“It Can’t Hurt!”: Why Many Patients With Limited Life Expectancy Decide to Accept Lung Cancer Screening

Eduardo R. Núñez; Rendelle E. Bolton; Jacqueline H. Boudreau; Samantha K. Sliwinski; Abigail N. Herbst; Lauren E. Kearney; Tanner J. Caverly; Renda Soylemez Wiener

doi:10.1370/afm.3081

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Figure 1.
American Geriatrics Society’s multiple chronic conditions action framework adapted for lung cancer screening.
LCS = lung cancer screening.
Note: Multiple chronic conditions (MCC) action steps and scripts were adapted from the MCC Action Framework including recommended resources https://geriatricscareonline.org and https://patientprioritiescare.org. These steps provide a continuous process for decision making that is tailored to each patient’s goals, trajectory, and preferences, which are dynamic and can change with future visits.

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Table 1.

Patient Characteristics

Characteristic	Patients (N = 40)
Age, median (SD; range)	70 (6.0; 57-79)
Male, no. (%)	38 (95.0)
White, no. (%)	40 (100)
Current smoker, no. (%)	18 (45.0)
Chronic obstructive pulmonary disease, no. (%)	18 (45.0)
CAN score, median (SD; range)^{^a}	85 (5.0; 70-96)
Agreed to screen, no. (%)	26 (65.0)
Screened at VA, no. (%)	21 (52.5)

CAN = Care Assessment Need; VA = Veterans Health Administration.
Note: No characteristic had missing data.
↵a CAN scores range from 0 to 99, measuring a Veteran’s risk of hospitalization and death compared to other Veterans; a score >75 represents the greatest-risk quartile, having a predicted probability of death or hospitalization in the next year >15%.^18,19

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Table 2.

Key Factors in Patient Decision Making Regarding LCS, With Representative Quotes

Key Factors^{^a}	Representative Quotes
Factors that influenced patients’ LCS decision making
Overall health and life goals	“My main reason [for screening] is I want to stay alive for my boy, I don’t want him going back to the Humane Society.” [3-82, agree] “As long as I can make it to the place, I have no problem getting screened.…If they do see something they’ll catch it early.” [3-94, agree]
Perceptions of LCS benefits: “it’s better to know”	“I would like to know [if I had lung cancer]. I figure that way I could get a lot of things in order. Paperwork, who to leave what to, stuff like that.” [3-83, agree] “It would probably be useful because it might find something to answer questions about what some of the things I have wrong.” [4-94, decline]
Trust in clinician recommendation and the VA	“I just do what they tell me. And I don’t even know why sometimes. It doesn’t matter to me why. Because the doctor said I needed to have it done, talk about a blind follower.” [2-15, agree] “If you’re a patient of the VA…if you listen to the doctors and you do what they tell you to do, I think it will do nothing but improve your health. And I have all the faith in the world for all the doctors and nurses at the VA.” [2-36, agree]
Anticipated regret about declining LCS	“No, I don’t understand why somebody wouldn’t want to pursue [LCS] unless they have a death wish.” [4-87, agree] “I would probably pursue [LCS] because I think it’s [lung cancer] more or less a ghost rider and it would sneak up and bite you in the butt any time.” [4-74, agree]
Circumstantial and logistical considerations	“I have a traveling problem. I don’t have a vehicle and I’ve got to arrange transportation and that affects my decision. I live way out in the boondocks. So, I’ll try to get to it when I can.” [6-08, decline]
Factors patients considered less in LCS decision making
Perceived health and symptoms	“My health issues, I’m not overly concerned about any of them. I just do what they ask me to do and go in and take the lab tests and stuff that they run to check.” [5-20, agree] “I’ve had 9 stents put in, 6 heart attacks and quadruple bypass. And my arteries in my lower extremity are plugged up. I get tired pretty easy.…Other than that, most of my health problems have just been accidents. I’ve never really, say, been sick.” [6-45, agree]
Perceptions of LCS harms: lack of knowledge about further evaluations and management	Many patients were unaware of LCS harms: “I had nothing to lose by it [LCS] for sure, and I wanted to take advantage of it.” [5-45, agree] When potential for downstream evaluations were raised by the interviewer, patients had concerns: “If it’s [LCS] like an x-ray, I don’t care. But if it ain’t and it’s like a needle poke then I don’t like it…just the needles, no more of those.” [5-11, decline] “That is a concern that, if they find something and then they say oh, we need more tests, more tests and then it turns out to be nothing and you’re wasting a lot of time and in the meantime you’re all stressed out because there might be something.” [6-10, decline]

LCS = lung cancer screening; VA = Veterans Health Administration.
Note: Each quote is followed by: [site ID-patient ID, initial LCS decision as documented in the VA clinical reminder].
↵a All key themes mapped to a priori domains in conceptual framework of factors posited to influence patient LCS decision making (Supplemental Figure), except for circumstantial and logistical considerations, which emerged as a key influence on patient decision making in analysis. Of note, whereas our conceptual framework asserted that perceived health and symptoms and perceptions of LCS harms would influence LCS decision making, our analysis revealed these domains to play a lesser role in patient decision making.