshan Hospital, Fudan University (No. B2023-367R2) and informed consent was taken from all participants.

Phase one: quantitative survey

Phase one: participants

A hospital-based convenience sampling approach was used for participant recruitment. In total, 500 patients with PNs were recruited from the Health Management Center and Department of Thoracic Surgery at Zhongshan Hospital between September and December 2023. The inclusion criteria were as follows: (I) any nodules with a diameter of ≤3 cm discovered on recent CT imaging; (II) no history of a cancer diagnosis; and (III) no surgical or ablative treatment for PNs.

A digital survey was given for all eligible participants. Assistance was provided for patients experiencing difficulties with the online survey interface. In order to minimize the potential geographical bias, the digital survey was also distributed via a social media platform. For patients participating online, a recent CT report was required to confirm eligibility.

Phase one: survey

The survey was designed by the whole research team. Follow-up adherence was defined as completing follow-up imaging within the timeframe advised by their doctors. Participants were asked to self-report whether they are adhered to doctor-recommended CT scan schedules and the cost of each visit. For those who did not comply, a further question was asked to clarify the reasons for nonadherence. The survey also asked for the future willingness to adhere to follow-up and the reasons for not being willing to do so Additionally, the questionnaires focused on participants’ engagement with any PN management programs. The survey queried whether patients had previously participated in such programs, reasons for not participating, and their preferences for specific types of services offered within these programs.

To quantitatively assess the impact of anxiety on patients with PNs, the Generalized Anxiety Disorder-7 (GAD-7) scale was employed. This scale is widely used to quantitatively evaluate the severity of generalized anxiety symptoms and consists of seven items that assess the signs of anxiety (21). The responses for the seven items are scored on a scale from 0 to 3, with 0 indicating “not at all” and 3 “nearly every day”. Other demographic data were also collected, including age (22,23), sex, personal income, education, family history of lung cancer, and health insurance status. The full survey is available in the supplementary materials (Appendix 1).

Phase one: statistical analysis

All submitted surveys were reviewed by researchers to ensure the completeness and overall quality of the answers. Descriptive statistics were used to outline the demographic information of the participants and their demands for specific types of services. Anxiety scores were calculated as the sum of the responses to the seven items of the GAD-7 scale. The anxiety score ranges from 0 to 21, and higher scores indicate greater anxiety severity. Due to the strong right skewness of the anxiety score, we used log(x+1) transformation to reduce the skewness.

To analyze the factors influencing participant adherence to doctor-recommended follow-up, a generalized logistic model was used, which consisted of potential participant factors as the independent variable and adherence as the dependent variable. Based on previous studies, we selected seven variables in the model including age (22,23), gender (24), nodule size, education (23,25), additional health insurance (26), current smoking status (27), family history of lung cancer, and the normalized anxiety scores. Statistical analyses were performed using R version 4.4.0 (The R Foundation for Statistical Computing).

Phase two: qualitative descriptive study

Phase two: recruitment

For this part of study, we used a qualitative research design by applying semistructured interviews. Physicians were recruited using a purposive sampling approach from seven tertiary hospitals in Shanghai. We initially created a list of potential participants from the pulmonology and thoracic surgery departments based on hospital affiliation and professional title. To ensure representativeness in terms of clinical experience and institutional background, 18 physicians were selected to reflect a range of professional titles and hospital affiliations. These physicians were invited to participate through departmental invitations. Out of the 18 physicians, 10 agreed to participate. The participants consisted of specialists from both pulmonology and thoracic surgery departments, with various years of experience in PN treatment.

Phase two: study procedures

The semistructured interview guide was designed based on the survey results from the phase one study. The development of the interview guide was conducted by the whole research team. To adjust the guide and ensure a comprehensive coverage of relevant themes, a pilot interview was conducted with two experienced physicians from our department, and refinements were made based on their feedback. The interview protocol was approved by the whole research team before the start of the interview.

The semistructured interview guide, comprising 10 open-ended questions, included the following themes: current PN management strategies, overall adherence of patients with PNs and reasons for nonadherences, reason for a lack of management programs, barriers to these programs, design of management programs, and future trends for these programs. The full interview framework is available in the Appendix 2.

The interviews were carried out face to face by two members of the research team (D.C. and J.G., MD) who was trained in semistructured interview techniques and have experience in both clinical research and health insurance research. Participants were informed that the study aimed to explore challenges and perspectives on PN management in China to inform future patient service programs. No prior relationship was established between the interviewers and the participants before. All participants were recruited formally through departmental invitations. Each interview lasted approximately 30 minutes and was recorded by the researcher. Data saturation was discussed during the interview process. After conducting 10 interviews, no new themes emerged in the final two interviews, and the team concluded that thematic saturation had been reached.

