Lung Cancer Screening Recommendations Research Articles

Attitudes of Clinicians about Screening Head and Neck Cancer Survivors for Lung Cancer Using Low-Dose Computed Tomography.

National guidelines recommend lung cancer screening (LCS) using low-dose computed tomography (LDCT) for high-risk patients, including survivors of other tobacco-related cancers like head and neck cancer (HNC). This qualitative study investigated clinicians' practices and attitudes toward LCS with LDCT with patients who have survived HNC, in the context of mandated requirements for shared decision making (SDM) using decision aids. Thematic analysis of transcribed semi-structured clinician interviews and focus group. Clinicians recognized LCS' utility for some HNC survivors with smoking histories. However, they identified many challenges to SDM in diverse clinic settings, including time, workflow, uncertainty about guidelines and reimbursement, decision aids, competing patient priorities, unclear evidence, potentially heightened patient receptivity and stress, and the complexity of discussions. They also identified challenges to LCS implementation. While clinicians feel that LDCT LCS may benefit some HNC survivors, there are barriers both to implementing LCS SDM for these patients in primary care as currently recommended and to integrating it into cancer clinics. Challenges for SDM across settings include a lack of decision aids tailored to patients with cancer histories. Given recommendations to broaden LCS eligibility criteria, more research may be required before refinement of current guidelines.

5-year overall survival in patients with lung cancer eligible or ineligible for screening according to US Preventive Services Task Force criteria: a prospective, observational cohort study.

The US Preventive Services Task Force (USPSTF) recommends lung cancer screening among individuals aged 55-80 years with a 30 pack-year cigarette smoking history and, if they are former smokers, those who quit within the past 15 years. Our previous report found that two-thirds of newly diagnosed patients with lung cancer do not meet these criteria; they are reported to be either long-term quitters (≥15 years since quitting) or from a younger age group (age 50-54 years). We aimed to assess survival outcomes in these two subgroups. For this prospective, observational cohort study we identified and followed up patients aged 50-80 years with lung cancer, with a smoking history of 30 pack-years or more, and included both current smokers and former smokers who quit within the past 30 years. We identified patients from two cohorts in the USA: a hospital cohort (Mayo Clinic, Rochester, MN) and a community cohort (Olmsted County, MN). Patients were divided into those meeting USPSTF criteria (USPSTF group) versus those not meeting USPSTF criteria (long-term quitters or the younger age group). The main outcome was overall survival at 5 years after diagnosis. 5-year overall survival was analysed with and without matching age and pack-years smoked for long-term quitters. The USPSTF group was subdivided into two age subgroups (55-69 years and 70-80 years) for multivariable regression analysis. Between Jan 1, 1997, and Dec 31, 2017, 8739 patients with lung cancer were identified and followed up. Median follow-up was 6·5 (IQR 3·8-10·0) years, and median overall survival was 16·9 months (95% CI 16·2-17·5). 5-year overall survival was 27% (95% CI 25-30) in long-term quitters, 22% (19-25) in the younger age group, and 23% (22-24) in the USPSTF group. In both cohorts, 5-year overall survival did not differ significantly between long-term quitters and the USPSTF group (hospital cohort: hazard ratio [HR] 1·02 [95% CI 0·94-1·10]; p=0·72; community cohort: 0·97 [0·75-1·26]; p=0·82); matched analysis showed similar results in both cohorts. 5-year overall survival also did not differ significantly between the younger age group and the USPSTF group in both cohorts (hospital cohort: HR 1·16 [95% CI 0·98-1·38], p=0·08; community cohort: 1·16 [0·74-1·82]; p=0·52); multivariable regression analyses stratified by age group yielded similar findings. Patients with lung cancer who quit 15 or more years before diagnosis and those who are up to 5 years younger than the age cutoff recommended for screening, but otherwise meet USPSTF criteria, have a similar risk of death to those individuals who meet all USPSTF criteria. Individuals in both subgroups could benefit from screening, as expansion of USPSTF screening criteria to include these subgroups could enable earlier detection of lung cancer and improved survival outcomes. National Institutes of Health and the Mayo Clinic Foundation.

