Perceptions and Utilization of Lung Cancer Screening Among Smokers Enrolled in a Tobacco Cessation Program

doi:10.1016/j.cllc.2018.09.013

Clinical Lung Cancer

Volume 20, Issue 1, January 2019, Pages e115-e122

https://doi.org/10.1016/j.cllc.2018.09.013 Get rights and content

Abstract

Background

Although lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality in high-risk patients, most of those eligible are not referred for screening. Tobacco cessation counseling may be an opportune time to educate people about LCS, but little is known about the utilization and perceptions of LCS among people undergoing tobacco cessation treatment.

Materials and Methods

We surveyed 185 current smokers, including 122 smokers between the ages of 55 and 80 years, who were attending a tobacco cessation class in a large integrated health care system regarding lung cancer risk perception and perceived benefits, harms, and barriers to LCS. We analyzed results according to whether participants had already undergone LCS and also whether they had undergone colorectal cancer screening.

Results

A minority (18.9%) of participants had undergone LCS, and no participant who had not undergone LCS was familiar with LCS. Perceived lung cancer risk was high, and screening was believed to be beneficial. Common barriers included being a current smoker (56.6%), worrying about test results (52.5%), lack of knowledge about the test (50.8%), absence of symptoms of lung cancer (40.2%), costs of the study (35.2%), and worrying about being blamed for having smoked (33.6%). Perceived risk and barriers to LDCT were similar among people who had or had not previously undergone colorectal cancer screening.

Conclusions

Utilization of LCS was low, and few smokers were aware of LDCT for LCS. A number of patient-related barriers to screening exist among smokers. Tobacco cessation counseling may be an opportune time to provide education regarding LCS with LDCT.

Introduction

Lung cancer is the most common cause of cancer death in the United States (US) and worldwide.¹ Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality.² The National Comprehensive Cancer Network (NCCN) and US Preventive Services Task Force (USPSTF) guidelines recommend LCS in high-risk patients, as do a number of other professional organizations.3, 4, 5 The USPSTF recommends screening current and former smokers aged 55 to 80 years who have smoked 30 pack-years or more, and who quit within 15 years if a former smoker. Although no data exist specifically on the proportion of high-risk people who undergo LCS, Pinsky and colleagues estimated, using National Lung Screening Trial (NLST) criteria, that 6.2% of adults over age 40 would be eligible for screening.⁶ Yet the number of patients screened at most LCS centers is anecdotally very low. We recently reported that only 8% of primary care physicians referred most or all high-risk patients to a LCS center over the prior 12 months.⁷

A number of barriers to utilization of LCS in high-risk patients exist. Barriers to health care can be organized into patient, physician, and health care system factors. There are relatively few studies on barriers to LCS, in contrast to other cancer screening interventions such as mammography. We previously conducted a survey assessing barriers to LCS among primary care physicians and found the following factors of greatest concern: (1) effectiveness of LDCT to prevent death from lung cancer; (2) potential risks of LDCT; and (3) costs of LDCT. There are several small studies evaluating perceived barriers to LCS among high-risk patients; however, no study has investigated barriers to screening in people eligible for LCS since screening recommendations were made.8, 9, 10, 11, 12, 13 Understanding perceived barriers to LCS in people eligible for LDCT screening is important when devising strategies to improve utilization of LCS for those who stand to benefit. Recently a validated survey tool was developed to assess LCS health beliefs, including perceived barriers to screening.¹⁴ Here, we surveyed current smokers who were enrolled in a tobacco cessation program and who met USPSTF eligibility criteria for LDCT regarding their perceptions of lung cancer risk and LCS.

