Lung Cancer Screening Practices of Primary Care Physicians: Results From a National Survey

Carrie N. Klabunde; Pamela M. Marcus; Paul K. J. Han; Thomas B. Richards; Sally W. Vernon; Gigi Yuan; Gerard A. Silvestri

doi:10.1370/afm.1340

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Figure 1
Percentage of primary care physicians who ordered lung cancer screening tests by types of patients for whom they would recommend lung cancer screening.

LDCT = low-dose spiral computed tomography.

Note: Brackets indicate 95% CIs.

^a Chest radiograph, sputum cytology, or LDCT.

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Table 1

Characteristics of Primary Care Physicians and Their Practice Settings (N = 962)

Characteristic	Unweighted n	Weighted %
Physician characteristics
Years since graduation from medical school
<10	136	14.0
10–19	309	32.7
20–29	288	30.5
≥30	229	22.8
Sex
Male	680	70.4
Female	282	29.6
Race/ethnicity
White, non-Hispanic	698	71.9
Asian	149	15.3
Other^a	115	12.8
Specialty
Family medicine	481	50.7
General practice	66	4.4
General internal medicine	415	45.0
Board certified	745	79.5
International medical graduate	236	24.4
Practice characteristics
Primary practice arrangement
Full/part owner of practice	521	53.8
Employee or other/missing	441	46.2
Practice size (number of physicians)
1	256	26.4
2–5	400	41.7
6–15	198	20.7
≥16	102	10.6
Missing	6	0.7
Geographic location
Urban^b	762	80.2
Large rural city/town^c	108	10.7
Small/isolated small rural town^d	92	9.1
Census region
Northeast	184	19.9
Midwest	253	23.9
West	205	22.9
South	320	33.3
Type of health record system used
Full EHR	177	18.7
Partial EHR	89	9.5
Transitioning from paper to EHR	144	15.2
Paper charts	545	55.9
Missing	7	0.8
Patients uninsured, %
0–5	564	59.5
6–25	291	29.6
≥26	68	6.8
Don’t know/missing	39	4.0
Physician practice style
Has an affiliation with a medical school	316	33.8
Patient volume during a typical week
≤75	316	32.7
76–100	303	31.7
101–125	202	21.3
≥126	126	12.8
Missing	15	1.5
Colorectal cancer screening intensity
Low/moderate	605	62.8
High	322	33.9
Unknown	35	3.4
Types of patients for whom the physician would recommend lung cancer screening
All, regardless of smoking exposure	167	17.2
Any smoking exposure, passive or active	293	30.4
Current and/or former smokers only	184	19.0
None	308	32.3
Missing	10	1.0

EHR=electronic health record.
↵a Includes Hispanic; black, non-Hispanic; American Indian/Alaska Native; Native Hawaiian/Other Pacific Islander; multiple races; other race; and unknown.
↵b Rural-Urban Commuting Area 2 (RUCA2) codes 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 7.1.
↵c RUCA2 codes 4.0, 4.2, 5.0, 5.2, 6.0.
↵d RUCA2 codes 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 9.0, 9.1, 10.0, 10.2, 10.4, 10.5, 10.6.

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Table 2

Primary Care Physicians’ Lung Cancer Screening Beliefs, Self-Reported Practices, and Patient Influence (N=962)

Measure	Unweighted n	Weighted % (95% CI)
Physician beliefs
Believes any expert group recommends lung cancer screening	239	25.1 (22.2–28.2)
Believes chest radiograph is effective in reducing lung cancer mortality for
Never smokers	269	27.7 (25.1–30.5)
Former smokers	510	52.4 (49.0–55.8)
Current smokers	468	48.0 (44.7–51.3)
Believes sputum cytology is effective in reducing lung cancer mortality for
Never smokers	175	17.8 (15.7–20.2)
Former smokers	273	28.3 (25.7–31.0)
Current smokers	319	33.3 (30.5–36.3)
Believes LDCT is effective in reducing lung cancer mortality for
Never smokers	325	34.0 (31.1–37.0)
Former smokers	574	60.4 (57.2–63.5)
Current smokers	634	66.8 (63.5–69.9)
Physician practices
Lung cancer screening tests ordered in past 12 months^a
Chest radiograph	530	55.3 (52.0–58.4)
Sputum cytology	41	4.5 (3.3–6.2)
LDCT	211	22.3 (19.9–24.9)
Patterns of lung cancer screening tests ordered in past 12 months
Chest radiograph only	329	34.0 (30.9–37.2)
LDCT only	34	3.6 (2.5–5.3)
Chest radiograph and LDCT, with or without sputum cytology	167	17.8 (15.4–20.5)
Sputum cytology, with or without chest radiograph or LDCT	21	2.0 (1.3–3.0)
None	360	37.6 (34.9–40.4)
Unknown	51	5.0 (3.7–6.7)
Patient influence
Number of patients who have asked about lung cancer screening in past 12 months
0	293	30.3 (27.7–33.0)
1–5	253	26.2 (23.2–29.4)
6–10	174	18.4 (15.8–21.4)
11–20	119	12.5 (10.5–14.8)
>20	108	11.1 (8.9–13.7)
Unknown	15	1.5 (0.9–2.5)

CI=confidence interval; LDCT = low-dose spiral computed tomography.
↵a Physicians responded to survey items asking, “During the past 12 months, to screen an asymptomatic patient for lung cancer, did you ever order…” None indicates negative response for all 3 tests.

