Attitudes towards lung cancer screening in a population sample

Impact of risk perception and disease cognition on the willingness to participate in screening for lung cancer in a high-risk population

OBJECTIVE

Risk perception and disease cognition may influence the efficiency of lung cancer screening by affecting the participation rate. There is still some uncertainty regarding the association between risk perception and disease cognition and how they affect participation in lung cancer screening. Therefore, we explored the influence of risk perception and disease cognition on the willingness to participate in screening among people at high risk of lung cancer.

METHODS

Subjects with high-risk factors for lung cancer were recruited in Lu'an City, Anhui Province, China. Questionnaires were used to determine their demographic characteristics, risk perception, disease cognition, and willingness to engage in screening.

RESULTS

Of the 1955 subjects with high risk factors for lung cancer, 1136 (58.12%) were willing to participate in lung cancer screening. Univariable and multivariable analyses showed that disease cognition ( adj OR = 2.012, 95% CI: 1.528-2.649, P  = 0.000), cognitive risk ( adj OR = 7.661, 95% CI: 6.049-9.704, P  = 0.000), and affective risk ( adj OR = 5.964, 95% CI: 4.552-7.815, P  = 0.000) were significant factors in promoting screening participation. For those with moderate risk perception, improving disease cognition was a key approach to increase screening participation.

CONCLUSION

This study elucidated the relationship between various factors and lung cancer screening participation and proposed a feasible route for the screening implementation, providing a theoretical basis to further improve the participation rate and efficiency of lung cancer screening.

Knowledge, attitude, and practice of lung cancer screening and associated factors among high-risk population in Lanzhou, China: A cross-sectional study

This study aimed to assess the knowledge, attitude, and practice (KAP) of high-risk populations toward lung cancer screening in Lanzhou, China. Using convenience sampling, this cross-sectional study enrolled outpatients at high-risk for lung cancer at Lanzhou University Second Hospital between November 2022 and March 2023. An anonymous, self-administered online questionnaire was distributed to each participant via the Sojump website (https://www.wjx.cn/), comprising 40 items to collect demographic information and evaluate KAP toward lung cancer screening. The analyses were descriptive. A total of 577 participants (average age of 61.8 ± 7.1 years; 306 males) were included in the study. The participants' scores for KAP were 4.9 ± 2.2, 27.4 ± 3.0, and 7.0 ± 2.1, respectively. Participants with occupational exposure had significantly lower knowledge score (3.3 ± 2.4 vs 5.2 ± 2.1, P < .001), and practice score (5.6 ± 2.4 vs 7.3 ± 1.9, P < .001) than those without occupational exposure. Participants with smoking or passive smoking history had significantly higher attitude scores (27.6 ± 2.9 vs 25.8 ± 3.2, P < .001) and practice scores (7.1 ± 2.0 vs 6.5 ± 2.5, P = .014) than those without smoking history. A total of 360 (62.4%) participants endorsed the doctors' counseling on lung cancer screening, and 355 (61.5%) participants were willing to have screening for lung cancer as doctors advised. The study revealed that 390 (67.6%) participants identified low-dose computed tomography as the appropriate method for lung cancer screening, while 356 (61.7%) participants believed that X-rays were a reliable screening method for lung cancer. However, 365 (63.3%) participants thought that the treatment outcomes for early and late-diagnosed lung cancer were the same. Additionally, 416 (72.10%) participants believed that annual lung cancer CT scanning is unnecessary. On the other hand, 339 (58.8%) participants expressed concerns about exposure to radiation from CT scans, while 349 (60.5%) participants were worried about the cost of lung cancer screening. Only 142 (24.6%) participants reported having undergone annual lung cancer screening. The high-risk population had limited knowledge and insufficient attitude and practice toward lung cancer screening in Lanzhou, China.

Public Attitudes Towards Lung Cancer Screening in Saudi Arabia: A Cross-Sectional Study

Objective

Lung cancer is one of the leading causes of death worldwide, and it is ranked as the first cause of death in more than 100 countries around the world. The aim of this study was to explore the knowledge and attitude of the general population in Saudi Arabia toward lung cancer screening.

Methods

A cross-sectional study employing an online survey was conducted between November 2021 and February 2022 in Saudi Arabia. This study utilized a previously developed questionnaire instrument. Logistic regression was used to identify predictors of positive attitude toward lung cancer screening.

Results

A total of 473 participants were involved in this study. The majority of the study participants (74.6%) reported that they are current smokers. Almost 31.5% of the study participants reported that if lung cancer is detected early, the person's chance of surviving is poor to very poor. The majority of the study participants reported that they would be willing to do tests to diagnose lung cancer if you were invited by the Ministry of Health or their doctor. Males, participants aged (24-34 years), and current smokers were more likely to have positive attitude towards lung cancer screening (p ≤ 0.05). On the other hand, patients aged 46 years and over and those with higher education had less positive attitude towards lung cancer screening (p ≤ 0.05).

