Challenges Addressing Lung Cancer Screening for Patients With Multimorbidity in Primary Care: A Qualitative Study

Minal S. Kale; Orly Morgan; Juan Wisnivesky; Julie Schnur; Michael A. Diefenbach

doi:10.1370/afm.3080

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Table 1.

Physician Characteristics (N = 15)

Characteristic	Value
Age, mean (SD), y	47 (14)
Female, %	60
Race/ethnicity, %
White	73
Black or African American	7
Asian	7
Latine/Hispanic	20
Years in practice, mean (SD)	15 (14)
Number of LDCT scans ever ordered, mean (SD)	70 (75)
Sources of lung cancer screening education, %
Medical school	33
Grand rounds	47
Continuing education	67
Other	20

LDCT = low-dose computed tomography.

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Table 2.

Illustrative Quotes of Subtheme 1a, How Sick Is My Patient?

Respondent	Quote
Respondent 1	I have had patients of mine that have got way too much going on, they’re too fragile in their other competing priorities that I would shy away from a number of preventive measures that would involve any risk of preventing something else from getting done.
Respondent 3	People who have other malignancies, pretty significant dementia, I guess I don’t usually bring it up. If they bring it up, I’m happy to talk about it with them, but [LCS is] not something I’m using [for these patients] right now.
Respondent 6	If I were to go further and talk about the risk stratification … I guess, conditions would prevent me from asking [about LCS]. Okay, so if they’re already being treated for cancer, I’m not going to bring [LCS] up, because they’re already in that pipeline and screen all that, with a CT scan already, usually. If it is something like cardiac, like a stage IV congestive heart failure, I probably will not bring [LCS] up either. They’re on stage IV, right? Then their quality of life has already changed quite a bit, and they might be at higher risk.
Respondent 7	Well, that’s a very difficult thing, but somebody with very advanced heart failure … dementia, people who are very basically bedbound and who are probably not going to be—I mean I actually have a patient with MS who’s been living for 10 years, but that’s unusual. She’s bedbound, but anyway, do I use any scores? No, but sometimes with people with ejection fractions of under 25%, who are basically barely getting out of the house and have a lot of readmissions to the hospital, I may not bring it up.
Respondent 9	Yes [a patient’s comorbidities influence whether I recommend LCS]. If I have someone that’s got … stage 2 cancer in some other organ and undergoing treatment, I’m probably not going to recommend [LCS] at that point, or if it’s like one of those patients that has like—they’re on dialysis, they’ve had a liver transplant, they have like everything in the book, and they’re very complicated and they have a lot going on, and they see 20 different specialists, I may not.
Respondent 12	Definitely [there are cases where LCS is not on my radar even if they are eligible]. Sometimes if I think a patient has many active issues currently going on, then I probably wouldn’t bring it up like right away. I probably would wait a little a bit. Like if they were in the middle of transitioning, like if they were getting a fistula in place, they can be on dialysis in the next few months, I would probably hold off from bringing it up. If they have like a big coronary event earlier in the year, and they’re still following up with their cardiologist very closely, I probably would wait a little bit.
Respondent 13	Yes. I think I’m more concerned that they have some other much more—well, I’ve already defined significant morbidity and whatever the diagnosis is, whether it’s like a severe CHF, things like significant other issues that—bringing this up and it’s almost like we’ll revert them with something that may not at the end help them as much as it would have helped the person who didn’t have those.

CT = computed tomography; CHF = congestive heart failure; LCS = lung cancer screening; MS = multiple sclerosis.

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Table 3.

Illustrative Quotes of Subtheme 1b, How Long Does My Patient Have to Live?

Respondent	Quote
Respondent 1	I would say that my general approach to cancer screening across the board is to take into account life expectancy with a general rule of thumb of the benefits outweighing the risks of cancer screening if patients have roughly more than a 10-year life expectancy.
Respondent 5	My perception of the time to benefit for lung cancer screening is like a year or 2. It’s like relatively quick. It’s more to sort of think of the like—would I be surprised if they died in a year–kind of question. Like if the answer is like no, that I wouldn’t be surprised, I might not bring [LCS] up. That’s what I guess is like who is like the denominator of all people who might be screened, but then the people who like actually get screened tend to be people who I perceive have a longer life expectancy, or at least a suitably long one or who have a ton of other issues, or mostly just people who have fewer like acute and chronic conditions to manage.
Respondent 6	I have to think about what is their life expectancy, right? If their life expectancy isn’t more than 5 years, I’m not sure that I would choose another thing for them to consider at this point.
Respondent 14	I think we all typically don’t necessarily screen or push screening as hard for patients who we think have less than a 10-year life expectancy. I think that would be sort of we’ll be able to use our clinical judgment for that. Even if they have significant comorbidities but I think they still have a life expectancy of more than 10 years, I would send [them] for screening regardless. I don’t think that I would—I think the key point there is life expectancy. Even if they have significant comorbidities but have a longer life expectancy.
Respondent 15	How many years you would have to be expected to live before the lung cancer screening becomes beneficial. I have a sense of some of the other cancers, the cancer screening we do. Let’s say if somebody looked like they had other illnesses that would cause their life to be over in 5 years, 7 years, I would probably not be enthusiastic about screening. If somebody had significant heart failure, it wouldn’t be something that would be high on my list of things that I’ll offer.

