Lung Cancer Screening Decision Aid Research Articles

Addressing knowledge and attitude barriers to lung cancer screening: Development and evaluation of web-based decision aid

ObjectiveLow-dose computed tomography screening reduces lung cancer and overall mortality, but the participation rate remains low. The objective of this study was to develop a decision aid (DA) that addresses the overabundance of healthcare options and barriers to participation in lung cancer screening (LCS) among the general population aged 40–79 years in Korea. Materials and MethodsThe DA was developed by following the International Patient Decision Aid Standards process. To evaluate the DA, participants aged 40–79 years were purposively sampled from four districts of the Seoul metropolitan area, with 25 individuals from each decade of the age range. Participants used the DA for LCS, and pre–post comparison was conducted. The primary outcome was a change in intention to undergo LCS after completing the DA. The secondary outcomes were changes in knowledge and attitude about LCS, decisional conflict, and the perceived usefulness of the DA. ResultsThe DA prototype contained lung cancer risk assessment and decision-making components that addressed knowledge, risks, benefits, costs, and personal values. In a pilot study of 100 participants (mean age 59.0 [SD 11.1] years, 80 % male, 25 % of whom had undergone LCS), knowledge about LCS increased (mean [SD] score [out of 100] before vs. after: 68.3 [13.4] vs. 73.6 [18.0], p < 0.001). A positive change in attitude was observed (p = 0.004), but the intention to screen remained consistent (70 % before vs. 72 % after; p = 0.650). Eighty-eight participants reported the lowest level of conflict in decision-making, and most reported that the DA was useful (mean [SD] score 78.8 [9.0] out of 100). 72 % reported that the DA facilitated self-decision-making, but 27 % felt the DA recommended LCS. ConclusionsThis study highlights the potential of a well-designed DA to enhance knowledge and attitudes about LCS, but those improvements did not translate to a significant change in screening intentions.

Physician preferences for an electronic lung cancer screening decision aid.

To present primary care physician (PCP) suggestions for design and implementation of a decision aid (DA) tool to support patient-provider shared decision-making on lung cancer screening (LCS). Semistructured interviews were conducted with 15 PCPs at an academic medical center. The deidentified transcripts were independently coded by 2 study interviewers and jointly reviewed every 5 interviews until we determined that data saturation had been achieved. We then identified themes in the data and selected illustrative quotes. Three main themes were identified: (1) make it brief and familiar (make the tool user-friendly and implement a similar format to other widely used DAs); (2) bring me to automation station (limit busywork; focus on the patient and on the decision); and (3) involve the patient (facilitate patient involvement in the DA with simple language, visual aids, and bullet-point takeaways). Findings contain concrete suggestions by PCPs to inform usable and acceptable LCS DA tool design and implementation. For an LCS DA to be most successful, PCPs emphasized that the tool must be easy to use and incorporate autopopulation functions to limit redundant patient charting.

Adaptation of a Tailored Lung Cancer Screening Decision Aid for People With HIV

BackgroundPeople with HIV (PWH) are both at elevated risk of lung cancer and high risk of multimorbidity, which makes shared decision-making (SDM) for lung cancer screening (LCS) in PWH complex. There are currently no tools adapted for SDM in PWH. Research QuestionCan a SDM decision aid be adapted to include HIV-specific measures with input from both PWH and their providers? Study Design and MethodsThis study utilized qualitative methods including focus groups with PWH and interviews with HIV-care providers to adapt and iterate an SDM tool for PWH. Eligible participants were PWH enrolled in an HIV primary care clinic who met age and smoking eligibility criteria for LCS and HIV care providers at the clinic. Both the focus groups and interviews included semi-structured discussions of SDM and decision aid elements for PWH. We used a framework-guided thematic analysis, mapping themes onto the Health Equity Implementation framework. ResultsForty-three PWH participated in 8 focus groups; 10 providers were interviewed. Key themes from patients included broad interest in adapting LCS SDM specifically for PWH, a preference for clear LCS recommendations, and the need for positive framing emphasizing survival. Providers were enthusiastic about personalized LCS risk assessments and point-of-care tools. Both patients and providers had mixed views on the utility of HIV-specific risk measures in patient-facing tools. Themes were utilized to adapt a personalized and flexible SDM tool for LCS in PWH. InterpretationPWH and providers were enthusiastic about specific tools for SDM which are personalized and tailored for PWH, make recommendations, and that inform LCS decision-making. Divergent views on presenting patient-facing quantitative risk assessments suggests these elements could be optional but available for review. This tool may have utility in complex decision-making for LCS in this population and is currently being evaluated in a pilot prospective trial.