Rural-Urban Differences in Access to Thoracic Surgery in the United States, 2010 to 2014

Because of recent lung cancer screening recommendations and corresponding insurance coverage, it is expected that more early stage cases will be identified that require thoracic surgery. However, these services may not be equally available in all regions. Our objective is to describe the availability of thoracic surgeons by examining geographic variation, rural-urban differences, and temporal changes before and after screening recommendation and insurance coverage policy changes. We examined the U.S. thoracic surgery workforce using the 2010 and 2014 Area Health Resource Files. We calculated the density of thoracic surgeons per 100,000 persons for each year at the state and county level. We performed descriptive statistics and developed maps highlighting changes over time and geographic regions. Despite an overall increase in thoracic surgeons from 2010 to 2014, we observed declining density nationwide (1.5% change) and in sparsely populated states. The difference in thoracic surgeon density widened slightly between 2010 from 0.80 per 100,000 compared with 0.84 per 100,000 in 2014 in all rural counties compared with urban counties (P < .001 for both years). The difference in thoracic surgeon density was most pronounced between small adjacent rural and urban counties (0.95 and 0.96 per 100,000 for 2010 and 2014, respectively; P < .001 for both years). The Northeast held a disproportionate share of the thoracic surgery workforce. Limited access to thoracic surgeons in rural areas is a concern, given an older and retiring surgical workforce, the higher burden of lung cancer in rural areas, and recent policy changes for screening reimbursement.

Change in prevalence of asbestos-related disease among sheet metal workers 1986 to 2016.

A medical screening program began in 1986 for sheet metal workers exposed to asbestos, primarily while working alongside insulators applying spray-on asbestos materials, a practice banned in 1973. Exposure continues during maintenance, renovation, and repair. Radiographic abnormalities among 26 397 sheet metal workers examined from 1986 to 2016 were analyzed by year of entry into the trade. Logistic regression was used to examine risk factors for parenchymal and pleural abnormalities among the overall study population and among the subcohort who entered the trade after 1973. Prevalence of parenchymal disease was 17.4% for those starting work before 1950 compared with 0.8% for those starting work after 1973 (adjusted prevalence odds ratio [pOR] = 26.65, 95% confidence interval [CI] = 18.46-38.46). For each calendar year after 1973, entering the trade 1 year later was associated with an estimated 12.7% decreased odds of acquiring asbestos-related disease (adjusted pOR = 0.873, 95% CI = 0.832-0.916). Sheet metal workers who began work after the US implemented environmental and occupational regulations develop asbestos-related disease at much reduced rates, consistent with regulatory projections made for nonmalignant asbestos-related disease by the Occupational Safety and Health Administration at the time. Cancer remains a concern among this cohort, and lung cancer screening recommendations should consider year of entry into the trade. This study highlights the importance of regulatory intervention and of continued surveillance.

Cost-Effectiveness Analysis of Lung Cancer Screening Accounting for the Effect of Indeterminate Findings.

BackgroundNumerous health policy organizations recommend lung cancer screening, but no consensus exists on the optimal policy. Moreover, the impact of the Lung CT screening reporting and data system guidelines to manage small pulmonary nodules of unknown significance (a.k.a. indeterminate nodules) on the cost-effectiveness of lung cancer screening is not well established.MethodsWe assess the cost-effectiveness of 199 screening strategies that vary in terms of age and smoking eligibility criteria, using a microsimulation model. We simulate lung cancer-related events throughout the lifetime of US-representative current and former smokers. We conduct sensitivity analyses to test key model inputs and assumptions.ResultsThe cost-effectiveness efficiency frontier consists of both annual and biennial screening strategies. Current guidelines are not on the frontier. Assuming 4% disutility associated with indeterminate findings, biennial screening for smokers aged 50–70 years with at least 40 pack-years and less than 10 years since smoking cessation is the cost-effective strategy using $100 000 willingness-to-pay threshold yielding the highest health benefit. Among all health utilities, the cost-effectiveness of screening is most sensitive to changes in the disutility of indeterminate findings. As the disutility of indeterminate findings decreases, screening eligibility criteria become less stringent and eventually annual screening for smokers aged 50–70 years with at least 30 pack-years and less than 10 years since smoking cessation is the cost-effective strategy yielding the highest health benefit.ConclusionsThe disutility associated with indeterminate findings impacts the cost-effectiveness of lung cancer screening. Efforts to quantify and better understand the impact of indeterminate findings on the effectiveness and cost-effectiveness of lung cancer screening are warranted.