LCS = lung cancer screening.

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Table 4.

Illustrative Quotes of Subtheme 1c, How Likely Is My Patient to Follow Up?

Respondent	Quote
Respondent 4	Maybe somebody who may be elderly or older, but maybe having dementia and has a lot of needs and other people are taking care of them, like is this really somebody who I’m trying to diagnose with lung cancer?
Respondent 5	I think it’s 2 things. One is sort of like my mental bandwidth to think about [LCS]. Then the second is I think my perception of [the patient’s] ability to kind of follow through.
Respondent 11	So, like if they’re on dialysis, and they are on oxygen, and like their arms are amputated already, I mean kind of also the thing you have to think about is like who’s going to take care of them when they’re undergoing, like, treatment.
Respondent 12	Like if they didn’t have a good support system, like how do they even survive? It’s like also what’s their mental state like because if they’re like, “Oh, I don’t want to know if anything happens.” Then like let them know that they have cancer not being able to do anything about it, is it going to kind of make them not sleep at night? Then that might be a decision to not go ahead.
Respondent 13	I mean these are good tests. I’m sure we can pick up tumors in the early stage and then we can do an intervention and potentially have a curable cancer, but [LCS] wouldn’t tell you you’d be willing to do [follow-up] and also well enough to do [treatment] … well enough to do this and that, as much as would it be something that you’d be willing to do should it be abnormal. I think just kind of getting the sense of how concerned they are and how willing they are to go for [LCS] and then for the follow-up workup.

LCS = lung cancer screening.

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Table 5.

Illustrative Quotes of Subtheme 1d, How Does Quality of Life Factor in to This?

Respondent

Quote

Respondent 12

I kind of take into account, is my patient enjoying the life that they’re living a lot? Like are they partaking in all the things that they want to partake in? If they are really enjoying it, I wouldn’t want them to go through a treatment if I thought it would harm them, but if I think the treatment would benefit them and the disease would harm them, then I would want them to go through it.
For my more fragile patients, I usually don’t [bring up LCS]. Like if they have many other comorbidities and their quality of life is already pretty poor, then I usually don’t. In people, whose quality of life I think can be improved, then, yes, I definitely do.

Respondent 13

I have a patient that is in her late 50s, early 60s, with pretty advanced diabetes. She is status-post BKA. The other leg isn’t doing that well either, advanced kidney disease, name it, she has it. We feel her quality of life is pretty difficult, and she doesn’t really get around much. She kind of just like stays at home. She already is kind of miserable and everything. I don’t know if she would really benefit [from LCS] as much. Like I would talk to her about [LCS], but I think the treatment might be really difficult for her on top of everything else.
I have like a 75-year-old, or like early mid-70s patient that still goes running every day, spends lots of time with his family, enjoys cooking. He is very involved in like movies and the arts, and tries to keep really busy. So, for him, for example, even if he did have CAD, diabetes, CKD and he was a smoker, he has a pretty good quality of life and he appears very well for his age. So, I would still recommend [LCS] to him.

BKA = below-knee amputation; CAD = coronary artery disease; CKD = chronic kidney disease; LCS = lung cancer screening.

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Table 6.

