Patient-centered outcomes among lung cancer screening recipients with computed tomography: a systematic review

Exploring experiences and coping strategies of the surveillance of indeterminate pulmonary nodules: a qualitative content analysis among participants in the SCAPIS trial

OBJECTIVE

To elucidate experiences and coping strategies among adults in the surveillance of indeterminate pulmonary nodules detected with CT in the population-based Swedish CardioPulmonary bioImage Study (SCAPIS).

DESIGN

A qualitative study of conventional content analysis.

SETTINGS

The study was conducted at a university hospital in a southern region of Sweden. The SCAPIS setting is similar to the first round of a population-based lung cancer screening programme.

PARTICIPANTS

Participants in SCAPIS who had experienced psychosocial consequences of the surveillance were eligible. Participants of both genders, current, former and non-smokers and of different follow-ups in the surveillance were included. Face-to-face semi-structured interviews with 19 participants were performed using an interview guide with open-ended questions. The participants were aged 56-68 years. Nine were women, 6 and 13 were non-smokers and smokers or former smokers, respectively, and all participants had undergone at least one follow-up of the lungs in the surveillance programme.

RESULTS

The results depicted an emotional and mental journey for the participants from being distressed when informed about the need of surveillance, and realising their risks of getting sick if they did not take care of their own health, to eventually gathering the strength to cope with the situation, so the surveillance was finally valued with trust and satisfaction. The experiences and coping strategies in the surveillance programme developed a revelation of the value of health consciousness among the participants.

CONCLUSION

The study results demonstrated that a surveillance programme of pulmonary nodules might develop health consciousness among people. Still, some individuals might experience psychosocial consequences of the surveillance of indeterminate nodules. Therefore, healthcare professionals should be facilitated to perform person-centred communication to support individuals under surveillance. Preventive care to engage individuals as partners in the management of their own health should receive more attention and needs to be explored.

"I've been really happy since I got that letter!": Longitudinal patient perspectives on lung cancer screening communication

OBJECTIVE

Experts recommend structured shared decision making when discussing lung cancer screening (LCS) and reporting low-dose computed tomography (LDCT) results. We examined patients' reactions to pre- and post-LDCT results communication processes at three medical centers in the US with established LCS programs.

METHODS

Multicenter, qualitative, longitudinal study of patients considering and receiving LCS using data from semi-structured interviews guided by a patient-centered communication model using conventional content analysis. We conducted 61 interviews among 32 patients (sixteen of whom had a nodule on their LDCT) at one month and 12 months after an initial LCS decision making interaction.

RESULTS

Participants were mostly satisfied with LCS communication processes pre- and post-LDCT even though guideline concordant shared decision making was rare. Most participants reported no more than mild distress even if the LDCT detected a pulmonary nodule, felt relief after getting the results, and reported the perceived benefits of LCS outweighed their distress. Nearly all participants were satisfied with recommended follow-up plans. They reported that they trusted their clinicians and health care system to provide appropriate care and recommendations. They did not appear to regret their decision since almost all participants planned to get their next LDCT. However, they were at risk of non-adherence to follow-up recommendations since they often relied on the health care system to ensure they received timely follow-up.

CONCLUSIONS

Despite receiving guideline discordant decision-making communication, patients seem very satisfied, rarely experience severe distress, and have low decisional regret after LCS decision making and receiving the results of their LDCT.

Risk-based lung cancer screening performance in a universal healthcare setting

Globally, lung cancer is the leading cause of cancer death. Previous trials demonstrated that low-dose computed tomography lung cancer screening of high-risk individuals can reduce lung cancer mortality by 20% or more. Lung cancer screening has been approved by major guidelines in the United States, and over 4,000 sites offer screening. Adoption of lung screening outside the United States has, until recently, been slow. Between June 2017 and May 2019, the Ontario Lung Cancer Screening Pilot successfully recruited 7,768 individuals at high risk identified by using the PLCOm2012noRace lung cancer risk prediction model. In total, 4,451 participants were successfully screened, retained and provided with high-quality follow-up, including appropriate treatment. In the Ontario Lung Cancer Screening Pilot, the lung cancer detection rate and the proportion of early-stage cancers were 2.4% and 79.2%, respectively; serious harms were infrequent; and sensitivity to detect lung cancers was 95.3% or more. With abnormal scans defined as ones leading to diagnostic investigation, specificity was 95.5% (positive predictive value, 35.1%), and adherence to annual recall and early surveillance scans and clinical investigations were high (>85%). The Ontario Lung Cancer Screening Pilot provides insights into how a risk-based organized lung screening program can be implemented in a large, diverse, populous geographic area within a universal healthcare system.

Validation of the psychosocial consequences of screening in lung cancer questionnaire in the international lung screen trial Australian cohort

BACKGROUND

Evaluation of psychosocial consequences of lung cancer screening with LDCT in high-risk populations has generally been performed using generic psychometric instruments. Such generic instruments have low coverage and low power to detect screening impacts. This study aims to validate an established lung cancer screening-specific questionnaire, Consequences Of Screening Lung Cancer (COS-LC), in Australian-English and describe early results from the baseline LDCT round of the International Lung Screen Trial (ILST).

METHODS

The Danish-version COS-LC was translated to Australian-English using the double panel method and field tested in Australian-ILST participants to examine content validity. A random sample of 200 participants were used to assess construct validity using Rasch item response theory models. Reliability was assessed using classical test theory. The COS-LC was administered to ILST participants at prespecified timepoints including at enrolment, dependent of screening results.

RESULTS

Minor linguistic alterations were made after initial translation of COS-LC to English. The COS-LC demonstrated good content validity and adequate construct validity using psychometric analysis. The four core scales fit the Rasch model, with only minor issues in five non-core scales which resolved with modification. 1129 Australian-ILST participants were included in the analysis, with minimal psychosocial impact observed shortly after baseline LDCT results.

CONCLUSION

COS-LC is the first lung cancer screening-specific questionnaire to be validated in Australia and has demonstrated excellent psychometric properties. Early results did not demonstrate significant psychosocial impacts of screening. Longer-term follow-up is awaited and will be particularly pertinent given the announcement of an Australian National Lung Cancer Screening Program.

TRIAL REGISTRATION

NCT02871856.

Liquid Biopsy as an Adjunct to Lung Screening Imaging

Current lung cancer screening protocols use low-dose computed tomography scans in selected high-risk individuals. Unfortunately, utilization is low, and the rate of false-positive screens is high. Peripheral biomarkers carry meaningful promise in diagnosing and monitoring cancer with added potential advantages reducing invasive procedures and improving turnaround time. Herein, the use of such blood-based assays is considered as an adjunct to further utilization and accuracy of lung cancer screening.

Lung Cancer Screening in Asia: An Expert Consensus Report

INTRODUCTION

The incidence and mortality of lung cancer are highest in Asia compared with Europe and USA, with the incidence and mortality rates being 34.4 and 28.1 per 100,000 respectively in East Asia. Diagnosing lung cancer at early stages makes the disease amenable to curative treatment and reduces mortality. In some areas in Asia, limited availability of robust diagnostic tools and treatment modalities, along with variations in specific health care investment and policies, make it necessary to have a more specific approach for screening, early detection, diagnosis, and treatment of patients with lung cancer in Asia compared with the West.

METHOD

A group of 19 advisors across different specialties from 11 Asian countries, met on a virtual Steering Committee meeting, to discuss and recommend the most affordable and accessible lung cancer screening modalities and their implementation, for the Asian population.

RESULTS

Significant risk factors identified for lung cancer in smokers in Asia include age 50 to 75 years and smoking history of more than or equal to 20 pack-years. Family history is the most common risk factor for nonsmokers. Low-dose computed tomography screening is recommended once a year for patients with screening-detected abnormality and persistent exposure to risk factors. However, for high-risk heavy smokers and nonsmokers with risk factors, reassessment scans are recommended at an initial interval of 6 to 12 months with subsequent lengthening of reassessment intervals, and it should be stopped in patients more than 80 years of age or are unable or unwilling to undergo curative treatment.