Conclusion

This is the first study to look into the general public's attitudes toward lung cancer screening in Saudi Arabia. According to our findings, the majority of people believe that early detection of lung cancer can lead to improved results and have a favourable attitude toward lung cancer screening if it is indicated. Thus, incorporating lung cancer screening into the local guidelines in at-risk population is highly recommended and considering the launch of nation-wide lung cancer screening program is advised.

Public Preferences for Determining Eligibility for Screening in Risk-Stratified Cancer Screening Programs: A Discrete Choice Experiment

BACKGROUND

Risk stratification has been proposed to improve the efficiency of population-level cancer screening. We aimed to describe and quantify the relative importance of different attributes of potential screening programs among the public, focusing on stratifying eligibility.

METHODS

We conducted a discrete choice experiment in which respondents selected between 2 hypothetical screening programs in a series of 9 questions. We presented the risk factors used to determine eligibility (age, sex, or lifestyle or genetic risk scores) and anticipated outcomes based on eligibility criteria with different sensitivity and specificity levels. We performed conditional logit regression models and used the results to estimate preferences for different approaches. We also analyzed free-text comments on respondents' views on the programs.

RESULTS

A total of 1,172 respondents completed the survey. Sensitivity was the most important attribute (7 and 11 times more important than specificity and risk factors, respectively). Eligibility criteria based on age and sex or genetics were preferred over age alone and lifestyle risk scores. Phenotypic and polygenic risk prediction models would be more acceptable than screening everyone aged 55 to 70 y if they had high discrimination (area under the receiver-operating characteristic curve ≥0.75 and 0.80, respectively).

LIMITATIONS

Although our sample was representative with respect to age, sex, and ethnicity, it may not be representative of the UK population regarding other important characteristics. Also, some respondents may have not understood all the information provided to inform decision making.

CONCLUSIONS

The public prioritized lives saved from cancer over reductions in numbers screened or experiencing unnecessary follow-up. Incorporating personal-level risk factors into screening eligibility criteria is acceptable to the public if it increases sensitivity; therefore, maximizing sensitivity in model development and communication could increase uptake.

HIGHLIGHTS

The public prioritized lives saved when considering changing from age-based eligibility criteria to risk-stratified cancer screening over reductions in numbers of people being screened or experiencing unnecessary follow-up.The risk stratification strategy used to do this was the least important component, although age plus sex or genetics were relatively preferable to using age alone and lifestyle risk scores.Communication strategies that emphasize improvements in the numbers of cancers detected or not missed across the population are more likely to be salient than reductions in unnecessary investigations or follow-up among some groups.Future research should focus on developing implementation strategies that maximize gains in sensitivity within the context of resource constraints and how to present attributes relating to specificity to facilitate understanding and informed decision making.

Lung cancer screening in rural primary care practices in Colorado: time for a more team-based approach?

BACKGROUND

Despite lung cancer being a leading cause of death in the United States and lung cancer screening (LCS) being a recommended service, many patients eligible for screening do not receive it. Research is needed to understand the challenges with implementing LCS in different settings. This study investigated multiple practice members and patient perspectives impacting rural primary care practices related to LCS uptake by eligible patients.

METHODS

This qualitative study involved primary care practice members in multiple roles (clinicians n = 9, clinical staff n = 12 and administrators n = 5) and their patients (n = 19) from 9 practices including federally qualified and rural health centers (n = 3), health system owned (n = 4) and private practices (n = 2). Interviews were conducted regarding the importance of and ability to complete the steps that may result in a patient receiving LCS. Data were analyzed using a thematic analysis with immersion crystallization then organized using the RE-AIM implementation science framework to illuminate and organize implementation issues.

RESULTS

Although all groups endorsed the importance of LCS, all also struggled with implementation challenges. Since assessing smoking history is part of the process to identify eligibility for LCS, we asked about these processes. We found that smoking assessment and assistance (including referral to services) were routine in the practices, but other steps in the LCS portion of determining eligibility and offering LCS were not. Lack of knowledge about screening and coverage, patient stigma, and resistance and practical considerations such as distance to LCS testing facilities complicated completion of LCS compared to screening for other types of cancer.

CONCLUSIONS

Limited uptake of LCS results from a range of multiple interacting factors that cumulatively affect consistency and quality of implementation at the practice level. Future research should consider team-based approaches to conduct of LCS eligibility and shared decision making.