Illustrative Quotes of Theme 2, Shared Decision Making Is Not a Simple Discussion

Respondent	Quote
Respondent 2	How are you going to present this to a patient? You want to present it as best as you can in a nonbiased way, but you also want to be honest. So, I would say to them, “[LCS] is available. It’s something we can do, but then we have to think about the next step because I never order a test without having a plan for what I’m going to do with the results. If we get a negative result, that’s great, right? If we get a positive result where we see something that really looks suspicious, is treatment something that you would eligible for and that you could tolerate, right?” I’m very honest. I say, “When they did the study, this is what they found when they studied the population, but for people like you, maybe you wouldn’t have been included in the study or maybe it’s not as clear given your age or that you have these other medical conditions, it’s not clear that this would be as beneficial to you as other patients and there could be more risks involved,” and also, the question is, “Are you someone who’s eligible to act on the results?” I think that’s really the bigger issue, right?
Respondent 5	I do have to talk [about] if the goal is to cure at that point and ask them what do they want the last years of their life to look like and what interventions, if anything, are they looking into, right? At that point, it’s sort of like, “Do you want to continue screening for colon cancer, breast cancer, lung cancer?” Right? If they do, then I’m like, “Okay, well, you are at higher risk for any complications given your lung capacity or your heart condition, or whatever. So, I’m going through the shared decision-making conversation with you partly because if a complication were to happen, you may have a higher morbidity than others. It may curtail your life more.”
Respondent 7	I always talk about the stress of knowing for what I think is something that’s not appropriate, so I’ll start with the emotional aspect of “Do you really want to know? This is something that you might be at risk for. Do you really want to have a test that may lead to need for biopsies and other testing?” As you know, these things are very sensitive and so all these patients have nodules so it becomes anxiety provoking for patients. So I address the emotional aspects of knowing, that you have a lung nodule that we may not do anything about. So that is one way I approach it.
Respondent 11	I mean, if they’re like really frail, I will bring it up and like that this is something that we could do, but that I’m not sure that it would be the right thing for them given everything that they’re already going through like seeing 15 specialists. They’re man-aging all their comorbidities.
Respondent 12	Like I kind of lay down the facts. I would say, “Okay. If you went through screening and then they find something, and then you have to go a biopsy, and then it’s cancer. Then you’d get a treatment, which potentially involves like X, Y, Z. Then how would you manage that? Like how would you do all those things, go to all those appointments? Do you have any help at home? I mean, the treatment might potentially be very toxic. You could have a lot of weakness. Like, you might not be able to eat. That can be very painful.” Things like that.
Respondent 13	Asking them what they would do with the abnormal findings should they happen and then the patients which really have like things that are—have other issues that are outstanding, they have other—like I said, really, if they have prior strokes, or if they have ... heart failure, if they have heavy-duty stuff, not your typical mild asthma, that’s [unintelligible]. But if they have a lot of things that are like, may not put them in a position that they would be able to go easily for further evaluation and workup, I probably definitely bring it up. But I have that discussion with them where I kind of say, “Well, you know, if we find something there that is accepted maybe for invasive testing, would that be something you would be up to?” I usually do that with a really sick patient.

LCS = lung cancer screening.

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Table 7.

Illustrative Quotes of Theme 3, Ultimately, the Decision Is Up to the Patient

Respondent	Quote
Respondent 3	I’ll go through the process and if they want to do [LCS], then I’ll certainly order it for them. I’m not going to withhold the test.
Respondent 4	If the patient comes to me specifically requesting some type of testing and they meet the criteria, I do not feel like it is—not that I don’t feel like it’s my place, but if the patient is requesting something that they clearly meet criteria for, regardless of how I feel the rest of their life is going to go, I don’t see it as my place to deny them that service.
Respondent 11	I do believe that ultimately the patient has to make that final decision because—I mean, it is something they have to live with. I would do my best to counsel them based on, I guess, all my concerns and my thoughts about the risk, benefits, but in the end, if they really strongly go for [LCS], then I will go along with their decision. I do think that in the end, [LCS] is the patient’s decision because it is their body, their own body. No matter what happens it’s like, even as a doctor, you can’t fully understand what it’s like to be the patient. Like, you might think that’s something—like from my standpoint, I might think, “This is the wrong decision,” but, I mean, ultimately whatever happens to the patient they have to deal with it. So, in the end, if they feel really strongly, I would go on with what they want. Yes. I mean sometimes I counsel patients against [LCS], but ultimately, it’s their decision to make. I usually go along with whatever the patient says. If they’re like, “Hey, I still want to screen because I would want to do anything like to treat a cancer if possible,” then I still go ahead and I do screening, and I see what happens.
Respondent 15	If the patient can make a compelling case for getting [LCS], even though I think it may not be in their—wouldn’t necessarily be my recommendation, I’ll pursue it. I’ll let them pursue it. So, if people are … declare themselves as somebody who’d want to do [LCS], “I’d be willing to take that extra risk of more imaging and procedures for the chance of living longer. I’m willing to take that risk,” then we would do [LCS].