Asking the GP to arrange nodule follow-up
Handing surveillance of a low-risk nodule to primary care, with the safety net written down rather than assumed.
Dear Dr [], Re: [patient name, date of birth, NHS number] This patient was referred to the [] team. The CT scan performed on [] showed an incidental [sub-solid or solid] nodule of [] mm in the [] lobe. The appearances are of a low-risk nodule. The calculated risk of malignancy was []%. Nodules of this kind are usually harmless, and an operation is not recommended at this size: in the great majority of cases the nodule turns out to be benign, and the treatment would be worse than the disease. If it grows on follow-up imaging, we would then recommend further investigation and possible removal. Under an arrangement agreed with [commissioner or ICB], follow-up CT for nodules of this type may be requested in primary care, to avoid unnecessary secondary care appointments. I would be grateful if you would arrange a non-contrast CT thorax [annually, or at the intervals below] for a total of [] years: Scan due [] Scan due [] Scan due [] Scan due [] Surveillance can stop after [] provided the nodule remains unchanged. If any report shows growth or a change in character, the radiologist will recommend re-referral, and the chest clinic will also be notified. Please refer the patient back to us at that point, or sooner if they develop new or worsening cough, haemoptysis, breathlessness or unexplained weight loss. The patient has been given written information explaining the nodule, the plan, and when the surveillance ends. If you would prefer that we retain follow-up in secondary care, please let me know and we will arrange it. Please do not hesitate to contact me on the number below with any queries. Yours sincerely,
How to use it
Handing surveillance to primary care only works if three things are written down and not assumed: the exact dates, who acts if the report shows growth, and when it stops. The original of this letter had all three implied; making them explicit is the difference between a shared plan and a dropped one. Two lines are deliberately included — the offer to keep follow-up in secondary care, and the sentence confirming the patient has their own written copy — because both make it harder for the plan to fail silently. Do not send this for nodules that are not genuinely low risk, and check that the local arrangement actually exists before citing it.
Why it says that
None of this is in the copied text. It is here so you can check the block against its source, and change it when the source changes.
- BTS guideline for the investigation and management of pulmonary nodules (2015) Surveillance intervals and duration, including annual CT to four years for subsolid nodules that persist.
- Fleischner Society 2017 guidelines for management of incidental pulmonary nodules The alternative interval schedule, where local radiology follows it.