Protocol for a randomized controlled trial of the Enhanced Smoking Cessation Approach to Promote Empowerment (ESCAPE) digitalized intervention to promote lung health in high-risk individuals who smoke

Low dose computed tomography (LDCT) is an effective screening test to decrease lung cancer deaths. Lung cancer screening may be a teachable moment helping people who smoke to quit, which may result in increased benefit of screening. Innovative strategies are needed to engage high-risk individuals in learning about LDCT screening. More precise methods such as polygenic risk scores quantify genetic predisposition to tobacco use, and optimize lung health interventions. We present the ESCAPE (Enhanced Smoking Cessation Approach to Promote Empowerment) protocol. This study will test a smoking cessation intervention using personal stories and a lung cancer screening decision-aide compared to standard care (brief advice, referral to a quit line, and a lung cancer screening decision-aide), examine the relationship between a polygenic risk score and smoking abstinence, and describe perceptions about integration of genomic information into smoking cessation treatment. A randomized controlled trial followed by a sequential explanatory mixed methods approach will compare the efficacy of the interventions. Interviews will add insight into the use of genomic information and risk perceptions to tailor smoking cessation treatment. Two-hundred and fifty individuals will be recruited from primary care, community-based organizations, mailing lists and through social media. Data will be collected at baseline, 1, 3 and 6-months. The primary outcomes are 7-day point prevalence smoking abstinence and stage of lung cancer screening at 6-months. The results from this study will provide information to refine the ESCAPE intervention and facilitate integration of precision health into future lung health interventions. Clinical trial registration number: NCT0469129T.

A Cross-Sectional Study on the Acceptability of Implementing a Lung Cancer Screening Program in Belgium

Lung cancer is the most common and deadliest cancer in the world, and its incidence is expected to grow. Nonetheless, this growth can be contained through smoking cessation programs and effective lung cancer screening programs. In 2018, Belgium had the seventh highest incidence of lung cancer in the world, with lung cancer incidence accounting for 11.8% of all cancers diagnosed and 23.8% of all cancer-related deaths that same year. The aims of this study were to determine the overall acceptability of a lung cancer screening program in the Flemish population and to determine the main factors that would influence the overall acceptability of such a program. A questionnaire-based cross-sectional study was performed in the Flemish population and distributed online and on paper. The results are presented with the variables of interest and the main outcome, i.e., the acceptability of participating in such a program if implemented. Odds ratios were used to compare acceptability between subgroups. A multivariate regression model was used to determine the key factors that would have the largest impact on the level of acceptability and, thus, on the possible efficiency of such a program. This study estimated that acceptability of participating in a lung cancer screening program was 92%. Irrespective of the smoking status, levels of acceptability were higher than 89%. The key factors which could significantly influence the acceptability of a lung cancer screening program were individuals with low education, low protective factor knowledge and total knowledge, and lung cancer screening reimbursement, which were significantly associated with acceptability (0.01, 0.001, 0.01, and 0.05 respectively). Low protective factor knowledge decreased the log odds of acceptability 3.08-fold. In conclusion, the acceptability of implementing a lung cancer screening program in Flanders seems to be extremely high and would be well received by all. When implementing such a program, policymakers should aim for it to be reimbursed, campaigns should be gender-specific, focused on those with lower educational and socioeconomic status, and there should be investment in increasing total knowledge about lung cancer and knowledge about protective factors.

Understanding patient barriers and facilitators to uptake of lung screening using low dose computed tomography: a mixed methods scoping review of the current literature

BACKGROUND

Targeted lung cancer screening is effective in reducing mortality by upwards of twenty percent. However, screening is not universally available and uptake is variable and socially patterned. Understanding screening behaviour is integral to designing a service that serves its population and promotes equitable uptake. We sought to review the literature to identify barriers and facilitators to screening to inform the development of a pilot lung screening study in Scotland.

METHODS

We used Arksey and O'Malley's scoping review methodology and PRISMA-ScR framework to identify relevant literature to meet the study aims. Qualitative, quantitative and mixed methods primary studies published between January 2000 and May 2021 were identified and reviewed by two reviewers for inclusion, using a list of search terms developed by the study team and adapted for chosen databases.

RESULTS

Twenty-one articles met the final inclusion criteria. Articles were published between 2003 and 2021 and came from high income countries. Following data extraction and synthesis, findings were organised into four categories: Awareness of lung screening, Enthusiasm for lung screening, Barriers to lung screening, and Facilitators or ways of promoting uptake of lung screening. Awareness of lung screening was low while enthusiasm was high. Barriers to screening included fear of a cancer diagnosis, low perceived risk of lung cancer as well as practical barriers of cost, travel and time off work. Being health conscious, provider endorsement and seeking reassurance were all identified as facilitators of screening participation.