Section snippets

Materials and Methods

Current smokers who attended at least 1 tobacco cessation group session, part of a 4-session course entitled “Freedom from Tobacco,” at 1 of 4 participating Kaiser Permanente medical centers in Southern California were eligible to participate between January 2017 and December 2017. These 4 centers average approximately 693 participants per year. A total of 185 volunteer participants completed surveys at the end of the class after distribution of the survey by tobacco cessation counselors. The

Results

We included 185 participants, including 122 participants between the ages of 55 and 80 years, who completed surveys. Most (62%) of them were 55 to 65 years old, at least 51% had a 30 pack-year or greater history of smoking, 39% were Hispanic or non-white, and 49% had an annual household income less than $50,000 per year (Table 1). Of respondents older than 55 years, 98 (80.3%) previously underwent colorectal cancer screening (colonoscopy, sigmoidoscopy, or fecal occult blood test). Twenty-three

Discussion

In this study, we reported on LCS adoption, lung cancer risk perception, and perceived barriers to LCS among current smokers who attended a tobacco cessation counseling class. We found that eligible smokers in this health care system had high rates of colorectal cancer screening and that a minority had already undergone at least 1 LDCT for LCS. No survey respondent who had not already undergone LDCT was familiar with LCS. We identified a number of barriers that were important to a large

Disclosure

D.R. reports grant funding from Merck.