Preliminary Testing of A Web-Based Lung Cancer Screening Decision Coaching Tool for Older Chinese American Smokers and Their Providers

ObjectivesTo examine the acceptability of a culturally targeted lung cancer screening decision aid developed for older Chinese Americans with a smoking history and primary care providers serving this patient population. MethodsStudy participants reviewed a web-based decision aid (DA) for lung cancer screening named "Lung Decisions Coaching Tool (LDC-T)." Participants completed a baseline survey and were invited to join an interview. During the interview, participants engaged with the Lung Decisions Coaching Tool and then completed standardized measures of acceptability, usability, and satisfaction. ResultsChinese American smokers (N =22) and Chinese American physicians (N=10) rated the acceptability and usability of a patient version and provider versions of the LDC-T, respectively. Patient version demonstrated high levels of acceptability, usability and satisfaction. Most participants rated the information provided as good or excellent, the amount of tool information was just right, and they thought the tool would be useful for making a screening decision. The tool was well received by participants for ease of use and well-integrated functions. Furthermore, participants indicated they would like to use the tool to help prepare for lung cancer screening shared decision-making with their provider. Similar results were found for the provider version of the LDC-T. ConclusionsLung cancer screening represents an evidence-based approach to reducing lung cancer morbidity and mortality among chronic high-frequency smokers. Study results suggest the acceptability of a culturally targeted lung cancer screening decision aid for Chinese American smokers and providers. Additional research is needed to determine the effectiveness of the DA in increasing appropriate levels of screening in this underserved population.

Adaptation and Preliminary Evaluation of a Lung Cancer Screening Decision Tool for Older Chinese American Populations

BackgroundLung cancer is a significant health issue among Chinese Americans. The study purpose was to translate and culturally adapt the Agency for Healthcare Research and Quality's (AHRQ) lung cancer screening decision tool to the needs of older Chinese American smokers. MethodsThis study used a mixed methods approach. In the first phase, AHRQ lung cancer screening decision aid was translated from English to Chinese. The second phase consisted of a paper and pencil survey (N = 50) designed to measure knowledge and attitudes regarding lung screening. Finally, focus groups (N = 5, 27 participants) were conducted to obtain input on the translated and culturally adapted AHRQ lung cancer screening DA. ResultsThe mean age of participants was 70.4 years (SD = 5.4) and the majority were male (n = 42; 84%). Seventy-four percent of the sample reported being a former smoker and 26% a current smoker. Perceived risk for lung cancer was low (26%) and the majority of participants (70%) were unaware of lung cancer screening. Perceived benefits (e.g., early cancer detection) and barriers of LDCT screening (e.g., costs) were reported by participants. The qualitative findings were largely consistent with the quantitative results. Following the revisions to the translated AHRQ DA, participants reported satisfaction with the readability and information provided. ConclusionsLung cancer screening represents an evidence-based approach for reducing lung cancer morbidity and mortality among chronic high frequency smokers. Culturally targeting evidence-based lung cancer screening decision-aids to the language, cultural and health literacy needs of high risk populations may increase uptake of lung cancer early detection screening.