CONCLUSIONS

Understanding patient reported barriers and facilitators to lung screening can help inform the implementation of future lung screening pilots and national lung screening programmes.

Early Diagnosis and Lung Cancer Screening

Lung cancer remains the most significant cause of cancer death, accounting for about 20% of all cancer-related mortality. A significant reason for this is delayed diagnosis, either due to lack of symptoms in early-stage disease or presentation with non-specific symptoms common with a broad range of alternative diagnoses. More is needed in terms of increasing public awareness, providing adequate healthcare professional education and implementing clinical pathways that improve the earlier diagnosis of symptomatic lung cancer. Low-dose computed tomography screening of high-risk, asymptomatic populations has been shown to reduce lung cancer mortality, with focus now shifting towards how best to implement lung cancer screening on a wider scale in a safe, efficient and cost-effective manner. For maximum benefit, efforts must be made to optimise uptake, especially among high-risk populations with significant socioeconomic deprivation, as well as successfully incorporate tobacco-dependency treatment. Quality assured programme management will be critical to minimising screening-related harms and adequately managing incidental findings. By undertaking the above, there can be optimism that lung cancer outcomes can be improved significantly in the near future.

Motivation is not enough: A qualitative study of lung cancer screening uptake in Australia to inform future implementation

Introduction

Participation in lung cancer screening (LCS) trials and real-world programs is low, with many people at high-risk for lung cancer opting out of baseline screening after registering interest. We aimed to identify the potential drivers of participation in LCS in the Australian setting, to inform future implementation.

Methods

Semi-structured telephone interviews were conducted with individuals at high-risk of lung cancer who were eligible for screening and who had either participated (‘screeners’) or declined to participate (‘decliners’) in the International Lung Screening Trial from two Australian sites. Interview guide development was informed by the Precaution Adoption Process Model. Interviews were audio-recorded, transcribed and analysed using the COM-B model of behaviour to explore capability, opportunity and motivation related to screening behaviour.

Results

Thirty-nine participants were interviewed (25 screeners; 14 decliners). Motivation to participate in screening was high in both groups driven by the lived experience of lung cancer and a belief that screening is valuable, however decliners unlike their screening counterparts reported low self-efficacy. Decliners in our study reported challenges in capability including ability to attend and in knowledge and understanding. Decliners also reported challenges related to physical and social opportunity, in particular location as a barrier and lack of family support to attend screening.

Conclusion

Our findings suggest that motivation alone may not be sufficient to change behaviour related to screening participation, unless capability and opportunity are also considered. Focusing strategies on barriers related to capability and opportunity such as online/telephone support, mobile screening programs and financial assistance for screeners may better enhance screening participation. Providing funding for clinicians to support individuals in decision-making and belief in self-efficacy may foster motivation. Targeting interventions that connect eligible individuals with the LCS program will be crucial for successful implementation.

Attitudes towards the integration of smoking cessation into lung cancer screening in the United Kingdom: A qualitative study of individuals eligible to attend

INTRODUCTION

There is limited research exploring how smoking cessation treatment should be implemented into lung cancer screening in the United Kingdom. This study aimed to understand attitudes and preferences regarding the integration of smoking cessation support within lung cancer screening from the perspective of those eligible.

METHODS

Thirty-one lung cancer screening eligible individuals aged 55-80 years with current or former smoking histories were recruited using community outreach and social media. Two focus groups (three participants each) and 25 individual telephone interviews were conducted. Data were analysed using the framework approach to thematic analysis.

RESULTS

Three themes were generated: (1) bringing lung cancer closer to home, where screening was viewed as providing an opportunity to motivate smoking cessation, depending on perceived personal risk and screening result; (2) a sensitive approach to cessation with the uptake of cessation support considered to be largely dependent on screening practitioners' communication style and expectations of stigma and (3) creating an equitable service that focuses on ease of access as a key determinant of uptake, where integrating cessation within the screening appointment may sustain increased quit motivation and prevent loss to follow-up.

CONCLUSIONS

The integration of smoking cessation into lung cancer screening was viewed positively by those eligible to attend. Screening appointments providing personalized lung health information may increase cessation motivation. Services should proactively support participants with possible fatalistic views regarding risk and decreased cessation motivation upon receiving a good screening result. To increase engagement in cessation, services need to be person-centred.

PATIENT OR PUBLIC CONTRIBUTION

This study has included patient and public involvement throughout, including input regarding study design, research materials, recruitment strategies and research summaries.

Acceptability of a standalone written leaflet for the National Health Service for England Targeted Lung Health Check Programme: A concurrent, think-aloud study

BACKGROUND

Many countries are introducing low-dose computed tomography screening programmes for people at high risk of lung cancer. Effective communication strategies that convey risks and benefits, including unfamiliar concepts and outcome probabilities based on population risk, are critical to achieving informed choice and mitigating inequalities in uptake.