CONCLUSIONS

Asian countries face several challenges in implementing low-dose computed tomography screening, such as economic limitations, lack of efforts for early detection, and lack of specific government programs. Various strategies are suggested to overcome these challenges in Asia.

Patient-centred outcomes of imaging tests: recommendations for patients, clinicians and researchers

BACKGROUND

Imaging tests are one of the most frequently used diagnostic modalities in healthcare, but the benefits of their direct impacts on clinical decision-making have been countered by concerns that they can be overused. Assessing the relative value of imaging tests has largely focused on measures of test accuracy, which overlooks more comprehensive benefits and risks of imaging tests, particularly their impact on patient-centred outcomes (PCOs). We present the findings of the Patient Reported Outcomes of Diagnostics (PROD) research study in response to a methodological gap in the area of diagnostic test comparative effectiveness research.

METHODS

Over a 3-year period, the PROD Study engaged with multiple stakeholders to identify existing conceptual models related to PCOs for imaging testing, conducted primary research and evidence synthesis, and developed consensus recommendations to describe and categorise PCOs related to imaging testing.

RESULTS

The PROD framework categorises PCOs from imaging studies within four main domains: information or knowledge yielded, physical impact, emotional outcomes and test burden. PCOs interact with each other and influence effects across domains, and can be modified by factors related to the patient, clinical situation, healthcare team and the testing environment.

CONCLUSIONS

Using PCOs to inform healthcare decision-making will require ways of collating and presenting information on PCOs in ways that can inform patient-provider decision-making, and developing methods to determine the relative importance of outcomes (including test accuracy) to one another.

Psychological impact of lung cancer screening using a novel antibody blood test followed by imaging: the ECLS randomized controlled trial

BACKGROUND

The Early CDT®-Lung antibody blood test plus serial computed tomography scans for test-positives (TPGs) reduces late-stage lung cancer presentation. This study assessed the psychological outcomes of this approach.

METHODS

Randomized controlled trial (n = 12 208) comparing psychological outcomes 1-12 months post-recruitment in a subsample (n = 1032) of TPG, test-negative (TNG) and control groups (CG).

RESULTS

Compared to TNG, TPG had lower positive affect (difference between means (DBM), 3 months (3m: -1.49 (-2.65, - 0.33)), greater impact of worries (DBM 1m: 0.26 (0.05, 0.47); 3m: 0.28 (0.07, 0.50)), screening distress (DBM 1m: 3.59 (2.28, 4.90); 3m: 2.29 (0.97, 3.61); 6m: 1.94 (0.61, 3.27)), worry about tests (odds ratio (OR) 1m: 5.79 (2.66, 12.63) and more frequent lung cancer worry (OR 1m: 2.52 (1.31, 4.83); 3m: 2.43 (1.26, 4.68); 6m: 2.87 (1.48, 5.60)). Compared to CG, TPG had greater worry about tests (OR 1m: 3.40 (1.69, 6.84)). TNG had lower negative affect (log-transformed DBM 3m: -0.08 (-0.13, -0.02)), higher positive affect (DBM 1m: 1.52 (0.43, 2.61); 3m: 1.43 (0.33, 2.53); 6m: 1.27 (0.17, 2.37)), less impact of worries (DBM 3m: -0.27 (-0.48, -0.07)) and less-frequent lung cancer worry (OR 3m: 0.49 (0.26, 0.92)).

CONCLUSIONS

Negative psychological effects in TPG and positive effects in TNG were short-lived and most differences were small.

Patient and Clinician Recommendations to Improve Communication and Understanding of Lung Cancer Screening Results

BACKGROUND

Patient understanding of chest low-dose CT (LDCT) scan results for lung cancer screening (LCS) may impact outcomes.

RESEARCH QUESTION

What are patient- and clinician-identified gaps in understanding and communication of LCS results and how might communication be improved through a patient-oriented tool?

STUDY DESIGN AND METHODS

We performed a mixed-methods study of participants recruited from a multisite LCS program to understand knowledge gaps after receiving LCS results and to guide development of a commonly asked questions (CAQ) after LCS information sheet. Initial patient surveys assessed understanding and reactions to LCS results (n = 190). We then conducted patient interviews and focus group discussions (n = 31) to understand experiences receiving LDCT scan results and reactions to results letters and the proposed CAQ; we also interviewed clinicians (n = 6) for feedback on these resources. We summarized survey responses and used thematic analysis to identify major themes in focus groups and interviews.

RESULTS

Of 190 survey respondents (43% response rate), although 88% agreed that they "understood" their LCS results, only 55% reported understanding what a lung nodule is. Approximately two-thirds thought it was "very important" to receive more information regarding lung nodules and incidental lung and heart disease. In interviews and focus groups, although patients believed that brief results letters for normal LDCT scan results generally were acceptable, most found letters explaining abnormal LDCT scan and incidental findings to be concerning and not a substitute for discussion with their clinician. Nearly all patients expressed that the CAQ sheet provided helpful information on nodules, results reporting and incidental findings, and helped them form questions to ask their clinicians.

INTERPRETATION

We identified patient-reported information needs regarding LCS results and developed a CAQ information sheet that was refined with patient and clinician input. The CAQ may represent a simple and feasible way to improve LCS results reporting and to augment clinician-patient discussions.

Impact of low-dose computed tomography (LDCT) screening on lung cancer-related mortality

BACKGROUND

Lung cancer is the most common cause of cancer-related death in the world, however lung cancer screening has not been implemented in most countries at a population level. A previous Cochrane Review found limited evidence for the effectiveness of lung cancer screening with chest radiography (CXR) or sputum cytology in reducing lung cancer-related mortality, however there has been increasing evidence supporting screening with low-dose computed tomography (LDCT).  OBJECTIVES: To determine whether screening for lung cancer using LDCT of the chest reduces lung cancer-related mortality and to evaluate the possible harms of LDCT screening.