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Table 3

Multivariate Models Assessing Factors Associated With Primary Care Physicians’ Ordering of Lung Cancer Screening Tests

Factor	Ordered Chest Radiograph OR (95% CI)	Ordered LDCT OR (95% CI)
Physician characteristics
Years since graduation from medical school
<10	1.0	1.0
10–19	1.2 (0.7–2.3)	1.7 (0.9–3.3)
20–29	2.2 (1.2–4.1)^a	3.0 (1.5–5.9)^a
≥30	1.5 (0.8–3.0)	2.5 (1.3–5.0)
Sex
Male	1.0	1.0
Female	1.2 (0.8–1.8)	0.8 (0.5–1.4)
Specialty
Family medicine/general practice	1.0	1.0
General internal medicine	1.2 (0.8–1.7)	1.6 (1.1–2.4)^a
Board certified
Yes	1.0	1.0
No	0.8 (0.5–1.3)	0.9 (0.6–1.5)
Practice characteristics
Primary practice arrangement
Full/part owner of practice	1.6 (1.0–2.3)	1.4 (0.9–2.1)
Employee or other/missing	1.0	1.0
Practice size (number of physicians)
1	1.0	1.0
2–5	0.1 (0.7–1.7)	1.5 (0.9–2.5)
6–15	1.4 (0.8–2.4)	1.9 (1.1–3.3)^a
≥16/missing	0.6 (0.3–1.1)	1.3 (0.7–2.7)
Census region
Northeast	1.0	1.0
Midwest	0.7 (0.5–1.2)	0.8 (0.5–1.4)
West	1.0 (0.6–1.6)	0.8 (0.5–1.5)
South	0.8 (0.5–1.4)	0.6 (0.3–1.0)
Type of health record system used
Full EHR	1.0	1.0
Partial EHR	0.7 (0.4–1.2)	0.9 (0.4–2.0)
Transitioning from paper to EHR	1.2 (0.7–2.1)	0.6 (0.3–1.1)
Paper charts/missing	1.1 (0.7–1.7)	0.8 (0.4–1.4)
Patients who are uninsured, %
0–5	1.0	1.0
6–25	0.9 (0.6–1.4)	1.0 (0.6–1.5)
≥26/don’t know/missing	0.5 (0.3–1.0)	0.6 (0.3–1.1)
Physician beliefs
Believes any expert group recommends lung cancer screening
No	1.0	1.0
Yes	1.7 (1.1–2.9)^a	1.8 (1.2–2.8)^a
Believes LDCT is effective for
Never, former, and current smokers (all 3)	–	8.2 (3.3–20.6)^a
Never, former, or current smokers	–	6.0 (2.3–15.8)^a
No patients	–	1.0
Physician practice style
Patient volume during a typical week
≤75	1.0	1.0
76–100	1.7 (1.1–2.7)^a	1.1 (0.7–1.9)
101–125	1.6 (1.0–2.6)	1.0 (0.6–1.8)
≥126/missing	1.1 (0.7–1.8)	1.5 (0.8–3.0)
Intensity of colorectal cancer screening recommendations
Low/moderate	1.0	1.0
High	1.0 (0.6–1.4)	0.7 (0.5–1.1)
Unknown	1.3 (0.5–3.1)	0.9 (0.4–1.8)
Types of patients for whom physician recommends lung cancer screening
All, regardless of smoking exposure	14.6 (7.0–30.4)^a	2.1 (1.1–4.0)^a
Any smoking exposure, active or passive	4.6 (3.1–6.8)^a	2.9 (1.7–5.0)^a
Current and/or former smokers only	2.4 (1.5–4.0)^a	2.4 (1.4–4.2)^a
None	1.0	1.0
Patient influence
Number of patients who have asked about lung cancer screening in past 12 months
0	1.0	1.0
1–5	2.7 (1.8–3.9)^a	1.8 (1.1–3.0)^a
6–10	2.9 (1.9–4.6)^a	2.0 (1.1–3.5)^a
>10	5.3 (3.2–8.8)^a	3.2 (1.9–5.6)^a
Unknown	1.3 (0.2–8.4)	1.7 (0.4–7.4)

EHR = electronic health record; LDCT = low-dose spiral computed tomography; OR = odds ratio.
Note: Race/ethnicity, geographic location, and medical school affiliation were not included in the models because these measures were not statistically significant in bivariate analyses at P <.10.
↵a Indicate a statistically significant odds ratio.

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The Article in Brief

Lung Cancer Screening Practices of Primary Care Physicians: Results From a National Survey

Carrie N. Klabunde , and colleagues

Background Major expert groups do not recommend screening people without symptoms for lung cancer, including people with heavy or long-term smoking histories, because of a lack of strong evidence. This study examines US primary care physicians' self-reported lung cancer screening practices.

What This Study Found Primary care physicians in the United States frequently order lung cancer screening tests for asymptomatic patients. In a nationally representative survey of 962 primary care physicians, which used clinical vignettes to assess screening practices, 57 percent of respondents ordered at least one of three lung cancer screening tests (chest radiograph, low-radiation does spiral computed tomography, or sputum cytology) in the past 12 months for patients without symptoms. Thirty-eight percent reported ordering no tests. Physicians were more likely to order screening tests if they believed expert groups recommend lung cancer screening or that screening tests are effective; if they graduated from medical school 20 to 29 years ago; if they would recommend screening for asymptomatic patients, including patients without substantial smoking exposure; and if their patients had asked them about screening.

Implications

To avoid inappropriate ordering, primary care physicians need more information about lung cancer screening's evidence base, guidelines, potential harms, and costs.