METHODS

This study investigated the acceptability of an aspect of NHS England's communication strategy in the form of a leaflet that was used to invite and inform eligible adults about the Targeted Lung Health Check (TLHC) programme. Acceptability was assessed in terms of how individuals engaged with, comprehended and responded to the leaflet. Semi-structured, 'think aloud' interviews were conducted remotely with 40 UK screening-naïve current and former smokers (aged 55-73). The verbatim transcripts were analysed thematically using a coding framework based on the Dual Process Theory of cognition.

RESULTS

The leaflet helped participants understand the principles and procedures of screening and fostered cautiously favourable intentions. Three themes captured the main results of the data analysis: (1) Response-participants experienced anxiety about screening results and further investigations, but the involvement of specialist healthcare professionals was reassuring; (2) Engagement-participants were rapidly drawn to information about lung cancer prevalence, and benefits of screening, but deliberated slowly about early diagnosis, risks of screening and less familiar symptoms of lung cancer; (3) Comprehension-participants understood the main principles of the TLHC programme, but some were confused by its rationale and eligibility criteria. Radiation risks, abnormal screening results and numerical probabilities of screening outcomes were hard to understand.

CONCLUSION

The TLHC information leaflet appeared to be acceptable to the target population. There is scope to improve aspects of comprehension and engagement in ways that would support informed choice as a distributed process in lung cancer screening.

PATIENT OR PUBLIC CONTRIBUTION

The insight and perspectives of patient representatives directly informed and improved the design and conduct of this study.

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.

Navigating new organisation forms: a qualitative study of primary care networks

BACKGROUND

NHS England (NHSE) instigated primary care networks (PCNs) as a collaboration of general practices working together at scale to improve population health in the local community.

AIM

To capture GP PCN leaders' perceptions of the opportunities and pitfalls of PCNs, as well as points of learning, during their inception and development, in order to guide the future development of PCN form and function.

DESIGN & SETTING

A qualitative study in UK primary care.

METHOD

Nine PCN GP leaders were interviewed in depth to gather their views and experiences of PCNs. In addition, 31 free-text survey responses pertaining to how participants perceived the purpose of PCNs were collated.

RESULTS

Four key themes were identified: defining purpose and managing ambiguity; bureaucracy versus local autonomy; relational working; and facilitative leadership. The need for purpose setting to remain adaptive was seen as crucial in avoiding the constraints of too rigid a structure in order to retain local ownership, while remaining focused around meeting complex population needs and reducing variation. Participants reported navigating their way through striking a balance between the 'top-down' mandate and recognising local need. Of importance to the success of PCNs was the necessity of effective relational working and facilitative leadership.

CONCLUSION

While the desire to be proactive and collaborative was emphasised by the PCN leaders, the importance of distributed leadership and time given to building trust and effective working relationships within new organisational forms cannot be underestimated.

Increasing uptake to a lung cancer screening programme: building with communities through co-design

Background

Lung cancer is the most common cause of cancer death in the UK. Low-dose computed tomography (LDCT) screening has been shown to identify lung cancer at an earlier stage. A risk stratified approach to LDCT referral is recommended. Those at higher risk of developing lung cancer (aged 55 + , smoker, deprived area) are least likely to participate in such a programme and, therefore, it is necessary to understand the barriers they face and to develop pathways for implementation in order to increase uptake.

Methods

A 2-phased co-design process was employed to identify ways to further increase opportunity for uptake of a lung cancer screening programme, using a risk indicator for LDCT referral, amongst people who could benefit most. Participants were members of the public at high risk from developing lung cancer and professionals who may provide or signpost to a future lung cancer screening programme. Phase 1: interviews and focus groups, considering barriers, facilitators and pathways for provision. Phase 2: interactive offline booklet and online surveys with professionals. Qualitative data was analysed thematically, while descriptive statistics were conducted for quantitative data.

Results

In total, ten barriers and eight facilitators to uptake of a lung cancer screening programme using a biomarker blood test for LDCT referral were identified. An additional four barriers and four facilitators to provision of such a programme were identified. These covered wider themes of acceptability, awareness, reminders and endorsement, convenience and accessibility. Various pathway options were evidenced, with choice being a key facilitator for uptake. There was a preference (19/23) for the provision of home test kits but 7 of the 19 would like an option for assistance, e.g. nurse, pharmacist or friend. TV was the preferred means of communicating about the programme and fear was the most dominant barrier perceived by members of the public.