Phase two: data analysis

We used a conventional content analysis approach to analyze the interviews. The recorded audio was transcribed into text by L.S., which was then refined by D.C. and returned to participants to ensure the accuracy of the transcriptions. The transcriptions were then reviewed by the authors and were managed and coded using NVivo 14 (Lumivero, London, UK). D.C. and C.L. independently conducted the coding process. After the coding process, both authors collaboratively cross-compared their codes for similarities and differences and reconciled their codes to ensure the reliability of the coding. Codes were then organized into groups that shared similar content. From this structured grouping, subthemes and themes were abstracted from the code groups.

Results

Phase one

Phase one: descriptive statistics

Among the 500 surveys collected during the phase one study, 43 were excluded due to incompleteness or low quality such as uniform responses across all questions. Consequently, 457 valid surveys were retained for the final analysis, 233 (48.8%) of which were completed by males. The other demographic information is summarized in Table 1. A comparison of the demographic data between participants that adhered and did not adhere to follow-up CT scans was also completed.

Logistic regression with follow-up adherence as the outcome

For the 457 patients with PNs included in the final analysis, 34 expressed an unwillingness to adhere to future follow-up protocols. A higher anxiety score was significantly associated with a greater intention to adhere to future follow-up in both the univariate [odds ratio (OR) =1.92; 95% confidence interval (CI): 1.10 to 3.36; P=0.02] and adjusted models (OR =1.92; 95% CI: 1.06 to 3.50; P=0.03). In contrast, a lack of smoking history was significantly associated with greater adherence intention only in the univariate model (OR =0.47; 95% CI: 0.22 to 0.99; P=0.048) (Table 2).

Among the 457 patients with PN, 311 (68.05%) were required to undergo frequent follow-up, and 35 (11.25%) of them reported that they did not adhere to the follow-up recommendations. Larger nodule size was significantly associated with better adherence to follow-up recommendations in both the univariate (OR =1.21; 95%; CI: 1.02 to 1.45; P=0.03) and multivariate models (OR =1.24; 95% CI: 1.03 to 1.50, P=0.03). Notably, in contrast to follow-up intention, higher anxiety was associated with better adherence to follow-up recommendations in both the univariate (OR =0.60; 95% CI: 0.39 to 0.91; P=0.02) and multivariate models (OR =0.49; 95% CI: 0.31 to 0.77; P=0.002) (Table 3).

PN management attendance and service preferences

Among the 457 patients with PNs, only 2 reported they had participated in any PN management program, and 293 (64.11%) reported that they had never heard of such programs, indicating the lack of these programs in China. We then assessed the service expectations of these patients with PN who had not participated in a management program. Their answers showed varying interests in different types of services. Specifically, 58.6% of respondents expressed a demand for online health consultation, which is the most popular service. Moreover, 54.5% of participants showed interest in a follow-up/examination fast track, and 51.6% showed interest in personalized electronic health records. Other services including multidisciplinary consultation (24.1%), health education courses (17.9%), lung disease insurance (18.6%), nutrition consultation (15.8%), surgery fast track (15.8%), and mental health counseling (7.2%) generated moderate interest. Interestingly, there was no demand for personalized follow-up plans. The detailed survey results are shown in Table 4.

Phase two

The semistructured interviews included 10 physicians from 7 large hospitals in Shanghai. Among these physicians, 7 were from a thoracic surgery department and 3 from a respiratory department. Years in practice ranged from less than 3 to more than 23, but most respondents had more than 10 years of practice. The demographic characteristics of them participants are summarized in Table 5.

Current management practice

Theme 1: discrepancy between medical guidelines and clinical practice

Nearly all physicians with at least 10 years of clinical experience reported using their own standards for assessing the risk of PNs and determining follow-up intervals. Although international guidelines such as the Fleischner Society’s serve as a useful reference, the physicians emphasized the subjective nature of reading CT images. In practice, these guidelines are consistently integrated into their own clinical experience to conduct risk assessment:

• The risk stratification (in guidelines) mainly evaluates the speed of malignancy progression to determine subsequent follow-up. However, in practice, not many doctors strictly adhere to these guidelines because they often lack precision. For instance, some cases labeled as needing close follow-up (in guidelines) might be considered harmless by us, while others for which longer follow-up intervals (in guidelines) are advised may cause us concern. A lot depends on our personal experience ... Everyone knows the standards, but judgment varies from person to person.

