Lung Nodule Management at Cleveland Clinic: Insights From a Growing Program

Recognizing the importance of early detection and the impact of challenges associated with lung nodule management, Cleveland Clinic established the Lung Nodule Program in 2020. Much has happened since its creation, and the program has grown significantly, particularly among the regional hospitals. The levels of collaboration and communication between pulmonologists, primary care physicians (PCPs) and radiologists have improved dramatically. However, the program’s expansion has introduced some new challenges, which program leaders have identified as key priorities to address.

“Our enrollment numbers have risen quite significantly over the past few years,” says Louis Lam, MD, Director of Cleveland Clinic’s Lung Nodule Program. “We’ve gone from a little over 6,800 patient visits in 2021 to just under 16,000 patient visits in 2025. The program is currently at 24 of our sites and includes 30 doctors and 17 APPs. That doesn’t include our radiology and primary care colleagues, who are a really critical piece of the program.”

A collaborative, multidisciplinary structure

The program relies on primary care physicians to refer potential cases to radiology. Working with the Pulmonology Department, radiology has developed systems to flag actionable lung nodules and provide guideline-based management recommendations. They have also worked closely with electronic health record experts.

The Pulmonology Department developed lung nodule management care pathways based on current guidelines. It has also established a team to review the nodules, communicate findings with patients and providers and schedule patients with appropriate providers across the health system.

“As the program has expanded, one of our biggest challenges is now improving our conversion rates from consultations to completed appointments,” says Dr. Lam. “When a nodule is marked by a radiologist, that patient gets siphoned into our automated patient outreach mechanism. One of the things we have found that could be a potential barrier here is alarm fatigue for patients. We send messages through MyChart and phone calls, but we don’t necessarily hear back. So, patients are technically being notified, but they don’t return.”

Dr. Lam recognizes that some of this could be improved with better workflow and patient communication from their medical team.

“Our primary care physicians are extremely busy,” explains Dr. Lam. “Some of these road bumps could be just related to a limited bandwidth on the PCP’s part to manage these findings. Additionally, most patients also only see their PCP once or twice a year, so that limited number of visits could also create a delay in referral.”

Despite these challenges, Dr. Lam says the group has still improved the consult-to-completed appointment rate, which is currently around 60%.

“In terms of our conversion rates, there's still work to be done in terms of making sure patients are aware of their findings and recognize what lung nodules are,” says Dr. Lam. “We’d like to get that number to 70%, which is ambitious, but I think it’s doable. There’s research showing that follow-up rates for lung nodules have a lot of variance, so we’re doing our best to control what we can control. One of the scariest statistics out there is that if the nodule was just reported in the body of the radiology report and not put in the actual impression of the radiology report, that follow-up rate drops to an absolute 0%.”

The impact of standardization

Part of what’s been beneficial for Cleveland Clinic’s Lung Nodule Program has been implementing a standardized reporting mechanism for radiology. This means making sure any incidental findings are not just left on the findings portion of the report, but are built into the impression, where most providers tend to only look. Radiology also classifies each nodule based on size, with larger nodules given a higher priority.

“These nodular findings get flagged in the electronic medical record system,” explains Dr. Lam. “But, again, I think part of the problem here is that we're dealing with a lot of alarm fatigue both from the patient side and on the PCP side. Having nodules broken down by size is one of the ways we’re trying to unburden our PCP colleagues.”

The group has also updated its care path since its creation. While the nodule classifications by radiology certainly help, there remains a lot of middle ground with nodules.

Dr. Lam explains, “We updated the management algorithms and further divided care paths for intermediate and high-risk nodules — i.e., those that are 8 mm or greater — into low-intermediate risk, high-intermediate risk, high-risk and very high-risk nodules to provide higher resolution guidance.”

The group has also placed more emphasis on continued surveillance of pure ground glass nodules and to only consider invasive testing when there is a discernible solid component. The group decided that for patients being referred for surgical biopsy without an established pathologic diagnosis, the case should be formally reviewed by the program’s multidisciplinary team, especially if the diagnosis requires greater than sub-lobar resection.

High quality of care at every location

While the Lung Nodule Program has expanded as a result of its own success and merits, the expansion of Cleveland Clinic as an Enterprise has also been a contributing factor to its growth. The acquisition of Cleveland Clinic Mercy Hospital in 2021, for example, helped increase the number of lung nodule visits in that region from around 570 in 2021 to just over 3,000 in 2025.

“As we’ve expanded, we’ve made consistency across locations a major priority,” says Dr. Lam. “We certainly want to respect the practice culture and momentum at these new facilities, but we also want to provide them with the resources to help them integrate smoothly into the Lung Nodule Program.”

Dr. Lam credits Peter Mazzone, MD, MPH, Director of the Lung Cancer Program and Lung Cancer Screening Program at Cleveland Clinic, for his help with these transitions. Each sub-market region has its own head: Ahmed Hussein, MD, in the southern region; Mamoun Abdoh, MD, in the eastern region; and Joseph Cicenia, MD, in the western region. Being able to have clinicians on the ground and involved with care at each region helps ensure that the quality of care a patient receives at the main campus is the same level of care provided at the regional sites. Beyond Northeast Ohio, Cleveland Clinic Florida is also working to integrate the Lung Nodule Program into its structure.

Next steps

Continuing to tailor patient communication and improve consultation conversion rates remains the biggest priority for the Program. Dr. Lam says he believes the recent hire of Kathryn Long, MD, will help with this. Dr. Long brings a great deal of research experience in patient populations and lung nodules

“We are working on a patient dashboard database that looks at the patients who have come through the program to help us determine how many of those patients are actually undergoing a diagnostic procedure,” explains Dr. Lam. “We're very interested in whether we are finding cancer or if we are over-testing and doing diagnostic procedures on benign findings. Dr. Long will help us review our data and help us determine if our care path is doing what it’s intended to do. We're actually hoping to expand the data science team specifically for this program to help us extract and translate this data.”

The potential impact of technological advancements on the field also represents opportunity. Advancements in robotic navigational bronchoscopy are leading to a change in thresholds for pursuing non-surgical biopsies over surgical ones. ICG marking of nodules for sub-lobar resection is also improving outcomes. The evolving role of biomarker testing for confirming or ruling out cancer is helping clinicians to be more precise in their care recommendations. The program is working to augment existing guidelines with consideration for these recent advancements in the field.

“We’ve seen exceptional growth and success with this program, but there’s always more that we can do to ensure our patients are receiving the best and timeliest care,” says Dr. Lam. “We hope that as we continue to identify and solve gaps in our care path, such as patient outreach and consultation conversion rates, we can advance lung nodule care even further.