SEARCH METHODS

We performed the search in collaboration with the Information Specialist of the Cochrane Lung Cancer Group and included the Cochrane Lung Cancer Group Trial Register, Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library, current issue), MEDLINE (accessed via PubMed) and Embase in our search. We also searched the clinical trial registries to identify unpublished and ongoing trials. We did not impose any restriction on language of publication. The search was performed up to 31 July 2021.  SELECTION CRITERIA: Randomised controlled trials (RCTs) of lung cancer screening using LDCT and reporting mortality or harm outcomes.  DATA COLLECTION AND ANALYSIS: Two review authors were involved in independently assessing trials for eligibility, extraction of trial data and characteristics, and assessing risk of bias of the included trials using the Cochrane RoB 1 tool. We assessed the certainty of evidence using GRADE. Primary outcomes were lung cancer-related mortality and harms of screening. We performed a meta-analysis, where appropriate, for all outcomes using a random-effects model. We only included trials in the analysis of mortality outcomes if they had at least 5 years of follow-up. We reported risk ratios (RRs) and hazard ratios (HRs), with 95% confidence intervals (CIs) and used the I2 statistic to investigate heterogeneity.  MAIN RESULTS: We included 11 trials in this review with a total of 94,445 participants. Trials were conducted in Europe and the USA in people aged 40 years or older, with most trials having an entry requirement of ≥ 20 pack-year smoking history (e.g. 1 pack of cigarettes/day for 20 years or 2 packs/day for 10 years etc.). One trial included male participants only. Eight trials were phase three RCTs, with two feasibility RCTs and one pilot RCT. Seven of the included trials had no screening as a comparison, and four trials had CXR screening as a comparator. Screening frequency included annual, biennial and incrementing intervals. The duration of screening ranged from 1 year to 10 years. Mortality follow-up was from 5 years to approximately 12 years.  None of the included trials were at low risk of bias across all domains. The certainty of evidence was moderate to low across different outcomes, as assessed by GRADE. In the meta-analysis of trials assessing lung cancer-related mortality, we included eight trials (91,122 participants), and there was a reduction in mortality of 21% with LDCT screening compared to control groups of no screening or CXR screening (RR 0.79, 95% CI 0.72 to 0.87; 8 trials, 91,122 participants; moderate-certainty evidence). There were probably no differences in subgroups for analyses by control type, sex, geographical region, and nodule management algorithm. Females appeared to have a larger lung cancer-related mortality benefit compared to males with LDCT screening. There was also a reduction in all-cause mortality (including lung cancer-related) of 5% (RR 0.95, 95% CI 0.91 to 0.99; 8 trials, 91,107 participants; moderate-certainty evidence).  Invasive tests occurred more frequently in the LDCT group (RR 2.60, 95% CI 2.41 to 2.80; 3 trials, 60,003 participants; moderate-certainty evidence). However, analysis of 60-day postoperative mortality was not significant between groups (RR 0.68, 95% CI 0.24 to 1.94; 2 trials, 409 participants; moderate-certainty evidence).  False-positive results and recall rates were higher with LDCT screening compared to screening with CXR, however there was low-certainty evidence in the meta-analyses due to heterogeneity and risk of bias concerns. Estimated overdiagnosis with LDCT screening was 18%, however the 95% CI was 0 to 36% (risk difference (RD) 0.18, 95% CI -0.00 to 0.36; 5 trials, 28,656 participants; low-certainty evidence). Four trials compared different aspects of health-related quality of life (HRQoL) using various measures. Anxiety was pooled from three trials, with participants in LDCT screening reporting lower anxiety scores than in the control group (standardised mean difference (SMD) -0.43, 95% CI -0.59 to -0.27; 3 trials, 8153 participants; low-certainty evidence). There were insufficient data to comment on the impact of LDCT screening on smoking behaviour.  AUTHORS' CONCLUSIONS: The current evidence supports a reduction in lung cancer-related mortality with the use of LDCT for lung cancer screening in high-risk populations (those over the age of 40 with a significant smoking exposure). However, there are limited data on harms and further trials are required to determine participant selection and optimal frequency and duration of screening, with potential for significant overdiagnosis of lung cancer. Trials are ongoing for lung cancer screening in non-smokers.

Barriers and facilitators to lung cancer screening and follow-up

Two randomized trials have shown that lung cancer screening (LCS) with low dose computed tomography (LDCT) reduces lung cancer mortality in patients at high-risk for lung malignancy by identifying early-stage cancers, when local cure and control is achievable. The implementation of LCS in the United States has revealed multiple barriers to preventive cancer care. Rates of LCS are disappointingly low with estimates between 5%-18% of eligible patients screened. Equally concerning, follow-up after baseline screening is far lower than that of clinical trials (44-66% v >90%). To optimize the benefits of LCS, programs must identify and address factors related to LCS participation and follow-up while concurrently recognizing and mitigating barriers. As a relatively new screening test, the most effective processes for LCS are uncertain. Therefore, LCS programs have adopted a wide range of approaches without clearly established best practices to guide them, particularly in rural and resource-limited settings. In this narrative review, we identify barriers and facilitators to LCS, focusing on those studies in non-clinical trial settings - reflecting "real world" challenges. Our goal is to identify effective and scalable LCS practices that will increase LCS participation, improve adherence to follow-up, inform strategies for quality improvement, and support new research approaches.

European lung cancer screening: valuable trial evidence for optimal practice implementation

Lung cancer screening (LCS) by low-dose computed tomography is a strategy for secondary prevention of lung cancer. In the last two decades, LCS trials showed several options to practice secondary prevention in association with primary prevention, however, the translation from trial to practice is everything but simple. In 2020, the European Society of Radiology and European Respiratory Society published their joint statement paper on LCS. This commentary aims to provide the readership with detailed description about hurdles and potential solutions that could be encountered in the practice of LCS.

Should psychological distress be listed as a surgical indication for indeterminate pulmonary nodules: protocol for a prospective cohort study in real-world settings

BACKGROUND

Pulmonary nodules (PNs) are documented in up to 30% of computed tomography (CT) reports. PNs of indeterminate nature (IPN) have been reported to be associated with increased psychological distress and deterioration of the quality of life. Despite lack of solid evidence, severe anxiety or depression has been proposed to be one of the surgical indications in expert consensus for IPN management. So far, there is no established criterion to guide the decision-making process, or to ensure evidence-based management. This study aims to evaluate whether psychological distress could be a surgical indication for IPN, and to establish an evidence-based distress threshold for necessary surgical intervention.

METHODS

This prospective observational study in real-world setting will involve an expected sample size of 1,253 IPN patients from the thoracic clinic of Guangdong Provincial People's Hospital. Web-based questionnaires powered by Wen Juan Xing (WJX) platform will be delivered to the patients for baseline data collection and psychological screening. Based on our pilot study, a total of 376 IPN patients with abnormal or borderline abnormal psychological states, as assessed by the Hospital Anxiety and Depression Scale (HADS), will be followed for 1 year before proceeding to the final analysis. The planned study period is from Jan 1, 2021, to Sept 30, 2022, and will entail two HADS assessments at baseline and follow-up. Sleep quality and indicators of healthcare-seeking behavior, such as the number of unplanned clinic visits or CT scans per year, will be used as anchors of psychological state. Patients who undergo surgical resection against the follow-up plan will be enrolled into a surgical group (expected n=94), while those who adhere to their plan will be automatically classified as a follow-up group after 1-year follow-up (expected n=282). Statistical measures such as independent-samples t-test and receiver operating characteristics (ROC) analysis will be used to assess the difference in psychological changes between the groups, and to generate an optimal threshold alerting surgical need. A Chi-square test or nonparametric test will be used to compare the baseline characteristics. Contributors to psychological burden and their effect sizes will be evaluated using general linear regression.

DISCUSSION

To date, data on the psychological benefits of surgical resection of IPN remains scanty. Evidence-based procedure of patient selection using appropriate psychological screening tools is crucial in improving the quality of care and preventing overtreatment. This protocol describes the rationale and methodology to address this unmet clinical need using real-world data, aiming to bridge the gap between clinical guidelines and real-world practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04857333. Registered April 23, 2021.

Patient-reported outcomes associated with cancer screening: a systematic review

Background

Multi-cancer early detection tests have been developed to enable earlier detection of multiple cancer types through screening. As reflected by patient-reported outcomes (PROs), the psychosocial impact of cancer screening is not yet clear. Our aim is to evaluate the impact of cancer screening through PRO assessment.

Methods

A systematic review was conducted using MEDLINE, EMBASE, and reference lists of articles from January 2000 to August 2020 for relevant publications assessing the psychosocial impact of cancer screening before and within 1 year after screening in the general asymptomatic population, including following receipt of results. Studies focused on diagnostic evaluation or involving patients previously diagnosed with cancer were excluded.

Results

In total, 31 studies (12 randomized controlled trials; 19 observational studies) were included, reflecting PRO assessments associated with lung, breast, colorectal, anal, ovarian, cervical, and prostate cancer screening procedures. The most commonly assessed construct was symptoms of anxiety, using the State-Trait Anxiety Inventory. Cancer-specific distress and worry were also assessed using a broad range of measures. Overall, individuals tolerated screening procedures well with no major psychosocial effects. Of note, increases in symptoms of anxiety and levels of distress and worry were generally found prior to communication of screening results and following communication of indeterminate or positive results that required further testing. These negative psychosocial effects were, however, not long-lasting and returned to baseline relatively soon after screening. Furthermore, individuals with higher cancer risk, such as current smokers and those with a family history of cancer, tended to have higher levels of anxiety and distress throughout the screening process, including following negative or indeterminate results.

Conclusions

The psychosocial impact of cancer screening is relatively low overall and short-lived, even following false-positive test results. Individuals with a higher risk of cancer tend to experience more symptoms of anxiety and distress during the screening process; thus, more attention to this group is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09261-5.