Low Rates of Patient-Reported Physician-Patient Discussion about Lung Cancer Screening among Current Smokers: Data from Health Information National Trends Survey.

Many professional societies published guidelines recommending lung cancer screening with low-dose CT scan. We examined the temporal trends in patient-reported physician-patient discussions about lung cancer screening, and aimed to determine the association of discussions of lung cancer screening with the smokers' attempt to quit and intent to quit. Data from years 2012, 2014, and 2017 of the National Cancer Institute's Health Information National Trends Survey (HINTS) were combined to create a multiple-year analytic dataset. We calculated the association between samples' characteristics and the presence of discussion about lung cancer screening. Using logistic regression, we estimated the probability of smokers' attempt to quit and intent to quit. Among 9,443 subjects, the crude estimated rates of physician-patient discussion decreased from 6.7% in 2012, to 4.2% in 2014 and 4.3% in 2017. Across the age and smoking status groups, the current smokers ages 55 to 74 in 2012 (26.8%), and current smokers older than 74 years in 2014 (23.5%) and 2017 (22.1%) had the highest rates of discussion. The physician-patient discussion about lung cancer screening was not associated with patients' intent to quit or attempt to quit in a multivariable analysis.Conclusions: Efforts are needed to improve the physician-patient discussion about lung cancer screening among individuals across a spectrum of lung cancer risk. Developing communication strategies for promoting beneficial lung cancer screening among lung cancer screening-eligible smokers and strategies for improving the quality of discussion on lung cancer screening integrating smoking cessation are needed to reduce the burden of lung cancer.

An Update on the European Lung Cancer Screening Trials and Comparison of Lung Cancer Screening Recommendations in Europe.

While lung cancer screening has been implemented in the United States, it is still under consideration in Europe. So far, lung cancer screening trials in Europe were not able to replicate the results of the National Lung Screening Trial, but they do show a stage shift in the lung cancers that were detected. While eagerly awaiting the final result of the only lung cancer screening trial with sufficient statistical power, the NELSON trial, a number of European countries and medical societies have published recommendations for lung cancer screening using computed tomography. However, there is still a debate with regard to the design of future lung cancer screening programs in Europe. This review summarizes the latest evidence of European lung cancer screening trials and gives an overview of the essence of recommendations from the different European medical societies and countries.

Changes in lung cancer screening knowledge, beliefs, and practices among health care providers.