Conclusion

Co-design has provided a fuller understanding of the barriers, facilitators and pathways for the provision of a future lung cancer screening programme, with a focus on the potential of biomarker blood tests for the identification of at-risk individuals. It has also identified possible solutions and future developments to enhance uptake, e.g. Embedding the service in communities, Effective communication, Overcoming barriers with options. Continuing the process to develop these solutions in a collaborative way helps to encourage the personalised approach to delivery that is likely to improve uptake amongst groups that could benefit most.

Development and psychometric testing of the self-regulatory questionnaire for lung cancer screening (SRQ-LCS)

BACKGROUND

Research implicates psychological factors in low uptake of lung cancer screening. We developed and psychometrically tested a standardised measure of these psychological determinants in preparation for a prospective, longitudinal cohort study of screening uptake.

METHODS

Leventhal's Common-Sense Model of Self-Regulation of Health and Illness provided the theoretical framework to generate the initial item pool. Items were refined during expert review and cognitive interviews which tested for face validity, redundancy, acceptability and comprehensibility. An online survey piloted the refined pool with 1500 current and former (quit ≤ 15 years) smokers aged 55-80. The response distributions, internal reliability and factor structure determined the final retained constructs. Regression analyses examined these constructs' associations with screening intention, smoking status and demographics.

RESULTS

The final measure included seven factor-derived subscales (consequences, personal control, treatment control, illness coherence, emotional representation, behavioural response and appraisal, risk perception) with Cronbach's alphas ranging from 0.59 to 0.91 and four single-item questions (response efficacy for smoking cessation, treatment intention, perceived stigma and lung cancer survival). Most constructs were associated with smoking status and screening intention (p's < .05).

CONCLUSIONS

The Self-Regulatory Questionnaire for Lung Cancer Screening (SRQ-LCS) is an acceptable, reliable and valid measure for investigating the psychological determinants of screening uptake.

Colorectal Cancer Survivors' Receptivity toward Genomic Testing and Targeted Use of Non-Steroidal Anti-Inflammatory Drugs to Prevent Cancer Recurrence

Genomic testing and targeted use of non-steroidal anti-inflammatory drugs (NSAIDs) may mitigate cancer recurrence risks. This study examines colorectal cancer (CRC) survivors' interest and receptivity to these strategies. Patients diagnosed with stage I-III CRC in 2004-2012 were recruited through the New Mexico Cancer Registry to complete a cancer survivorship experiences survey. We assessed interest in genomic testing, daily aspirin (ASA) and NSAID use, and receptivity to future daily ASA/NSAIDs. Descriptive statistics and multivariable logistic regression models estimated factors associated with genomic testing interest. Receptivity to future ASA/NSAIDs use was estimated for non-users of ASA/NSAIDs. Among CRC survivors (n = 273), 83% endorsed interest in genomic testing, 25% were ASA users and 47% ASA/NSAIDs users. In our final model, genomic testing interest was associated with being uncoupled [OR = 4.11; 95% CI = 1.49-11.35], low income [OR = 0.35, 95% CI: 0.14-0.88], smoking history [OR = 0.35, 95% CI: 0.14-0.90], low [OR: 0.33, 95% CI: 0.07-1.43] and moderate [OR: 0.26, 95% CI: 0.11-0.61] health literacy, and personal CRC risk worry [OR: 2.86, 95% CI: 1.63-5.02, p = 0.0002]. In our final model, ASA use was associated with age [OR: 1.05, 95% CI: 1.01-1.10] and cardiovascular disease history [OR: 2.42, 95% CI: 1.23-4.73, p = 0.010]. Among non-users ASA/NSAIDs, 83% reported receptivity to ASA/NSAIDs to reduce cancer risks, and no significant correlates were identified. The majority of survivors' expressed genomic testing interest and endorsed receptivity toward ASA/NSAIDs use for cancer risk management. Further research to optimize ASA/NSAIDs use guided by genomic testing is warranted.

Psychological Targets for Lung Cancer Screening Uptake: A Prospective Longitudinal Cohort Study

INTRODUCTION

Low uptake of low-dose computed tomography lung cancer screening by high-risk groups compromises its effectiveness and equity as a population-level early detection strategy. Numerous psychological factors are implicated qualitatively or retrospectively, but prospective data are needed to validate their associations with uptake behavior and specify psychological targets for intervention.

METHODS

This is a prospective, longitudinal cohort study evaluating psychological correlates of lung cancer screening uptake. Ever-smokers (aged 55-77 y) were invited to a lung health check, at which low-dose computed tomography screening was offered through the SUMMIT Study-a multicenter screening implementation trial. One week after their screening invitation, 44,000 invitees were mailed the self-regulatory questionnaire for lung cancer screening. Regression analyses evaluated the constructs' associations with uptake (telephoning for an appointment) and sociodemographic characteristics.