Cost-effectiveness and health impact of lung cancer screening with low-dose computed tomography for never smokers in Japan and the United States: a modelling study

BACKGROUND

Never smokers in Asia have a higher incidence of lung cancer than in Europe and North America. We aimed to assess the cost-effectiveness of lung cancer screening with low-dose computed tomography (LDCT) for never smokers in Japan and the United States.

METHODS

We developed a state-transition model for three strategies: LDCT, chest X-ray (CXR), and no screening, using a healthcare payer perspective over a lifetime horizon. Sensitivity analyses were also performed. Main outcomes were costs, quality-adjusted life-years (QALYs), life expectancy life-years (LYs), incremental cost-effectiveness ratios (ICERs), and deaths from lung cancer. The willingness-to-pay level was US$100,000 per QALY gained.

RESULTS

LDCT yielded the greatest benefits with the lowest cost in Japan, but the ICERs of LDCT compared with CXR were US$3,001,304 per QALY gained for American men and US$2,097,969 per QALY gained for American women. Cost-effectiveness was sensitive to the incidence of lung cancer. Probabilistic sensitivity analyses demonstrated that LDCT was cost-effective 99.3-99.7% for Japanese, no screening was cost-effective 77.7% for American men, and CXR was cost-effective 93.2% for American women. Compared with CXR, LDCT has the cumulative lifetime potential for 60-year-old Japanese to save US$117 billion, increase 2,339,349 QALYs and 3,020,102 LYs, and reduce 224,749 deaths, and the potential for 60-year-old Americans to cost US$120 billion, increase 48,651 QALYs and 67,988 LYs, and reduce 2,309 deaths.

CONCLUSIONS

This modelling study suggests that LDCT screening for never smokers has the greatest benefits and cost savings in Japan, but is not cost-effective in the United States. Assessing the risk of lung cancer in never smokers is important for introducing population-based LDCT screening.

The person behind the nodule: a narrative review of the psychological impact of lung cancer screening

Lung cancer is the leading cause of cancer mortality globally, responsible for an estimated 1.76 million deaths worldwide in 2018 alone. Screening adults at high risk of lung cancer using low-dose computed tomography (LDCT) significantly reduces lung cancer mortality by finding the disease at an early, treatable stage. Many countries are actively considering whether to implement screening for their high-risk populations in light of the recently published Dutch-Belgian trial 'NELSON'. In deciding whether to implement a national screening programme, policymakers must weigh up the evidence for the relative risks posed to the entire screened population, including the potential psychological burden. This narrative review aimed to critically summarise the evidence for both negative and positive psychological responses experienced throughout the LDCT screening pathway, to describe their magnitude, duration and clinical relevance, and to draw out different aspects of measurement design crucial to their interpretation. A further aim was to discuss the available evidence for individual differences in psychological response, as well as interventions designed to promote psychological well-being. In summary, there was no evidence that the LDCT screening process caused adverse psychological outcomes overall, although those receiving indeterminate and suspicious LDCT results did report clinically raised anxiety and lung cancer-specific distress in the short-term. There was early evidence that demographic factors, smoking status and screening-ineligibility could be associated with individual differences in propensity to experience distress. Qualitative data suggested health beliefs could be modifiable mediators of these individual differences, but their aetiology requires quantitative and prospective research. There was also some evidence of positive psychological responses that could be capitalised on, and of the potential for person-centred communication interventions to achieve this. Further research needs to be embedded in real-world LDCT lung cancer screening services and use condition-specific measures to monitor outcomes and test evidence-based communication interventions in promoting psychological well-being.

Psychosocial consequences of a three-month follow-up after receiving an abnormal lung cancer CT-screening result: A longitudinal survey

BACKGROUND

Participation in lung cancer CT-screening can be associated with a need for follow-up procedures. The screening and waiting for test results introduce the risk of experiencing psychosocial consequences. Therefore, the aims of this study were: 1) To investigate if the psychosocial consequences changed from before an annual screening round to before a three-month follow-up CT-scan in participants with a positive screening result. 2) To investigate potential differences in psychosocial consequences between false positives (FP) and true positives (TP). FP were defined as those where cancer was not confirmed in the follow-up CT-scan and TP where it was.

MATERIALS AND METHODS

This longitudinal study was based on data from the Danish Lung Cancer Screening Trial (DLCST). The Consequences of Screening - Lung cancer (COS-LC) questionnaire was used to measure psychosocial consequences among 130 participants who all received an abnormal CT-screening result at their annual screening round. Eligible participants completed the COS-LC before their annual CT-screening and before the three-month follow-up.

RESULTS

We found a statistically significant increase in negative psychosocial consequences between the annual lung cancer CT-screening and the three-month follow-up CT-scan in four of nine psychosocial scales; Sense of dejection, Self-blame, Focus on airway symptoms and Harm of smoking. Furthermore, an increase, however not statistically significant, was identified in all remaining scales, except for the scale Stigmatisation which was slightly decreased. We found no evidence of an association between psychosocial consequences and diagnostic groups, FP and TP.

CONCLUSIONS

An increase in negative psychosocial consequences was observed between the annual lung cancer CT-screening and the three-month follow-up CT-scan. Since we found no statistically significant difference between the diagnostic groups, the increase in negative psychosocial consequences is interpreted as a nocebo effect of living three months in uncertainty not knowing if one's positive CT-screening result was true or false.

Intergroupe francophone de cancérologie thoracique, Société de pneumologie de langue française, and Société d'imagerie thoracique statement paper on lung cancer screening

Following the American National Lung Screening Trial results in 2011 a consortium of French experts met to edit a statement. Recent results of other randomized trials gave the opportunity for our group to meet again in order to edit updated guidelines. After literature review, we provide here a new update on lung cancer screening in France. Notably, in accordance with all international guidelines, the experts renew their recommendation in favor of individual screening for lung cancer in France as per the conditions laid out in this document. In addition, the experts recommend the very rapid organization and funding of prospective studies, which, if conclusive, will enable the deployment of lung cancer screening organized at the national level.

When Is a Harm a Harm? Discordance between Patient and Medical Experts' Evaluation of Lung Cancer Screening Attributes

BACKGROUND

A shared decision-making (SDM) process for lung cancer screening (LCS) includes a discussion between clinicians and patients about benefits and potential harms. Expert-driven taxonomies consider mortality reduction a benefit and consider false-positives, incidental findings, overdiagnosis, overtreatment, radiation exposure, and direct and indirect costs of LCS as potential harms.

OBJECTIVE

To explore whether patients conceptualize the attributes of LCS differently from expert-driven taxonomies.

DESIGN

Cross-sectional study with semistructured interviews and a card-sort activity.

PARTICIPANTS

Twenty-three Veterans receiving primary care at a Veterans Affairs Medical Center, 55 to 73 y of age with 30 or more pack-years of smoking. Sixty-one percent were non-Hispanic African American or Black, 35% were non-Hispanic White, 4% were Hispanic, and 9% were female.

APPROACH

Semistructured interviews with thematic coding.

MAIN MEASURES

The proportion of participants categorizing each attribute as a benefit or harm and emergent themes that informed this categorization.

KEY RESULTS

In addition to categorizing reduced lung cancer deaths as a benefit (22/23), most also categorized the following as benefits: routine annual screening (8/9), significant incidental findings (20/23), follow-up in a nodule clinic (20/23), and invasive procedures (16/23). Four attributes were classified by most participants as a harm: false-positive (13/22), overdiagnosis (13/23), overtreatment (6/9), and radiation exposure (20/22). Themes regarding the evaluation of LCS outcomes were 1) the value of knowledge about body and health, 2) anticipated positive and negative emotions, 3) lack of clarity in terminology, 4) underlying beliefs about cancer, and 5) risk assessment and tolerance for uncertainty.