Acknowledgments

Research reported in this publication is supported by the Lung Cancer Research Foundation, and the National Cancer Institute of the National Institutes of Health under award numbers NIH 5K12CA001727-20 (Raz) and P30CA33572 through the use of the City of Hope Survey Research Core. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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To investigate current screening behaviors among high-risk individuals and analyse the factors that influence them.
A cross-sectional of 1652 high-risk individuals were recruited in Fujian Province, China from February to October 2022. Socio-demographic characteristics of participants were collected and other survey measures included a lung cancer and lung cancer screening knowledge questionnaire and a stage of adoption algorithm. Standardized measures on surveys were comprised of the: Lung Cancer Screening Health Belief Scales, Cataldo Lung Cancer Stigma Scale, Generalized Anxiety Disorder Scale-7, Patient Health Questionnaire-9, and the Patient Trust in the Medical Profession Scale. Factors associated with screening behavior were identified using binary logistic regression analysis.
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Among potentially LCS-eligible patients, 19% had never heard of LDCT and only 9.4% had discussed LCS with their provider within the past year. Those who accessed online patient portals were more likely to discuss LCS with their healthcare provider (OR, 4.25; 95% CI, 1.67, 10.81; P, .003), as were respondents with a history of current (vs. former) smoking (OR, 3.15; 95% CI, 1.21, 8.19; P, .019). Among LCS-ineligible, 1.9% discussed LCS with their providers. Individuals with a personal history of cancer (OR, 6.70; 95% CI, 1.65, 27.19; P, .009), and those who discussed colorectal cancer screening (OR, 5.74; 95% CI, 1.63, 20.14; P, .007) were more likely to discuss LCS with their provider.
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Liquid biopsy (LB) is clinically utilized to detect minute amounts of genetic material or protein shed by cancer cells, most commonly cell free DNA (cfDNA), as a noninvasive precision oncology tool to assess genomic alterations to guide cancer therapy or to detect the persistence of tumor cells after therapy. LB is also being developed as a multi-cancer screening assay. The use of LB holds great promise as a tool to detect lung cancer early. Although lung cancer screening (LCS) with low-dose computed tomography (LDCT) substantially reduces lung cancer mortality in high-risk individuals, the ability of current LCS guidelines to reduce the public health burden of advanced lung cancer through early detection has been limited. LB may be an important tool to improve early lung cancer detection among all populations at risk for lung cancer. In this systematic review, we summarize the test characteristics, including sensitivity and specificity of individual tests, as they pertain to the detection of lung cancer. We also address critical questions in the use of liquid biopsy for early detection of lung cancer including: 1. How might liquid biopsy be used to detect lung cancer early; 2. How accurate is liquid biopsy in detecting lung cancer early; and 3. Does liquid biopsy perform as well in never and light-smokers compared with current and former smokers.
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Lung cancer mortality has been declining since the 1990s largely due to decreases in smoking, yet it remains the leading cause of cancer mortality in the United States. While effective screening tests have been available for the three other cancers with highest mortality in the United States, specifically breast, colorectal, and prostate cancers, lung cancer screening (LCS) has become available only in recent years. Early attempts at developing a LCS test focused largely on chest radiography, often in conjunction with sputum cytology, though those modalities have since been shown to not be effective screening methods. More recently, studies have focused on screening with low-dose computed tomography (LDCT). These recent and ongoing studies differ considerably from each other in gender ratios, age cutoffs, and total number of pack-years of smoking burden for participants. The National Lung Screening Trial was the first prospective randomized trial to demonstrate that screening individuals at high risk for lung cancer with LDCT could decrease mortality. In 2013, the US Preventative Services Task Force provided a “grade B” recommendation for annual screening for lung cancer using LDCT in adults aged 55 to 80 years with a 30 pack-year smoking history, who currently smoke or quit within the past 15 years. National guidelines now standardize findings on LDCT screening examinations and delineate next steps for additional evaluation and follow-up. Ongoing work to refine LCS screening algorithms, identify individuals most likely to benefit from screening, and increase adoption of screening will likely improve its future utility.
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Citation Excerpt :
The modified factors cited most often as contributing to improving uptake of LCS included individualsdeveloping good health beliefs (n = 18) [11,18,26,36–37,40–41,44–45,52–60], intention to quit smoking (n = 2) [37,55], desire to decrease uncertainty (n = 3) [50,53,62], personal reassurance/peace of mind (n = 2) [36,37], self-efficacy beliefs (n = 2) [39,53], concerns about lung cancer (n = 1) [36], recommended LCS or clinical reminders by HCPs (n = 6) [18,33,39,44,54,63], pleasantness of appointment or staff (n = 2) [42,56], nursing intervention (n = 1) [33], and family values (n = 2) [18,37]. The modified factors cited most often as contributing to decreasing uptake of LCS included medical mistrust (n = 8) [15 34,37,39–40,44,52–53], lack of knowledge (n = 10) [18,34,37,39,42–44,46,51,52], fatalistic beliefs (n = 2), [39,53] perceived difficulties in cancer screening (n = 1) [11], psychological distress (e.g., fear, worry, stigma, health anxiety related to screening, claustrophobia/tight spaces) (n = 11) [15 18,34,37,39,41–42,45,52,57,61], discomfort in screening (n = 3) [53–54,56], and complexity of communication between individuals and HCPs (n = 3) [42,46,49]. This is the first systematic review to investigate the barriers and facilitators of LCS uptake at the level of both individuals and HCPs.
Numerous factors contribute to the low adherence to lung cancer screening (LCS) programs. A theory-informed approach to identifying the obstacles and facilitators to LCS uptake is required. This study aimed to identify, assess, and synthesize the available literature at the individual and healthcare provider (HCP) levels based on a social-ecological model and identify gaps to improve practice and policy decision-making. Systematic searches were conducted in nine electronic databases from inception to December 31, 2020. We also searched Google Scholar and manually examined the reference lists of systematic reviews to include relevant articles. Primary studies were scored for quality assessment. Among 3938 potentially relevant articles, 36 studies, including 25 quantitative and 11 qualitative studies, were identified for inclusion in the review. Fifteen common factors were extracted from 34 studies, including nine barriers and six facilitators. The barriers included individual factors (n = 5), health system factors (n = 3), and social/environmental factors (n = 1). The facilitators included only individual factors (n = 6). However, two factors, age and screening harm, remain mixed. This systematic review identified and combined barriers and facilitators to LCS uptake at the individual and HCP levels. The interaction mechanisms among these factors should be further explored, which will allow the construction of tailored LCS recommendations or interventions for the Chinese context.

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Original StudyPerceptions and Utilization of Lung Cancer Screening Among Smokers Enrolled in a Tobacco Cessation Program

Abstract

Background

Materials and Methods

Results

Conclusions

Introduction

Section snippets

Materials and Methods

Results

Discussion

Disclosure

Acknowledgments

J Thorac Oncol

Lung Cancer

Lung Cancer

Reduced lung-cancer mortality with low-dose computed tomographic screening

N Engl J Med

Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement

Ann Intern Med

Lung Cancer Screening, Version 1.2015

Original Study
Perceptions and Utilization of Lung Cancer Screening Among Smokers Enrolled in a Tobacco Cessation Program