Veterans' Lung Cancer Risk Conceptualizations versus Lung Cancer Screening Shared Decision-Making Conversations with Clinicians: A Qualitative Study.

Abstract

The Veterans Health Administration (VA) recommends lung cancer screening (LCS), including shared decision making between clinicians and veteran patients. We sought to characterize 1) veteran conceptualization of lung cancer risk and 2) veteran and clinician accounts of shared decision-making discussions about LCS to assess whether they reflect veteran concerns. We conducted qualitative interviews at 6 VA sites, with 48 clinicians and 34 veterans offered LCS in the previous 6 mo. We thematically analyzed transcripts, focusing on lung cancer risk perceptions, LCS decision making, and patient-clinician conversations. Three themes emerged. 1) Veterans' lung cancer risk conceptualizations incorporated smoking, occupational hazards, and family history, whereas clinicians focused on smoking as the primary risk factor. 2) Veterans' risk perceptions were influenced by symptoms, recency of exposures, and anecdotes about smoking, cancer, and lung disease, leading some veterans to believe other risk factors outweighed smoking in increasing lung cancer risk. 3) Both veterans and clinicians described LCS conversations centered on smoking, with little mention of other risks. Our findings may not reflect non-VA settings; for example, veterans may be more concerned about airborne hazards. While airborne hazards strongly influenced veterans' lung cancer risk conceptualizations, clinicians seldom addressed this risk factor during LCS shared decision making, instead focusing on smoking. In 2022, the US Congress highlighted the link between military toxic exposures and lung cancer risk, requiring VA clinicians to discuss these exposures and conferring automatic VA benefits to exposed veterans with cancer. There is a time-sensitive need for tools to support VA clinicians in discussing military hazards as a lung cancer risk factor, which may result in more engaging, less stigmatizing LCS shared decision-making conversations. Veterans' conceptualizations of their lung cancer risk were multifactorial and sometimes ranked exposure to occupational airborne hazards and family history above smoking in increasing lung cancer risk.However, patient-clinician lung cancer screening (LCS) conversations were typically brief and focused on smoking, which could stigmatize patients and failed to engage veterans in discussing what mattered most to them in thinking about their lung cancer risk.These findings are of heightened importance in light of the 2022 Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act, which requires VA clinicians to discuss toxic military exposures and their relationship to lung cancer and other health conditions.Tools that help clinicians assess and incorporate multiple risk factors into discussions about lung cancer may better address patients' concerns and beliefs and lead to more engaging, less stigmatizing shared decision-making conversations about LCS.