CONCLUSIONS

Anticipating discordance between patient- and expert-driven taxonomies of the benefits and harms of LCS can inform the development and interpretation of value elicitation and SDM discussions.

Consequences of screening in colorectal cancer (COS-CRC): development and dimensionality of a questionnaire

BACKGROUND

Harms of colorectal cancer (CRC) screening include psychosocial consequences. We have not identified studies using a participant-relevant questionnaire with adequate measurement properties to investigate these harms. However, Brodersen et al. have previously developed a core questionnaire consequences of screening (COS) for use in screening for life-threatening diseases. Therefore, the objectives were: (1) To investigate content validity of COS in a CRC screening setting and in case of gaps in content coverage (2) generate new items and themes and (3) test the possibly extended version of COS for dimensionality and differential item functioning (DIF) using Rasch Models.

METHODS

We performed two-part-focus-groups with CRC screenees. Screenees were recruited by strategic sampling. In the first part 16 screenees with false-positive results (n = 7) and low-risk polyps (n = 9) were interviewed about their CRC screening experiences and in the second part COS was examined for content validity. When new information was developed in the focus groups, new items covering this topic were generated. Subsequently, new items were, together with COS, tested in the subsequent interviews. A random subsample (n = 410) from a longitudinal questionnaire study, not yet published, was used to form the data for this paper. We analysed multidimensionality and uniform DIF with Andersen's conditional likelihood ratio test. We assessed individual item fit to the model. We also analysed Local Dependence (LD) and DIF by partial gamma coefficients using Rasch Models.

RESULTS

COS was found relevant in a CRC screening setting. However, new information was discovered in the focus groups, covered by 18 new CRC screening-specific items. The Rasch analyses only revealed minor problems in the COS-scales. The 18 new items were distributed on four new CRC screening-specific dimensions and one single item.

CONCLUSION

An extended version of COS specifically for use in a CRC screening setting has been developed. The extended part encompasses four new scales and one new single item. The original COS with the CRC-screening specific extension is called consequences of screening in colorectal cancer (COS-CRC). COS-CRC possessed reliability, unidimensionality and invariant measurement.

[Smoking cessation and lung cancer screening]

Several studies have shown that lung cancer screening, using annual low-dose computed tomography (CT) scan in a targeted population of smokers and ex-smokers reduces overall and lung cancer specific mortality rates. This form of screening strategy is not currently established for use in France by the French High Authority for Health. Quitting smoking is the most important measure in reducing mortality from lung cancer. The maximum benefit in reducing mortality from lung cancer should be seen through an effective combination of smoking cessation intervention and chest CT screening to identify early, curable disease. However, current data to guide clinicians in the choice of smoking cessation interventions in this specific context are limited due to the small number of randomized studies that have been carried out. The optimal approach to smoking cessation during lung cancer screening needs to be clarified by new studies comparing different motivation strategies, establishing the ideal moment to propose stopping smoking and the most effective therapies to use.

Low-Dose Computed Tomography: Effects of Oncology Nurse Navigation on Lung Cancer Screening

BACKGROUND

Low-dose computed tomography (LDCT) lung cancer screening is an evidence-based and reimbursable strategy to decrease lung cancer and all-cause mortality in qualifying patients, but there remains low use and variation in providers' LDCT screening, ordering, and referring knowledge.

OBJECTIVES

The purpose of this quality improvement project was to examine the effects of oncology nurse navigation on assisting patients and ensuring optimal LDCT lung cancer screening.

METHODS

Oncology nurse navigators conducted LDCT provider education and navigated 133 eligible patients to LDCT during a five-month intervention time period.

FINDINGS

Provider education resulted in improved documented tobacco cessation discussions and increased LDCT screening ordering fidelity. Mean days from LDCT to provider notification and mean days from LDCT to patient notification improved significantly.

Qualitative study to explore radiologist and radiologic technologist perceptions of outcomes patients experience during imaging in the USA

OBJECTIVE

We aimed to explore the patient-centred outcomes (PCOs) radiologists and radiologic technologists perceive to be important to patients undergoing imaging procedures.

DESIGN

We conducted a qualitative study of individual semi-structured interviews.

PARTICIPANTS

We recruited multiple types of radiologists including general, musculoskeletal neuroradiology, body and breast imagers as well as X-ray, ultrasound, CT or MRI radiologic technologists from Washington and Idaho.

OUTCOME

Thematic analysis was conducted to identify themes and subthemes related to PCOs of imaging procedures.

RESULTS

Ten radiologists and six radiology technologists participated. Four main domains of PCOs were identified: emotions, physical factors, knowledge and patient burden. In addition to these outcomes, we also identified patient and provider factors that can potentially moderate these outcomes.

CONCLUSIONS

Radiologists and technologists perceived outcomes related to the effect of imaging procedures on patients' emotions, physical well-being, knowledge and burden from financial and opportunity costs to be important to patients undergoing imaging procedures. There are opportunities for the radiology community to measure and use these PCOs in comparisons of imaging procedures and potentially identify areas where these outcomes can be leveraged to drive a more patient-centred approach to radiology.

What Exactly Is Shared Decision-Making? A Qualitative Study of Shared Decision-Making in Lung Cancer Screening

BACKGROUND

Shared decision-making (SDM) is widely recommended and required by the Centers for Medicare and Medicaid for patients considering lung cancer screening (LCS).

OBJECTIVE

We examined clinicians' communication practices and perceived barriers of SDM for LCS at three medical centers with established screening programs.

DESIGN

Multicenter qualitative study of clinicians participating in LCS.

APPROACH

We performed semi-structured interviews, which were transcribed and analyzed using directed content analysis, guided by a theoretical model of patient-clinician communication.

PARTICIPANTS

We interviewed 24 clinicians including LCS coordinators (2), pulmonologists (3), and primary care providers (17), 4 of whom worked for the LCS program, a thoracic surgeon, and a radiologist.

RESULTS

All clinicians agreed with the goal of SDM, to ensure the screening decision was congruent with the patient's values. The depth and type of information presented by each clinician role varied considerably. LCS coordinators presented detailed information including numeric estimates of benefit and harm. Most PCPs explained the process more generally, focusing on logistics and the high rate of nodule detection. No clinician explicitly elicited values or communication preferences. Many PCPs tailored the conversation based on their implicit understanding of patients' values and preferences, gained from past experiences. PCPs reported that time, lack of detailed personal knowledge of LCS, and patient preferences were barriers to SDM. Many clinicians perceived that a significant proportion of patients were not interested in specific percentages and preferred to receive a clinician recommendation.

CONCLUSIONS

Our results suggest that clinicians support the goal of SDM for LCS decisions but PCPs may not perform some of its elements. The lack of completion of some elements, such as PCPs' lack of in-depth information exchange, may reflect perceived patient preferences for communication. As LCS is implemented, further research is needed to support a personalized, patient-centered approach to produce better outcomes.

Exploring Novel Technologies in Lung Cancer Diagnosis: Do We Have Room for Improvement?

Lung cancer remains the leading cause of cancer-related death worldwide. Preventive strategies, mainly smoking cessation have a big impact on the reduction of lung cancer-related mortality. Screening with low dose computed tomography (LDCT) has proven to be beneficial in reducing the mortality related to lung cancer mainly based on early detection of cancer and timely initiation of treatment. Despite its beneficial effects, guideline-directed LDCT screening could lead to high false positive results, subjecting patients to harmful radiation, increase cost of healthcare and induce anxiety amongst the patients. Thus, it is imperative to look beyond the prevailing modalities of lung cancer screening and diagnosis to achieve better yield and mitigate the existent drawbacks.

Multidisciplinary Team-Based Management of Incidentally Detected Lung Nodules

BACKGROUND

Each year, > 1.5 million Americans are diagnosed with an incidentally detected lung nodule. Practice guidelines attempt to balance the benefit of early detection of lung cancer with the risks of diagnostic testing, but adherence to guidelines is low. The goal of this study was to determine guideline adherence rates in the setting of a multidisciplinary nodule clinic and describe reasons for nonadherence as well as associated outcomes.