Theme 2: patient anxiety as a major obstacle

Most physicians agreed that only a small portion of patients requiring follow-up for PNs fail to return. However, four physicians highlighted a contrasting issue of patient anxiety leading to nonadherence. These anxious patients often undergo CT scans and schedule follow-up visits more frequently than is recommended. Additionally, some of these anxious patients seek surgical interventions for their nodules at other hospitals, where surgical indications may be less strict. This behavior represents a different form of nonadherence that deviates from standard clinical recommendations.

• Many people are very anxious. … For example, if I ask them to have a follow-up visit once every one to two years, but they do it every 3–6 months, would you say that’s good or bad adherence? It’s hard to say whether it’s good or bad. It’s good because they are continuously monitored; however, excessive radiation from CT scans is unnecessary. Why undergo unnecessary radiation, right? … Many patients think they have cancer and ask, “Why don’t you apply surgical interventions? If it’s cancer and it needs to be removed sooner or later, then why not do it sooner?” But as my colleague said, “Everyone is going to die eventually, so why not die sooner?” If it’s possible to avoid surgery, it should be avoided.

Theme 3: lack of large-scale PN management programs

Overall, there are currently no large-scale PN management programs run by hospitals or insurance companies among the 7 large hospitals we interviewed in Shanghai. However, some small-scale approaches were identified in individual practices. One physician reported that physicians in his department used WeChat groups to manage their PN patients, with medical assistants being responsible for sending follow-up reminders.

• There’s no specific (program). Each doctor has his or her own team and invite patients to join a dedicated WeChat group. … They [medical assistants] create a group to help with follow-up appointments and management.

One physician discussed a department-run clinical research program targeting patients with ground-glass nodules. This program offers participants discounted fees for specialist visits and follow-up reminder services.

• …Doctor W has specific follow-up programs for those with ground-glass lung nodules. He has been doing this for several years. … By joining this follow-up program, patients no longer need to pay the special consultation fees and can be charged at the regular rate instead. … Therefore, many patients prefer to join this, especially since getting an appointment with Doctor W is particularly difficult.

Despite these efforts, these approaches are available to only a small portion of patients and provide limited services due to insufficient funding. This highlights a significant lack of structured support for PN management at a higher level.

Difficulties and prospects of PN management programs

Theme 1: variability in standards and challenges to establishing uniform PN management programs

In practice, physicians always consider international guidelines in combination with their own clinical experience for conducting risk assessment and providing follow-up recommendations. This variability can result in different standards across hospitals and even within departments of the same hospital. Consequently, it is difficult to establish a comprehensive PN management program across multiple hospitals. This challenge is exacerbated by the fact that reliance on individual experience can also lead to subjective interpretations of guidelines. In addition to the subjectivity nature of clinical decision-making, there are also barriers between institutions. has enough influence to persuade others to adopt its guidelines which make unification of management strategies challenging.

• The standards are not unified, so it’s hard to do [establish management programs]. … I still believe that it’s very difficult to standardize. Setting a standard is hard and involves many interests. On the one hand, how do you define a nodule? What size qualifies as a nodule? On the other hand, there are too many hospitals. What can you do? You can’t restrict the range to just one hospital.

Theme 2: technical problems in sharing CT imaging data between institutions

Unlike the management of other chronic diseases such as diabetes, which can be monitored through easily shared test results, PN management relies on CT imaging. However, sharing CT imaging data between hospitals, and even within a single hospital, remains challenging due to the large file sizes of these images. Physicians reported that it is difficult to require all patients to bring their digital CT imaging data to follow-up visits, and paper versions of CT reports provide very limited information.

• The connectivity between hospitals for sharing data is still inadequate. If we could view electronic versions of images on a digital device, it would be ideal, even if it takes some time. However, patients usually bring physical films or paper version CT reports, which are of no help to us. We cannot make comparisons with these physical copies.

Even when patients do bring the digital data, the process of opening these images is time-consuming. As physicians in China often have extremely overloaded schedules, there is insufficient time to repeat this process for every patient.

• However, accessing these scans depends on the efficiency of the computer, the speed of the network ... This preliminary work takes a lot of time. If the scans are not from our hospital and are on a patient’s mobile device, it takes even longer. Some patients might buffer the images ahead of time to avoid delays. Otherwise, buffering in real time wastes a lot of time. … The number of patients is high, and the expert has limited time … This time constraint prevents the expert from effectively serving more patients due to the time wasted on these preparations.