RESULTS

Higher odds of uptake were associated with both positive and negative perceptions. Positive perceptions included lung cancer controllability, benefits of early diagnosis, improved survival when lung cancer is detected early, willingness to be treated, and believing smoking cessation is effective in reducing risk. Negative perceptions included a higher lung cancer risk perception, negative beliefs about the consequences of lung cancer, perceiving lung cancer as stigmatized, and a negative emotional response. Although current smokers held the highest risk perceptions, they also reported negative perceptions that could undermine how they behave in response to their risk.

CONCLUSIONS

Interventions to improve uptake should focus on changing perceptions that affect how an individual reacts when they believe their risk of lung cancer is high.

Use of Diagnostic CT and Patient Retention in a Lung Cancer Screening Program

PURPOSE

The aims of this study were to assess the rate of subsequent diagnostic chest CT examinations in a lung cancer screening (LCS) program and examine the effect on retention of patients in the program.

METHODS

Patients who underwent LCS CT between June 2011 and August 2018 were included. The occurrence of patients' being subsequently imaged with diagnostic CT versus LCS CT and the effect this had on patients' returning for LCS CT (patient retention) were evaluated. Multivariable logistic regression was used to evaluate variables associated with undergoing diagnostic CT and risk factors associated with loss of patient retention.

RESULTS

Of the 5,912 patients who underwent LCS CT, 2,756 underwent subsequent diagnostic or LCS chest CT. Increasing Lung-RADS® score was more likely to lead to subsequent diagnostic chest CT (P < .0001). A total of 1,240 patients underwent at least three chest CT examinations in the time interval. For the 711 patients whose subsequent CT studies were for LCS, 585 (82%) were retained, whereas of the 529 patients who underwent subsequent diagnostic CT, only 208 (39%) were retained (P < .0001). For the 197 subsequent diagnostic CT examinations performed for pulmonary nodule or screening indications, 81 patients (41%) returned for LCS CT, compared with 498 of 612 patients (81%) who underwent subsequent LCS CT (P < .0001). In multivariable analysis, subsequent diagnostic chest CT and increasing Lung-RADS score were associated with loss of retention.

CONCLUSIONS

A higher Lung-RADS score is a risk factor for subsequent diagnostic chest CT, and this is an independent risk factor for loss from the LCS program.

Lung cancer screening: targeting the hard to reach-a review

Lung cancer (LC) is the leading cause of cancer death in the USA for both men and women, and also worldwide, it is the commonest cause of cancer death. The five-year survival rate for LC depends on the stage at which it is diagnosed. It is over 50% for cases detected in a localized stage but when the disease has spread to other organs, the five-year survival rate is only 5%. Unfortunately, only 16% of LC cases are diagnosed at an early stage. In 2013, the US Preventive Services Task Force (USPSTF) recommended annual LC screening with low dose chest computed tomography (CT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years, based on the evidence from the National Lung Screening Trial (NLST) in the USA. When it comes to recruiting the target group for lung cancer screening (LCS), there are several barriers to overcome, such as whom exactly to include, where to find the target group, how to convince the target to participate or how to attract participants from all socioeconomic groups. The aim of this review is to find out what is already known about how the target group for LCS can be contacted and how participation can be improved, since uptake is a key issue in every (cancer) screening program. A review of the literature was conducted using 'lung cancer screening and participation and uptake' as search string. We searched in Web of Science and PubMed for reviews, systematic reviews and articles, published between 2015 and 2020. Compared to the target groups for screening in the long-running cancer screening programs of breast, cervical and colorectal cancer, there are several additional obstacles regarding defining, locating and recruiting of the target group for LCS. Shared decision-making is crucial when we want to reach the hard to reach for LCS and it should be improved, by educating primary care practitioners about LCS guidelines and providing them with the necessary tools, such as decision aids, to facilitate their job in this respect. Moreover, the information materials should be more tailored to specific groups who participate least.

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.

Risk Perception Among a Lung Cancer Screening Population

BACKGROUND

A successful lung cancer screening program requires a patient cohort at sufficient risk of developing cancer who are willing to participate. Among other factors, a patient's lung cancer risk perception may inform their attitudes toward screening and smoking cessation programs.

RESEARCH QUESTION

This study analyzed data from the Pan-Canadian Early Detection of Lung Cancer (PanCan) Study to address the following questions: Which factors are associated with the perception of lung cancer risk? Is there an association between risk perception for lung cancer and actual calculated risk? Is there an association between risk perception for lung cancer and the intent to quit smoking? Are there potential targets for lung cancer screening awareness?

STUDY DESIGN AND METHODS

The PanCan study recruited current or former smokers aged 50 to 75 years who had at least a 2% risk of developing lung cancer over 6 years to undergo low-dose screening CT. Risk perception and worry about lung cancer were captured on a baseline questionnaire. Cumulative logistic regression analysis was used to assess the relationship between baseline risk variables and both lung cancer risk perception and worry.