117 Background: In 2013, the U.S. Preventative Task Force began recommending lung cancer screening (LCS) annually for patients ages 55-80 years who are current or former (quit within the last 15 years) smokers with a 30 pack-year history. Since then, the proportion of eligible patients undergoing LCS has been reported to be low, ranging from 3-5%. We sought to compare LCS practices and beliefs among health care providers at a large academic medical center from 2015 to 2018. Methods: In 2015 and 2018, we surveyed physicians and residents in pulmonology, family, and internal medicine using a 23-item Qualtrics survey developed with the Tailored Design Method. To evaluate potential workforce issues in LCS we compared responses regarding provider’s opinions, referral patterns, and barriers to LCS from 2015 to 2018 using chi-squared tests. Results: Response rates were 39% in 2015 and 26% in 2018. From 2015 to 2018 there was an increase in the proportion of providers who reported LCS as beneficial (44.6% vs 75.7%, p &lt; 0.0001), cost effective (20.0% vs 38.6%, p = 0.002), and as having enough knowledge to explain the risks and benefits of LCS (53.6% vs 75.7%, p = 0.001). In both years, the majority of providers reported time restrictions during a patient’s clinic visit meant that other problems had higher priority than LCS (65.1% vs 71.4%, p = 0.85). Over the 3-year period the proportion of providers who reported ordering a LCS exam more than doubled (32.2% to 74.6%, p &lt; 0.00001) and the percentage who initiated discussion about the risks and benefits increased from 45.9% to 87.3%. The proportion of providers who reported that a patient asked about LCS increased (22.8% to 37.7%, p = 0.001). While some reported barriers did not change from 2015 to 2018 (concern regarding false negatives, false positives, cost to system/patients, or potential for physical/emotional harm), more providers reported low patient acceptance or adherence (7.4% vs 13.0%, p = 0.01). Conclusions: From 2015 to 2018 healthcare providers reported a more favorable opinion of LCS and a higher proportion of providers reported ordering a LCS exam. Time constraints during the patient visit remained an issue and a higher proportion reported low patient acceptance/adherence as a barrier.

The OncoSim Cancer Simulation Platform: A Tool to Project the Population Effects of Cancer Control Interventions in Canada

Background: Cancer control interventions exert their effects over multiple decades. To evaluate diverse and competing opportunities to reduce future cancer burden it is desirable to understand long-term effects prior to any new program implementation or significant change. Internationally, modeling is becoming an accepted source of planning information for decision-makers. Aim: We will describe the construction and use of the OncoSim microsimulation model, which was developed to evaluate cancer control strategies in Canada. Methods: OncoSim is a suite of models (cancers of the lung, colorectum, cervix and breast, plus a composite 32-cancer model) used to address key policy questions and support decision-making. It is led by the Canadian Partnership Against Cancer with model development by Statistics Canada. OncoSim incorporates risk factors, cancer natural history, screening, treatment, survival and end-of-life care. Wherever possible it is informed by Canadian data sources. Models are calibrated to reproduce a range of cancer-specific statistics, e.g., current and historical Canadian cancer-specific incidence and mortality, smoking patterns, and results of screening. The site-specific models have undergone further validation by replicating reported short-term effects of cancer prevention and screening interventions. Users may customize interventions through modifying input parameters. Outputs include incidence, mortality, costs, cost-effectiveness, and resource utilization. Users from the public sector have access at no cost to OncoSim and receive extensive support from a multidisciplinary technical team. The model is continually updated to incorporate emerging knowledge. Results: OncoSim has been used to support cancer control decision-making at the national and provincial/territorial levels. Applications include: national guidelines recommendations for colorectal and lung cancer screening; comparison of cytology vs. HPV based cervical cancer screening; and integration of smoking cessation into low-dose CT lung cancer screening. Conclusion: Validated simulation models such as OncoSim can be a versatile and efficient tool for cancer control planners to evaluate and prioritize cancer control strategies.

Focus Groups and In-depth Interviews to Guide the Development of Lung Cancer Screening Informational Materials.

Lung cancer is one of the most lethal cancers in the USA. In 2013, new guidelines issued by the United States Preventive Services Task Force recommended lung cancer screening using low-dose computed tomography among a selected group of high-risk individuals. Specifically, lung cancer screening is recommended for heavy smokers between the ages of 55 to 79, with at least 30 pack-year smoking exposure. Former smokers who meet these guidelines and stopped smoking ≤ 15years ago are also eligible. There is a need to promote lung cancer screening to increase early diagnosis rates and treatment options, thereby decreasing disease-specific mortality. This study was conducted to refine educational materials used to inform eligible high-risk individuals about the risks and benefits of lung cancer screening. Focus groups (n = 16) and in-depth telephone interviews (n = 5) were conducted among screening-eligible participants recruited from western New York. Main themes that emerged from the discussions included cost of obtaining the exam, eligibility criteria/information about the exam, apprehension regarding results, and an increased desire for discussions with their physician to learn more about the screening. The information gained from this study is vital to understanding concerns held by current and former smokers regarding lung cancer screening, as well as critical to determining which information is most valuable for decreasing barriers and correcting misperceptions about the lung cancer screening exam.