A Comparison of Smoking History in the Electronic Health Record With Self-Report

Knowing patients' smoking history helps guide who may benefit from preventive services such as lung cancer screening. The accuracy of smoking history electronic health records remains unclear. This was a secondary analysis of data collected from a portal-based lung cancer screening decision aid. Participants of an academically affiliated health system, aged 55-76 years, completed an online survey that collected a detailed smoking history including years of smoking, years since quitting, and smoking intensity. Eligibility for lung cancer screening was defined using the Centers for Medicare and Medicaid Services criteria. Data analysis was performed May-December 2018, and data collection occurred between November 2016 and February 2017. A total of 336 participants completed the survey and were included in the analysis. Of 175 participants with self-reported smoking intensity, 72% had packs per day and 62% had pack-years recorded in the electronic health record. When present, smoking history in the electronic health records correlated well with self-reported years of smoking (r =0.78, p≤0.0001) and years since quitting (r =0.94, p≤0.0001). Self-reported smoking intensity, including pack-years (r =0.62, p<0.0001) and packs per day (r =0.65, p≤0.0001), was less correlated. Of those participants eligible for lung cancer screening by self-report, only 35% met criteria for screening by electronic health records data alone. Others were either incorrectly classified as ineligible (23%) or had incomplete data (41%). The electronic health records frequently misses critical elements of a smoking history, and when present, it often underestimates smoking intensity, which may impact who receives lung cancer screening.

The Reach and Feasibility of an Interactive Lung Cancer Screening Decision Aid Delivered by Patient Portal.

Health systems could adopt population-level approaches to screening by identifying potential screening candidates from the electronic health record and reaching out to them via the patient portal. However, whether patients would read or act on sent information is unknown. We examined the feasibility of this digital health outreach strategy. We conducted a single-arm pragmatic trial in a large academic health system. An electronic health record algorithm identified primary care patients who were potentially eligible for lung cancer screening (LCS). Identified patients were sent a patient portal invitation to visit a LCS interactive Web site which assessed screening eligibility and included a decision aid. The primary outcome was screening completion. Secondary outcomes included the proportion of patients who read the invitation, visited the interactive Web site, and completed the interactive Web site. We sent portal invitations to 1,000 patients. Almost all patients (86%, 862/1,000) read the invitation, 404 (40%) patients visited the interactive Web site, and 349 patients (35%) completed it. Of the 99 patients who were confirmed screening eligible by the Web site, 81 made a screening decision (30% wanted screening, 44% unsure, 26% declined screening), and 22 patients had a chest computed tomography completed. The digital outreach strategy reached the majority of patient portal users. While the study focused on LCS, this digital outreach approach could be generalized to other health needs. Given the broad reach and potential low cost of this digital strategy, future research should investigate best practices for implementing the system.

Developing and testing a brief clinic-based lung cancer screening decision aid for primary care settings.

BackgroundCancer screening‐related decisions require patients to evaluate complex medical information in short time frames, often with primary care providers (PCPs) they do not know. PCPs play an essential role in facilitating comprehensive shared decision making (SDM).ObjectiveTo develop and test a decision aid (DA) and SDM strategy for PCPs and high‐risk patients.DesignThe DA was tested with 20 dyads. Each dyad consisted of one PCP and one patient eligible for screening. A prospective, one‐group, mixed‐method study design measured fidelity, patient values, screening intention, acceptability and satisfaction.ResultsFour PCPs and 20 patients were recruited from an urban academic medical centre. Most patients were female (n = 14, 70%), most had completed high school (n = 15, 75%), and their average age was 65 years old. Half were African American. Patients and PCPs rated the DA as helpful, easy to read and use and acceptable in terms of time frame (observed t = 11.6 minutes, SD 2.7). Most patients (n = 16, 80%) indicated their intent to be screened. PCPs recommended screening for most patients (n = 17, 85%).ConclusionsEvidence supports the value of lung cancer screening with LDCT for select high‐risk patients. Guidelines endorse engaging patients and their PCPs in SDM discussions. Our findings suggest that using a brief, interactive, plain‐language, culturally sensitive, theory‐based DA and SDM strategy is feasible, acceptable and may be essential to effectively translate and sustain the adoption of LDCT screening recommendations into the clinic setting.