METHODS

This cohort study included 3 years of follow-up of patients aged ≥ 35 years with an incidentally detected lung nodule evaluated in a multidisciplinary clinic that used the 2005 Fleischner Society Guidelines.

RESULTS

Among 113 patients, 67% (95% CI, 58-76) were recommended a guideline-concordant nodule evaluation; 7.1% (95% CI, 3.1-13) and 26% (95% CI, 18-25) were recommended less or more intense evaluation, respectively. In contrast, 58% (95% CI, 48-67), 22% (95% CI, 18-25), and 23% (95% CI, 16-32) received a guideline-concordant, less intense, or more intense evaluation. The most common reason for recommending guideline-discordant care was concern for two different diagnoses that would each benefit from early detection and treatment. A majority of lung cancer diagnoses (88%) occurred in patients who received guideline-concordant care. There were no lung cancer cases in those who received less intense nodule care.

CONCLUSIONS

A multidisciplinary nodule clinic may serve as a system-level intervention to promote guideline-concordant care, while also providing a multidisciplinary basis by which to deviate from guidelines to address the needs of a heterogeneous patient population.

Challenges to Educating Smokers About Lung Cancer Screening: a Qualitative Study of Decision Making Experiences in Primary Care

We sought to qualitatively explore how those at highest risk for lung cancer, current smokers, experienced, understood, and made decisions about participation in lung cancer screening (LCS) after being offered in the target setting for implementation, routine primary care visits. Thirty-seven current smokers were identified within 4 weeks of being offered LCS at seven sites participating in the Veterans Health Administration Clinical Demonstration Project and interviewed via telephone using semi-structured qualitative interviews. Transcripts were coded by two raters and analyzed thematically using iterative inductive content analysis. Five challenges to smokers' decision-making lead to overestimated benefits and minimized risks of LCS: fear of lung cancer fixated focus on inflated screening benefits; shame, regret, and low self-esteem stemming from continued smoking situated screening as less averse and more beneficial; screening was mistakenly believed to provide general evaluation of lungs and reassurance was sought about potential damage caused by smoking; decision-making was deferred to providers; and indifference about numerical educational information that was poorly understood. Biased understanding of risks and benefits was complicated by emotion-driven, uninformed decision-making. Emotional and cognitive biases may interfere with educating and supporting smokers' decision-making and may require interventions tailored for their unique needs.

Common mental disorders in Taiwanese consumers of commercial low-dose computed tomography lung cancer screening: Comparison with a nationally representative sample

BACKGROUND/PURPOSE

We examined the prevalence of probable common mental disorders (CMDs) in commercial low-dose computed tomography (LDCT) lung cancer screening consumers relative to the general population and to determine the correlates of probable CMDs among screening participants.

METHODS

Commercial LDCT lung cancer screening consumers (N = 1323) were compared with a nationally representative sample from the Taiwan Social Change Survey (TSCS) (N = 2034). Respondents scoring ≥3 on the Chinese Health Questionnaire were classified as having a probable CMD. Logistic regression was used to investigate differences between the two groups and correlates of probable CMDs among LDCT lung cancer screening participants.

RESULTS

The prevalence of probable CMDs was higher among LDCT lung cancer screening participants (25.47%) than among TSCS adults (21.56%). Compared with the TSCS sample, the screening participants had a higher probability of CMDs (OR = 1.40, 95% CI = 1.13-1.73), higher education levels (OR = 7.95, 95% CI = 6.00-10.53), and a history of drinking (OR = 11.85, 95% CI = 9.45-14.85) or betel-quid use (OR = 5.43, 95% CI = 3.98-7.42) but were less likely to smoke (OR = 0.52, 95% CI = 0.40-0.68). Among the screening participants, being female (OR = 1.37, 95% CI = 1.02-1.84) and a current smoker (OR = 1.74, 1.19-2.54) and living near ≥2 smoking family members (OR = 2.30, 95% CI 1.57-3.38) were associated with an increased likelihood of having CMDs.

CONCLUSION

Commercial LDCT lung cancer screening users may have a positive association with probable CMDs compared to the general population. Screening programs should consider including criteria and providing psychoeducation to improve the physical and mental outcomes of participants.

CLINICAL TRIAL REGISTRATION

Purely observational studies (those in which the assignment of the medical intervention is not at the discretion of the investigator) do not require registration.

Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.

Individual decision making about lung cancer screening: A conjoint analysis of perspectives among a high-risk national sample

OBJECTIVES

Lung cancer screening (LCS) is effective in reducing lung cancer mortality, but there is limited information available regarding preferences among high-risk individuals concerning LCS. In this study, we use a conjoint valuation analysis (CVA) to better understand which LCS attributes most affect LCS preferences.

MATERIALS AND METHODS

We implemented a web-based nationally representative survey that included a full-profile CVA exercise. Participants were over the age of 45, had at least a 20 pack-year smoking history, and no history of lung cancer. The CVA instrument included five LCS attributes, and additional survey items collected demographic and psychosocial information.

RESULTS

Participants (n = 210) had a mean age of 61 (SD 8.5) years, approximately half were female (51.9%), and were racially/ethnically diverse. Average relative importance of the LCS program attributes was (from high to low): out of pocket costs (27.3 ± 17.7); provider recommendation (24.8 ± 13.4); mortality reduction (17.2 ± 8.9); false-positive rate (15.8 ± 10.4); and ease of access (14.8 ± 7.3). There was large variation among individuals, but few significant associations of propensity to screen with individual demographic characteristics. Average screening propensity across individuals (1-9 scale) was 3.63 ± 1.6, and average rates of individual scenarios ranged from 2.60 ± 2.00 to 5.57 ± 2.13, indicating low inclination for screening.

CONCLUSIONS

We found that overall propensity for screening is low in a high-risk population, and that out of pocket costs were of greater importance to potential screeners than mortality reduction or false-positive rates. Thus, individuals considering or eligible for LCS need additional education and support regarding the LCS landscape in order to achieve informed decision making.

Patient-Level Trajectories and Outcomes After Low-Dose CT Screening in the National Lung Screening Trial

BACKGROUND

Shared decision-making is an essential element of low-dose CT (LDCT) screening for lung cancer. Understanding patient-level outcomes from the National Lung Screening Trial (NLST) is critical to effectively communicate risks and benefits of screening to patients.

METHODS

We performed a secondary analysis of data collected in the NLST. We determined outcomes of each LDCT scan performed in the NLST (downstream evaluation, complications, lung cancer diagnoses), and compared outcomes at the test level with outcomes calculated at the patient level for those randomized to LDCT screening. To assess the impact of COPD on patient outcomes, we compared outcomes among patients with and without COPD.

RESULTS

Of 75,138 LDCT scans, 14.2% led to a diagnostic study and 1.5% to an invasive procedure, with 0.3% of LDCT scans resulting in a procedure-related complication and 0.1% in a serious complication. Among 24,453 patients who underwent LDCT screening, 30.5% underwent a diagnostic study and 4.2% an invasive procedure, with 0.9% of screened patients experiencing a procedure-related complication and 0.3% a serious complication. Patients with COPD (defined by self-report) were more likely to need a diagnostic study (adjusted OR [aOR], 1.29; P < .01) and an invasive procedure (aOR, 1.41; P < .01) and more likely to experience a complication (aOR, 1.83; P < .01) and a serious complication (aOR, 1.78; P = .01). Patients with COPD also were more likely to be diagnosed with lung cancer (aOR, 1.43; P < .01).

CONCLUSIONS

We provide important patient-level data from the NLST that can be used to guide shared decision-making. The risk-to-benefit ratio of screening may vary significantly in some patients, such as those with COPD, in whom both risks and benefits of screening may be increased.

Low-dose computed tomography for lung cancer screening in high-risk populations: a systematic review and economic evaluation

BACKGROUND

Diagnosis of lung cancer frequently occurs in its later stages. Low-dose computed tomography (LDCT) could detect lung cancer early.