P2.06-011 Assessing and Addressing Knowledge Gaps to Improve Lung Cancer Screening Rates

In 2011, the National Lung Screening Trial showed that annual screening with low-dose computed tomography (LDCT) in high-risk patients reduced lung cancer mortality by 20%. The United States Preventative Services Task Force (USPSTF) now recommends lung cancer screening (LCS) for high-risk individuals (Grade B). Evidence from the National Health Interview Survey suggests that only 2-4% of eligible individuals are referred for LDCT, likely in part due to a lack of familiarity among primary care physicians with LCS guidelines.

P3.10-003 Assessing and Addressing Knowledge Gaps to Improve Lung Cancer Screening Rates

The National Lung Screening Trial showed that annual screening with low-dose computed tomography (LDCT) in high-risk patients reduced lung cancer mortality by 20%. The United States Preventative Services Task Force (USPSTF) now recommends lung cancer screening (LCS) for high-risk individuals. However, only about 10% of eligible individuals are referred for LDCT possibly in part due to a lack of familiarity among primary care physicians with LCS guidelines. In this analysis, we sought to obtain a baseline acumen of providers’ knowledge and awareness about LCS and develop a series of interventions including embedding USPSTF criteria into electronic medical record (EMR) ordering to educate providers and facilitate more effective use of LCS for high-risk patients. A Lung Cancer Screening Program was started in 2015 led by a nurse practitioner. Internal medicine residents at the University of Illinois – Chicago (UIC) General Medicine Clinic (GMC) were surveyed using paper questionnaires. The survey included 6 questions on USPSTF LCS guidelines. Next, educational efforts were addressed through a lecture, email reminders, and informational clinic flyers. Finally the EMR order set was updated to include USPSTF criteria directed ordering. The number of appropriately ordered screens through GMC was tracked monthly. A post-intervention survey was distributed to evaluate if providers’ knowledge was improved by these interventions. Fifty-three IM residents were surveyed regarding LCS guidelines appropriate for LDCT screening. Of the respondents, 87% knew the correct test for screening was LDCT, 66% knew only smokers with ≥30 pack year history were eligible, 45% knew the minimum age criteria (55 years-old), 28% knew the maximum age (80 years-old), 42% knew interval to re-order screening for a negative test (1 year), and 38% knew the maximum time since quitting (15 years). Following the initial interventions there was an increase in the rate of appropriately ordered LDCT screening tests ordered through GMC clinic (from 6.8 per month [May 2016 to September 2016] to 10.8 per month [Oct. 2016 to Apr. 2017]). Post-intervention knowledge assessment is underway and will be presented. Although LCS is recommended by USPSTF, there are gaps in knowledge about eligibility criteria among internal medicine residents. We present data that suggests using educational interventions and changes in EMR to increase awareness and knowledge is associated with an increase in appropriate usage of LDCTs for LCS. Ultimately, we plan to broaden these interventions to additional primary care clinics (e.g., Family Medicine, Pulmonary) to improve proper use of LCS at our institution.

Selecting high-risk individuals for lung cancer screening; the use of risk prediction models vs. simplified eligibility criteria

In 2011 the US National Lung Cancer Screening Trial (NLST) showed a 20% reduction in lung-cancer mortality among long-term heavy smokers screened by low-dose spiral computed tomography (LDCT) compared to standard X-ray diagnostics (1), and the US Prevention Services Task Force (USPSTF) recommends lung cancer screening for all individuals who meet the original NLST eligibility criteria of being 55 to 80 years of age, having smoked 30 or more pack years, and not having quit smoking more than 15 years ago.