A pre-post study testing a lung cancer screening decision aid in primary care

BackgroundThe United States Preventive Services Task Force (USPSTF) issued recommendations for older, heavy lifetime smokers to complete annual low-dose computed tomography (LDCT) scans of the chest as screening for lung cancer. The USPSTF recommends and the Centers for Medicare and Medicaid Services require shared decision making using a decision aid for lung cancer screening with annual LDCT. Little is known about how decision aids affect screening knowledge, preferences, and behavior. Thus, we tested a lung cancer screening decision aid video in screening-eligible primary care patients.MethodsWe conducted a single-group study with surveys before and after decision aid viewing and medical record review at 3 months. Participants were active patients of a large US academic primary care practice who were current or former smokers, ages 55–80 years, and eligible for screening based on current screening guidelines. Outcomes assessed pre-post decision aid viewing were screening-related knowledge score (9 items about screening-related harms of false positives and overdiagnosis, likelihood of benefit; score range = 0–9) and preference (preferred screening vs. not). Screening behavior measures, assessed via chart review, included provider visits, screening discussion, LDCT ordering, and LDCT completion within 3 months.ResultsAmong 50 participants, knowledge increased from pre- to post-decision aid viewing (mean = 2.6 vs. 5.5, difference = 2.8; 95% CI 2.1, 3.6, p < 0.001). Preferences across the overall sample remained similar such that 54% preferred screening at baseline and 50% after viewing; however, 28% of participants changed their preference (to or away from screening) from baseline to after viewing. We assessed screening behavior for 36 participants who had a primary care visit during the 3-month period following enrollment. Eighteen of 36 preferred screening after decision aid viewing. Of these 18, 10 discussed screening, 8 had a test ordered, and 6 completed LDCT. Among the 18 who preferred no screening, 7 discussed screening, 5 had a test ordered, and 4 completed LDCT.ConclusionsIn primary care patients, a lung cancer screening decision aid improved knowledge regarding screening-related benefits and harms. Screening preferences and behavior were heterogeneous.Trial registrationThis study is registered at www.clinicaltrials.gov. NCT03077230 (registered retrospectively,November 22, 2016).

A pre-post study testing a lung cancer screening decision aid in primary care

A pre-post study testing a lung cancer screening decision aid in primary care

P1.03-055 LuCaS DA: A Lung Cancer Screening Decision Aid to Improve Screening Decisions

Although lung cancer (LC) continues to be one of the leading causes of cancer morbidity and mortality world-wide, the NLST trial showed that low dose computed tomography (LDCT) screening can substantially reduce mortality in specific high-risk populations. However, most individuals are not making informed decisions which take into account the risks of screening although US guidelines advocate for informed decision-making. We report preliminary results of a web-based interactive LC decision aid (LuCaS DA) on LC screening knowledge and decision making compared to the US National Cancer Institutes’ web-pages on LC screening. Individuals in the study (n=50; from rural Kentucky and SE Florida, USA) had an elevated risk for lung cancer (n=50) due to smoking. Participants completed a baseline survey and were randomized to viewing the LuCaS DA or the NCI website. After 2 weeks, participants completed an online survey. Surveys collected information on: demographics, health status, smoking history, knowledge of CT screening, decisions about being screened for lung cancer, and decisional conflict about screening. Participants were 52.6 (SD 5.1) years old on average; were majority female (77.1%), White (62.0%), and non-Hispanic (83.7%), and reported have some insurance coverage (88.0%). Most were current daily smokers (70.2%), and overall had smoked an average of 27.9 (SD 7.7) years. Mean Decisional Conflict overall participants was 39.3 (SD 13.5) at baseline and 34.4 (SD 11.1) at 2 week follow up, with no differences between the arms. The percentage of participants show stated that they had made a decision about screening increased slightly from 32.7% at baseline to 37.5% at follow up. Preparedness for making a decision about screening (measured POST only) showed no differences between the arms. There were some increases in knowledge about CT screening and knowledge about LCS guidelines from initial to 2-week follow up. Finally, a qualitative exploration of the LuCaS DA showed that it had high levels of acceptability. DAs can facilitate informed decisions about participation in cancer screening, and US policies have required their use. This is the first study that we are aware of that assesses the use and effects of a lung cancer screening decision aid. These preliminary results show that the LuCaS DA can improve some outcomes, but not consistently more than the NCI webpages. Additional analyses will include the full sample of participants, evaluate a broader array of decision and behavioral outcomes, and consider longer term outcomes of the LuCaS DA.