One of the physicians suggested that instead of requiring every patient to bring their imaging data, physicians can develop a more reliable medical record through using a fill-in-the-blank type of medical record system that could provide detailed information regarding the size and characteristics of PNs instead of the written medical records which contain too many irrelevant and meaningless details. However, this approach also requires additional resources to realize and maintain, in addition to administrative support from hospitals.

• The medical histories are written by young doctors. The follow-up times and other details don’t truly capture the essence of their development process. Therefore, we now require a more structured, fill-in-the-blank type of medical history system. However, this is very challenging. Overhauling such a large system in the hospital and creating a new form-based medical record system is very difficult. … Although we have considered doing this, it would mean that the hospital medical record still needs to be maintained, and we would have to create a separate system. It would be too burdensome for a resident doctor to handle both, and we don’t want to impose that on them.

Theme 3: prospects for enhancing patient support and trust

Physicians also provided recommendations on the services that should be included in the management programs. In addition to follow-up visit reminders, four physicians agreed that the program should offer patient education seminars, and one physician agreed that the program should also provide online consultation services. Both recommendations aim to enhance trust between physicians and patients, reduce patient anxiety, and eventually prevent patients from becoming overanxious and seeking unnecessary medical treatment.

• We can invite experts to conduct regular seminars like this, helping patients understand that surgery might not be necessary, right? This way, they can feel reassured and more willing to participate in follow-ups.

However, a potential barrier to patient education initiatives is accessibility. Many older patients may struggle to use online consultation services. Additionally, hospital workloads and limited resources restrict physicians’ ability to conduct frequent patient education programs as.

Discussion

This mixed methods study provides a comprehensive overview of several critical aspects in the management of PNs in China, addressing both current practices and the identified challenges from both patients’ and physicians’ perspectives. In the qualitative analysis, nodule size was significantly correlated with follow-up adherence in both the adjusted and unadjusted models. This observation aligns with a prior study which reported that higher adherence to follow-up was observed among individuals who received higher Lung Imaging Reporting and Data System (Lung-RADS) scores during the initial screening CT (28). More severe PNs may heighten patient perception of risk, and eventually increase their likelihood of returning for follow-up visits. Additionally, our study revealed that higher anxiety scores were associated with lower actual adherence to follow-up recommendations, both in the unadjusted and adjusted models, which is contrary to expectations that anxiety can enhance motivation for follow-up (28). However, this unexpected outcome is consistent with previous research indicating that higher distress levels are associated with poorer adherence among veterans with PNs (29). Similar results have been observed in follow-up studies for other cancer screenings, such as mammography (30,31). Interestingly, while higher anxiety was associated with lower follow-up adherence, our model also shown higher anxiety scores linked to greater intention to return for follow-up. These inconsistent findings underscore the complex relationship between psychological factors and patients’ follow-up behavior. The association between a high level of anxiety and a low level of adherence may be explained by the fact that patients are looking to avoid more diagnostic procedures to decrease their anxiety, which may delay necessary interventions and adversely impact patient outcomes. The effect of psychological distress on adherence suggests the need for comprehensive patient support systems.

Smoking history was also shown to be associated with follow-up adherence, which is in line with previous findings demonstrating that smokers are less likely to adhere to lung cancer screening protocols (28,32) and also less likely to receive recommended follow-up care after a positive result (33). Research also suggests that smokers are less likely to adhere to medical treatment among patients with other chronic diseases such as asthma, chronic obstructive pulmonary disease (COPD) (34), and hypertension (35). The lower adherence of smokers may be due to their engagement in risky lifestyle behaviors, which causes them to more easily justify their low adherence to recommended care (35). This observation, together with the results from our study, highlights the need for targeted interventions to improve adherence among the smoking population.

Our qualitative interviews with physicians showed that there was large discrepancy between medical guidelines and clinical practice, with most relying on personal experiences in the evaluation of risks to determine follow-up intervals. It is unclear whether these personal experiences work better for the Chinese population as compared to other evidence-based guidelines. A previous study showed that clinical practice guidelines outside of China, such as the clinical practice guidelines developed by the American College of Chest Physicians, may not be completely applicable for the Asian population (36). This variability is also a source of difficulty in establishing uniform standards for practice across different hospitals and in implementing an effective PN management program. Physicians emphasized how difficult it was to standardize management practices because of the subjective nature of risk assessment. These interviews are evidence supporting the creation of a modified, uniform guideline specific to the Chinese population. The development of such guidelines should combine evidence-based practice with real-world experiences obtained from clinical practitioners and be sufficiently standardized to provide clear guidance. In turn, this will help foster uniformity in the quality and process of care across health care facilities and provide a foundation for large-scale PN management programs. However, this will inevitably be a challenging, long-term process, because, as one physician said, “Setting a standard is hard and involves many interests. … there are too many hospitals.”