Frequency of Incidental Findings and Subsequent Evaluation in Low-Dose Computed Tomographic Scans for Lung Cancer Screening.

The U.S. Preventive Services Task Force recommends lung cancer screening with low-dose chest computed tomographic scans (LDCT) for a well-defined high-risk population. Data on the frequency and impact of incidental findings (IFs) based on LDCT scans performed within a centralized lung cancer screening program have not been reported. Researchers in previous studies have reported IFs in the setting of clinical trials. We present our findings in a real clinical setting where the decision to manage these findings may depend on factors that are not captured in a research trial such as disclosing IFs, patient preferences, severity of comorbidities, and physician expertise. We conducted a retrospective chart review of participants in the Cleveland Clinic Lung Cancer Screening Program from April 1, 2015, to February 17, 2016. Lung Imaging Reporting and Data System categories and all reported findings were extracted from the structured radiology report. Downstream investigations that occurred as a result of the imaging findings were recorded. Medicare reimbursement rates were documented for all screening-related testing and treatment. A total of 320 LDCT-screened patients' records were reviewed. The most commonly reported IFs were pulmonary (69.6%), cardiovascular (67.5%), and gastrointestinal (25.9%). Fifteen percent of the scans had an IF that resulted in further evaluation. The majority of patients who underwent further testing had cardiovascular findings (10.3%); less frequently, they had thyroid or adrenal nodules (2.1%), hepatic lesions (0.9%), renal masses (0.6%), or pulmonary disease (0.6%). The most frequently ordered investigations were echocardiography (n = 9), cardiac stress test (n = 9), and CT angiography (n = 6). Reimbursement for the screening process, evaluation, and treatment of screening-detected findings averaged $817 per screened patient. Clinically significant IFs on LDCT scans for lung cancer screening are common, and their potential impact should be included in the shared decision-making process. Screening program staff should develop a standard approach for the evaluation of these findings and consider the financial impact when seeking infrastructure support for screening program implementation.

Multilevel Barriers to the Successful Implementation of Lung Cancer Screening: Why Does It Have to Be So Hard?

The U.S. Preventive Services Task Force recommends lung cancer screening with low-dose computed tomography for long-term current and former smokers. However, lung cancer screening and its implementation are a complex issue. Screening has associated risks and potential harms that complicate the decision to screen for the patient, add to the already time-constrained clinical encounter for the provider, and present logistical and sociopolitical challenges in creating and implementing lung cancer screening programs in the health care system. As lung cancer screening is more widely implemented in the United States, it is critical for those in the health care system to be cognizant of potential barriers to effective screening implementation at the patient, provider, and system levels when designing effective support interventions, as well as to proactively address potential impediments to this new screening option. This paper presents perspectives on these multilevel barriers to lung cancer screening.

Evaluating the impact of varied compliance to lung cancer screening recommendations using a microsimulation model

The US preventive services task force (USPSTF) recently recommended that individuals aged 55-80 with heavy smoking history be annually screened by low-dose computed tomography (LDCT), thereby extending the stopping age from 74 to 80 compared to the national lung screening trial (NLST) entry criterion. This decision was made partly with model-based analyses from cancer intervention and surveillance modeling network (CISNET), which assumed perfect compliance to screening. As part of CISNET, we developed a microsimulation model for lung cancer (LC) screening and calibrated and validated it using data from NLST and the prostate, lung, colorectal, and ovarian cancer screening trial (PLCO), respectively. We evaluated population-level outcomes of the lifetime screening program recommended by the USPSTF by varying screening compliance levels. Validation using PLCO shows that our model reproduces observed PLCO outcomes, predicting 884 LC cases [Expected(E)/Observed(O)=0.99; CI 0.92-1.06] and 563 LC deaths (E/O=0.94 CI 0.87-1.03) in the screening arm that has an average compliance rate of 87.9% over four annual screening rounds. We predict that perfect compliance to the USPSTF recommendation saves 501 LC deaths per 100,000 persons in the 1950 U.S. birth cohort; however, assuming that compliance behaviors extrapolated and varied from PLCO reduces the number of LC deaths avoided to 258, 230, and 175 as the average compliance rate over 26 annual screening rounds changes from 100 to 46, 39, and 29%, respectively. The implementation of the USPSTF recommendation is expected to contribute to a reduction in LC deaths, but the magnitude of the reduction will likely be heavily influenced by screening compliance.