OBJECTIVES

To estimate the clinical effectiveness and cost-effectiveness of LDCT lung cancer screening in high-risk populations.

DATA SOURCES

Bibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library.

METHODS

Clinical effectiveness - a systematic review of randomised controlled trials (RCTs) comparing LDCT screening programmes with usual care (no screening) or other imaging screening programmes [such as chest X-ray (CXR)] was conducted. Bibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library. Meta-analyses, including network meta-analyses, were performed. Cost-effectiveness - an independent economic model employing discrete event simulation and using a natural history model calibrated to results from a large RCT was developed. There were 12 different population eligibility criteria and four intervention frequencies [(1) single screen, (2) triple screen, (3) annual screening and (4) biennial screening] and a no-screening control arm.

RESULTS

Clinical effectiveness - 12 RCTs were included, four of which currently contribute evidence on mortality. Meta-analysis of these demonstrated that LDCT, with ≤ 9.80 years of follow-up, was associated with a non-statistically significant decrease in lung cancer mortality (pooled relative risk 0.94, 95% confidence interval 0.74 to 1.19). The findings also showed that LDCT screening demonstrated a non-statistically significant increase in all-cause mortality. Given the considerable heterogeneity detected between studies for both outcomes, the results should be treated with caution. Network meta-analysis, including six RCTs, was performed to assess the relative clinical effectiveness of LDCT, CXR and usual care. The results showed that LDCT was ranked as the best screening strategy in terms of lung cancer mortality reduction. CXR had a 99.7% probability of being the worst intervention and usual care was ranked second. Cost-effectiveness - screening programmes are predicted to be more effective than no screening, reduce lung cancer mortality and result in more lung cancer diagnoses. Screening programmes also increase costs. Screening for lung cancer is unlikely to be cost-effective at a threshold of £20,000/quality-adjusted life-year (QALY), but may be cost-effective at a threshold of £30,000/QALY. The incremental cost-effectiveness ratio for a single screen in smokers aged 60-75 years with at least a 3% risk of lung cancer is £28,169 per QALY. Sensitivity and scenario analyses were conducted. Screening was only cost-effective at a threshold of £20,000/QALY in only a minority of analyses.

LIMITATIONS

Clinical effectiveness - the largest of the included RCTs compared LDCT with CXR screening rather than no screening. Cost-effectiveness - a representative cost to the NHS of lung cancer has not been recently estimated according to key variables such as stage at diagnosis. Certain costs associated with running a screening programme have not been included.

CONCLUSIONS

LDCT screening may be clinically effective in reducing lung cancer mortality, but there is considerable uncertainty. There is evidence that a single round of screening could be considered cost-effective at conventional thresholds, but there is significant uncertainty about the effect on costs and the magnitude of benefits.

FUTURE WORK

Clinical effectiveness and cost-effectiveness estimates should be updated with the anticipated results from several ongoing RCTs [particularly the NEderlands Leuvens Longkanker Screenings ONderzoek (NELSON) screening trial].

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016048530.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Reviewing Lung Cancer Screening: The Who, Where, When, Why, and How

Lung cancer screening with annual low-dose computed tomography (CT) decreases lung cancer mortality in high-risk patients, as defined by smoking history (> 30 pack-years) and age (55-74 years). Risks to screening include overdiagnosis, anxiety about indeterminate nodules, and radiation exposure. To be effective, lung cancer screening must combine individualized risk assessment, shared decision-making, smoking cessation, structured reporting, high quality and multi-specialty cancer care, and reliable follow-up; a multidisciplinary approach is crucial. Specialty organizations have outlined both the components of high quality lung cancer screening programs and the proposed metrics that programs should track. Long-term outcomes of lung cancer screening in the general population, further refinement of who to screen, and use of biomarkers for early cancer detection are ongoing research questions.

Health-related quality of life and anxiety in the PAN-CAN lung cancer screening cohort

OBJECTIVES

The impact of lung cancer screening with low-dose chest CT (LDCT) on participants' anxiety levels and health-related quality of life (HRQoL) is an important consideration in the implementation of such programmes. We aimed to describe changes in anxiety and HRQoL in a high-risk Canadian cohort undergoing LDCT lung cancer screening.

METHODS

2537 subjects who had 2% or greater lung cancer risk over 6 years using a risk prediction tool were recruited from eight centres across Canada in the Pan-Canadian Early Detection of Lung Cancer Study (2008-2010). We compared HRQoL and anxiety levels before and after screening of 1237 participants with LDCT (excluding a subset of 1300 participants who also underwent autofluorescence bronchoscopy screening), as well as after investigations performed because of a positive screening examination. The 12-item short-form Physical and Mental Component Scales (SF-12), EQ-5D-3L scores and State Trait Anxiety Inventory-State anxiety were used at each assessment.

RESULTS

Overall, there were no clinically significant differences in HRQoL outcomes between baseline and each of the survey time points following initial screening. No mean change in anxiety in the overall cohort was noted following baseline LDCT, but more participants had clinically significant increase in anxiety versus decrease after baseline screening (increase >minimal clinically important difference (MCID) (n=180) vs decrease >MCID (n=50), p<0.001). This finding persisted but to a lesser degree at the 12 month time point (increase >MCID (n=146) vs decrease >MCID (n=87), p<0.001).

CONCLUSIONS

CT screening for lung cancer has no major overall impact on HRQoL among participants, although a minority of participants (number-needed-to-harm=7 after baseline screening and 18 at 1 year) demonstrated clinically significant increased anxiety levels.

TRIALREGISTRATION NUMBER

NCT00751660; Results.

Lung cancer screening in a community setting: Characteristics, motivations, and attitudes of individuals being screened

We describe the characteristics of individuals being screened in community settings including factors influencing screening decisions and the level of information sought prior to screening. Individuals from two community-based radiology clinics (N = 27) were surveyed after screening. Screening efficacy and salience were the most important factors in screening decisions, whereas healthcare provider recommendations were rated not important. Half of participants reported no or little conversation about screening with their primary care provider, and 61.5 percent had not sought any information on screening. Individuals being screened in a community setting are unlikely to have sufficient information for an informed decision about screening.

Pilot study of a video intervention to reduce anxiety and promote preparedness for lung cancer screening

BACKGROUND

Lung cancer screening (LCS) with low dose computed tomography (LDCT) is associated with a 20% reduction in lung cancer mortality. Psychological burden is a potential harm associated with LCS, and is a major barrier to utilization. We aimed to examine the feasibility and acceptability of a video intervention designed to reduce anxiety and promote psychological preparedness of LCS.

PATIENTS AND METHODS

This is a two group, sequential enrollment pilot study of a video intervention that integrates information on screen criteria, procedures, benefits and harms, and follow-up plan. Participants were enrolled 1-2 weeks prior to baseline LDCT, and the intervention was administered in one in-person session on the day of LDCT. Outcomes were assessed at baseline (pre-screen), immediately after LDCT, and at 1 week, 3 months, and 7 months post-screen. Outcome measures included the SF-12 (HRQOL), STAI (anxiety), psychosocial consequences of LCS (COS-LC), risk perceptions for lung cancer, and a satisfaction tool. The student's t-test was used for exploratory evaluations on change from baseline scores both within and between groups.

RESULTS

Sixteen participants (8 intervention, 8 controls) enrolled and completed the study (61.5% retention). Participants in the control group reported a significantly increased sense of dejection at 1-month and 7-months post-screen as measured by the COS-LC (p = 0.01). Participants were highly satisfied with the intervention.

CONCLUSION

A video intervention that promoted psychological preparedness for LCS was feasible to implement as part of an LCS program and highly accepted by participants.