The qualitative interviews also illustrated that some patients’ anxiety often resulted in overfrequent follow-ups and unnecessary interventions. This may be an issue unique to China. The bulk of studies on this subject have focused on noncompliance with follow-up recommendations (29,37,38), and the phenomenon of overfrequent follow-up due to anxiety adds another dimension to the understanding of patient behavior. Such overanxiety can lead to unnecessary exposure of the patient to radiation, increased health care costs, and unnecessary utilization of health care resources. Anxiety is highly common among patients with PNs (39), and thus health care providers should address the psychological needs of patients with PNs to optimize care outcomes. Patient education can play a critical role in managing PN-related anxiety. With better understanding, patients are more likely to make informed choices in their care and be less inclined to demand unnecessary follow-up due to anxiety. For instance, a standardized PN fact sheet was shown to be helpful in reducing anxiety and improving understanding (40). Other methods, such as education seminars, may also generate positive effects: one physician said, “We can invite experts to conduct regular seminars like this, helping patients understand that surgery might not be necessary”. Furthermore, it should be also considered important to aggressive introduction of low-dose CT screening system into China in order to reduce excessive exposure doses by overfrequent follow-up.

There are considerable deficiencies in PN management programs. Some hospitals have initiated small-scale efforts, for example, groups on WeChat or departmental programs for clinical research; however, these are far from adequate and indicate that top-down, comprehensive, standardized management programs with funding and administrative support in place are sorely needed. Many participants reported their being technical restrictions in the sharing of imaging data from CT scans and a lack of a reliable, efficient medical record system. They emphasized how difficult it is to access and share large imaging files. These barriers require interventions, including a structured medical record system and data-sharing software, for the development of better practices in follow-up and management. New technologies, such as data compression schemes, may facilitate data sharing in the future (41). Our findings serve to establish a foundational understanding of the challenges and current practices in PN management in China and point to the areas that can be improved. Our study also emphasizes the need for continued collaboration between healthcare providers, policymakers, and researchers in developing solutions that are practical and sustainable.

Limitations and future directions

This mixed methods study provides a comprehensive overview of several critical aspects in the management of PNs in China. However, it also involved several limitations. First, both the quantitative and qualitative findings were derived from patients and physicians in Shanghai, which potentially reduces the generalizability of the conclusions. Additionally, the patients involved in the quantitative survey were mainly recruited from the health management center of a large tertiary hospital, which may have introduced selection bias. These individuals may be more concerned with their health and have greater access to resources compared to patients visiting community healthcare facilities. Third, the qualitative part included only 10 physicians, all from tertiary hospitals in Shanghai, which is a relatively small and geographically limited sample. Future studies should consider enrolling patients and healthcare providers from multiple sites in different regions to enhance the applicability of the results. Additionally, all the information, including follow-up adherence, was self-reported, and thus the results may not be completely accurate. Future studies should consider using medical record to generate these data.

Conclusions

This mixed methods study identified several key aspects in the management of PNs in China, including current practices and the challenges identified by both patients and physicians. The quantitative part of the study revealed that nodule size, patient anxiety, and smoking history significantly influence adherence to PN management recommendations. Furthermore, the lack of uniform management guidelines and difficulties in sharing CT imaging data were identified as major obstacles to implementing a large-scale PN management program. These insights underscore the need for standardized guidelines and improved data-sharing systems to enhance PN management efficiency and improve patient outcomes in China.

Acknowledgments

The authors thank the physicians from Zhongshan Hospital; Fudan University Shanghai Cancer Center; Renji Hospital; Shanghai General Hospital; Shanghai Pulmonary Hospital; Shanghai Ninth People’s Hospital and Shanghai Chest Hospital for participating in this study.

Footnote

Reporting Checklist: The authors have completed the COREQ reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-610/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-610/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-610/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-610/coif). L.S. and Y.D. are from PICC Health Insurance Company, Beijing, China. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Ethics Committee of Zhongshan Hospital, Fudan University (No. B2023-367R2) and informed consent was taken from all participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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