Clinical validation of a blood-based classifier for diagnostic evaluation of asymptomatic individuals with pulmonary nodules

BackgroundThe number of pulmonary nodules detected in the US is expected to increase substantially following recent recommendations for nationwide CT-based lung cancer screening. Given the low specificity of CT screening, non-invasive adjuvant methods are needed to differentiate cancerous lesions from benign nodules to help avoid unnecessary invasive procedures in the asymptomatic population. We have constructed a serum-based multi-biomarker panel and assessed its clinical accuracy in a retrospective analysis of samples collected from participants with suspicious radiographic findings in the Prostate, Lung, Chest and Ovarian (PLCO) cancer screening trial.MethodsStarting with a set of 9 candidate biomarkers, we identified 8 that exhibited limited pre-analytical variability with increasing clotting time, a key pre-analytical variable associated with the collection of serum. These 8 biomarkers were evaluated in a training study consisting of 95 stage I NSCLC patients and 186 smoker controls where a 5-biomarker pulmonary nodule classifier (PNC) was selected. The clinical accuracy of the PNC was determined in a blinded study of asymptomatic individuals comprising 119 confirmed malignant nodule cases and 119 benign nodule controls selected from the PLCO screening trial.ResultsA PNC comprising 5 biomarkers: CEA, CYFRA 21-1, OPN, SCC, and TFPI, was selected in the training study. In an independent validation study, the PNC resolved lung cancer cases from benign nodule controls with an AUC of 0.653 (p < 0.0001). CEA and CYFRA 21-1, two of the markers included in the PNC, also accurately distinguished malignant lesions from benign controls.ConclusionsA 5-biomarker blood test has been developed for the diagnostic evaluation of asymptomatic individuals with solitary pulmonary nodules.

A qualitative analysis of smokers\u2019 perceptions about lung cancer screening

BackgroundIn 2013, the US Preventive Services Task Force (USPSTF) began recommending lung cancer screening for high risk smokers aged 55–80 years using low-dose computed tomography (CT) scan. In light of these updated recommendations, there is a need to understand smokers’ knowledge of and experiences with lung cancer screening in order to inform the design of patient education and tobacco cessation programs. The purpose of this study is to describe results of a qualitative study examining smokers’ perceptions around lung cancer screening tests.MethodsIn 2009, prior to the release of the updated USPSTF recommendations, we conducted 12 120-min, gender-specific focus groups with 105 current smokers in Charlotte, North Carolina and Cincinnati, Ohio. Focus group facilitators asked participants about their experience with three lung cancer screening tests, including CT scan, chest x-ray, and sputum cytology. Focus group transcripts were transcribed and qualitatively analyzed using constant comparative methods.ResultsParticipants were 41–67 years-old, with a mean smoking history of 38.9 pack-years. Overall, 34.3% would meet the USPSTF’s current eligibility criteria for screening. Most participants were unaware of all three lung cancer screening tests. The few participants who had been screened recalled limited information about the test. Nevertheless, many participants expressed a strong desire to pursue lung cancer screening. Using the social ecological model for health promotion, we identified potential barriers to lung cancer screening at the 1) health care system level (cost of procedure, confusion around results), 2) cultural level (fatalistic beliefs, distrust of medical system), and 3) individual level (lack of knowledge, denial of risk, concerns about the procedure). Although this study was conducted prior to the updated USPSTF recommendations, these findings provide a baseline for future studies examining smokers’ perceptions of lung cancer screening.ConclusionWe recommend clear and patient-friendly educational tools to improve patient understanding of screening risks and benefits and the use of best practices to help smokers quit. Further qualitative studies are needed to assess changes in smokers’ perceptions as lung cancer screening with CT scan becomes more widely used in community practice.