Pulmonary Nodules: A Small Problem for Many, Severe Distress for Some, and How to Communicate About It

Every year, millions of patients are diagnosed with pulmonary nodules, and as increasing numbers of people undergo lung cancer screening, even more patients will be found to have a nodule. The vast majority of patients cannot benefit from the detection of a pulmonary nodule because most are benign. Accordingly, it is important to develop strategies to minimize harm, in particular the distress of a "near-cancer" diagnosis. In other settings, communication strategies are critical mediators of patient-centered outcomes for those with cancer and those at-risk of cancer. We conducted multiple studies to characterize the experience of patients with the diagnosis and evaluation of incidental pulmonary nodules, measure patient-centered outcomes for patients with pulmonary nodules, and determine the association of patient-clinician communication practices with those outcomes. We learned that a substantial proportion of patients experience distress and inadequate communication about pulmonary nodules and their evaluation, and yet many clinicians are unaware of the degree to which some patients are affected by the finding of a pulmonary nodule. The present review provides a comprehensive summary of our results and offers suggestions for how clinicians can best provide high-quality communication for their patients.

Screening for early stage lung cancer and its correlation with lung nodule detection

Currently, the most effective way of reducing lung cancer mortality is early diagnosis of lung cancer. The National Lung Screening Trial has proved the efficacy of lung cancer screening using low-dose computed tomography to reduce lung cancer mortality. However, many questions remain surrounding lung cancer screening implementation, among which include how to select the optimal risk population, the personalized screening interval based different levels of risk, methods to improve diagnostic discrimination between malignant and benign disease in detected lung nodules, and the roles of biomolecular markers in stratifying risk and in guiding the management of indeterminate nodules. This review concentrates on the latest developments of lung cancer screening and provides an overview of the main unanswered questions on lung nodule detection.

Longitudinal Assessment of Distress among Veterans with Incidental Pulmonary Nodules

RATIONALE

Millions of patients are diagnosed with pulmonary nodules every year. Increased distress may be a common harm, but methods of mitigating this distress are unclear.

OBJECTIVES

We aimed to determine whether high-quality communication regarding the discovery of a pulmonary nodule is associated with a lower level of patient distress.

METHODS

We conducted a prospective, repeated-measures cohort study of 121 patients with newly reported, incidentally detected pulmonary nodules. The primary exposure was participant-reported quality of communication regarding the nodule. Secondary exposures included communication measures regarding participants' values, preferences, and decision making. The main outcome was nodule-related distress measured using the Impact of Event Scale. We used adjusted generalized estimating equations to measure the association between nodule communication quality and at least mild distress.

MEASUREMENTS AND MAIN RESULTS

Most participants (57%) reported at least mild distress at least once. While average distress scores decreased over time, one-fourth still had elevated distress after 2 years of surveillance for a nodule. The average calculated risk of cancer at baseline was 10% (SD, 13%), but 52.4% believed they had a greater than 30% risk of lung cancer at baseline, and this percentage remained fairly constant at all visits. High-quality nodule communication was associated with decreased odds of distress (adjusted odds ratio, 0.42; 95% confidence interval, 0.24-0.73). Lower-quality communication processes regarding participants' values and preferences were also associated with increased odds of distress, but concordance between the actual and preferred decision-making roles was not.

CONCLUSIONS

Among patients with incidentally discovered pulmonary nodules, distress is common and persistent for about 25%. Many participants substantially overestimate their risk of lung cancer. Incorporating patients' values and preferences into communication about a pulmonary nodule and its evaluation may mitigate distress.

Patient and Clinician Characteristics Associated with Adherence. A Cohort Study of Veterans with Incidental Pulmonary Nodules

RATIONALE

Many patients are diagnosed with small pulmonary nodules for which professional societies recommend subsequent imaging surveillance. Adherence to these guidelines involves many steps from both clinicians and patients but has not been well studied.

OBJECTIVES

In a health care setting with a nodule tracking system, we evaluated the association of communication processes and distress with patient and clinician adherence to recommended follow up and Fleischner Society guidelines, respectively.

METHODS

We conducted a prospective, longitudinally assessed, cohort study of patients with incidentally detected nodules who received care at one Veterans Affairs Medical Center. We measured patient-centered communication with the Consultation Care Measure and distress with the Impact of Event Scale. We abstracted data regarding participant adherence to clinician recommendations (defined as receiving the follow-up scan within 30 d of the recommended date) and clinician adherence to Fleischner guidelines (defined as planning the follow-up scan within 30 d of the recommended interval) from the electronic medical record. We measured associations of communication and distress with adherence using multivariable-adjusted generalized estimating equations.

MEASUREMENTS AND MAIN RESULTS

Among 138 veterans, 39% were nonadherent at least once during follow up. Clinicians were nonadherent to Fleischner guidelines for 27% of follow-up scans. High-quality communication (adjusted odds ratio, 3.65; P = 0.02) and distress (adjusted odds ratio, 0.38; P = 0.02) were associated with increased and decreased participant adherence, respectively. Neither was associated with clinician adherence.

CONCLUSIONS

Patients and clinicians often do not adhere to nodule follow-up recommendations. Interventions designed to improve communication quality and decrease distress may also improve patient adherence to nodule follow-up recommendations.

Lung cancer screening: latest developments and unanswered questions

The US National Lung Screening Trial showed that individuals randomly assigned to screening with low-dose CT scans had 20% lower lung cancer mortality than did those screened with conventional chest radiography. On the basis of a review of the literature and a modelling study, the US Preventive Services Task Force recommends annual screening for lung cancer for individuals aged 55-80 years who have a 30 pack-year smoking history and either currently smoke or quit smoking within the past 15 years. However, the balance between benefits and harms of lung cancer screening is still greatly debated. The large number of false-positive results and the potential for overdiagnosis are causes for concern. Some investigators suggest the ratio between benefits and harms could be improved through various means. Nevertheless, many questions remain with regard to the implementation of lung cancer screening. This paper highlights the latest developments in CT lung cancer screening and provides an overview of the main unanswered questions.

Demographic, clinical, dispositional, and social-environmental characteristics associated with psychological response to a false positive ovarian cancer screening test: a longitudinal study

Cancer screening can facilitate early detection that improves survival, but also can identify an abnormal finding that is not malignant and deemed benign. While such false positive (FP) results can impact a variety of psychological outcomes, little is known about demographic, clinical, dispositional, and social-environmental characteristics associated with psychological outcomes after a FP result. Women participating in an ovarian cancer (OC) screening program and experiencing a FP screening test result (n = 375) completed assessments at baseline and 4-months. Results indicated greater social constraint and less education were linked to greater OC-specific distress at both assessments. Short-term predictors included less optimism and no previous abnormal test, while longer-term predictors were fewer previous screens and the interaction between OC family history and monitoring coping style. Younger age, less education, less optimism, greater social constraint, and family history of OC were associated with greater perceptions of OC risk. Brief interventions prior to screening may minimize the negative impact of a false positive result and not interfere with compliant participation in screening programs.

Lung cancer screening

PURPOSE OF REVIEW

Lung cancer screening with low-dose chest computed tomography is now recommended for high-risk individuals by the US Preventive Services Task Force. This recommendation was informed by several randomized controlled trials, the largest of which, the National Lung Screening Trial, demonstrated a 20% relative reduction in lung cancer mortality with annual low-dose chest computed tomography compared with chest radiography.

RECENT FINDINGS

The benefit of lung cancer screening must be balanced against potential harms, including a high false-positive rate with consequent further evaluative studies and invasive testing. It is critical that harms be minimized as screening generalizes to the broad community. Informed decision making between providers and patients should include individualized risk assessment, a discussion of both potential benefit and harm, and tobacco treatment. Given the multiple components required for high quality, screening should ideally occur in the context of a multidisciplinary program.

SUMMARY

We are in the early days of lung cancer screening, still with much to learn. Ongoing studies are necessary to refine the definition of a positive screen and develop better methods of distinguishing between true positive and false-positive results. Novel approaches, including the development of multicomponent lung cancer biomarkers, will likely inform and improve our future screening practice.