Evaluations of Implementation at Early-Adopting Lung Cancer Screening Programs: Lessons Learned

Guidelines recommend lung cancer screening (LCS), and it is currently being adopted nationwide. The American College of Chest Physicians advises inclusion of specific programmatic components to ensure high-quality screening. However, little is known about how LCS has been implemented in practice. We sought to evaluate the experience of early-adopting programs, characterize barriers faced, and identify strategies to achieve successful implementation. We performed qualitative evaluations of LCS implementation at three Veterans Administration facilities, conducting semistructured interviews with key staff (n= 29). Guided by the Promoting Action on Research Implementation in Health Services framework, we analyzed transcripts using principals of grounded theory. Programs successfully incorporated most recommended elements of LCS, although varying in approaches to patient selection, tobacco treatment, and quality audits. Barriers to implementation included managing workload to ensure appropriate evaluation of pulmonary nodules detected by screening and difficulty obtaining primary care "buy-in." To manage workload, programs used nurse coordinators to actively maintain screening registries, held multidisciplinary conferences that generated explicit management recommendations, and rolled out implementation in a staged fashion. Successful strategies to engage primary care providers included educational sessions, audit and feedback of local outcomes, and assisting with and assigning clear responsibility for nodule evaluation. Capitalizing on pre-existing relationships and including a designated program champion helped facilitate intradisciplinary communication. Lung cancer screening implementation is a complex undertaking requiring coordination at many levels. The insight gained from evaluation of these early-adopting programs may inform subsequent design and implementation of LCS programs.

P1.03-053 The Effect of Primary Care Physician Knowledge of Lung Cancer Screening Guidelines on Perceptions and Utilization of Low Dose CT

Lung cancer screening with low-dose computed tomography (LDCT) is recommended by the U.S. Preventive Services Task Force (USPSTF) in high-risk patients, but a minority of eligible people is screened. It is unknown whether knowledge of USPSTF recommendations among primary care physicians (PCP) impacts perceived benefits and utilization of LDCT. As we previously reported, a randomly selected sample of 1384 primary care physicians in Los Angeles County was surveyed between January and October 2015, using surveys sent by mail, fax, and email. The response rate was 18%. Training background, years in practice, practice type, and respondent demographics were collected. We analyzed results based on the response to a question on whether the USPSTF recommends the use of LDCT to screen high-risk individuals for lung cancer. One hundred seventeen (47%) PCPs responded that the USPSTF recommends LDCT for LCS. Of PCPs who were aware of USPSTF recommendations, 94% responded that CT was somewhat or very effective at reducing lung cancer mortality among individuals meeting eligibility criteria, compared with 79% who were unaware (p=0.013). 27% of those aware of the recommendations thought chest X-ray (CXR) was effective at reducing lung cancer mortality compared with 62% of unaware PCPs (p=0.001). A similar number of PCPs in each group ordered CXR for screening over the past 12 months, but a larger proportion of PCPs aware of guidelines ordered LDCT (69% vs 36%, p <0.001) and initiated a discussion on screening (84% vs 59%, p<0.001) over the past 12 month. 14% of PCPs aware of guidelines reported that benefits of LCS were not clear to them compared with 43% of those unaware of guidelines (p<0.001). Both groups of PCPs reported similar scores when questioned on other barriers to screening such as insurance coverage, risks of LCS, and cost to society. There were no differences between groups by practice size, training background, years in practice, or PCP demographics. Awareness of USPSTF recommendations for lung cancer screening is associated with the perception of benefit of LDCT and with increased utilization of LDCT for screening. Educational interventions for PCPs may improve adherence with LCS recommendations.