RESULTS

Among the 2,514 individuals analyzed, a higher perceived risk of lung cancer was positively associated with calculated risk (P = .032). Younger age, being a former smoker, respiratory symptoms, lower FEV₁, COPD, and a family history of lung cancer were associated with higher perceived risk. Conversely, a consistent relationship between calculated risk and worry was not identified. There was a positive association between risk perception and lung cancer worry and reported intent to quit smoking.

INTERPRETATION

Individuals' lung cancer risk perception correlated positively with calculated risk in a screening population. Promotion of screening programs may benefit from focusing on factors associated with higher risk perception; conversely, harnessing worry seemingly holds less value.

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.

Participation in lung cancer screening

Although there is now strong evidence for the efficacy of low-radiation dose computed tomography in reducing lung cancer mortality, the challenge is to establish screening programmes that have the maximum impact on the disease. In screening programmes, participation rates are a major determinant of the success of the programme. Informed uptake, participation, and adherence (to successive screening rounds) determine the overall impact of the intervention by ensuring the maximum number of people at risk of the disease are screened regularly and therefore have the most chance of benefiting. Existing cancer screening programmes have taught us a great deal about methods that improve participation. Although evidence is emerging for the efficacy of some of those methods in lung cancer screening, there is still much work to do in the specific demographic that is most at risk of lung cancer. This demographic, characterised by higher levels of socioeconomic deprivation, may be less willing to engage with healthcare interventions and present a particular challenge in the process of ensuring informed choice. In this article we review the evidence for improving participation and describe the challenges that need to be addressed to ensure the successful implementation of CT screening programmes.

Public attitudes towards screening for kidney cancer: an online survey

BACKGROUND

Kidney cancer is often asymptomatic, leading to proposals for a screening programme. The views of the public towards introducing a new screening programme for kidney cancer are unknown. The aim of this study was to explore attitudes towards kidney cancer screening and factors influencing intention to attend a future screening programme.

METHODS

We conducted an online population-based survey of 1021 adults aged 45-77 years. The main outcome measure was intention to attend four possible screening tests (urine, blood, ultrasound scan, low-dose CT) as well as extended low-dose CT scans within lung cancer screening programmes. We used multivariable regression to examine the association between intention and each screening test.

RESULTS

Most participants stated that they would be 'very likely' or 'likely' to undergo each of the screening tests [urine test: n = 961 (94.1%); blood test: n = 922 (90.3%); ultrasound: n = 914 (89.5%); low-dose CT: n = 804 (78.8%); lung CT: n = 962 (95.2%)]. Greater intention to attend was associated with higher general cancer worry and less perceived burden/inconvenience about the screening tests. Less worry about the screening test was also associated with higher intention to attend, but only in those with low general cancer worry (cancer worry scale ≤ 5). Compared with intention to take up screening with a urine test, participants were half as likely to report that they intended to undergo blood [OR 0.56 (0.43-0.73)] or ultrasound [OR 0.50 (0.38-0.67)] testing, and half as likely again to report that they intended to take part in a screening programme featuring a low dose CT scan for kidney cancer screening alone [OR 0.19 (0.14-0.27)].

CONCLUSION

Participants in this study expressed high levels of intention to accept an invitation to screening for kidney cancer, both within a kidney cancer specific screening programme and in conjunction with lung cancer screening. The choice of screening test is likely to influence uptake. Together these findings support on-going research into kidney cancer screening tests and the potential for combining kidney cancer screening with existing or new screening programmes.

Evaluating Knowledge, Attitudes, and Beliefs About Lung Cancer Screening Using Crowdsourcing

BACKGROUND

Lung cancer screening, despite its proven mortality benefit, remains vastly underutilized. Previous studies examined knowledge, attitudes, and beliefs to better understand the reasons underlying the low screening rates. These investigations may have limited generalizability because of traditional participant recruitment strategies and examining only subpopulations eligible for screening. The current study used crowdsourcing to recruit a broader population to assess these factors in a potentially more general population.

METHODS

A 31-item survey was developed to assess knowledge, attitudes, and beliefs regarding screening among individuals considered high risk for lung cancer by the United States Preventive Services Task Force. Amazon's crowdsourcing platform (Mechanical Turk) was used to recruit subjects.

RESULTS

Among the 240 respondents who qualified for the study, 106 (44%) reported knowledge of a screening test for lung cancer. However, only 36 (35%) correctly identified low-dose CT scanning as the appropriate test. A total of 222 respondents (93%) reported believing that early detection of lung cancer has the potential to save lives, and 165 (69%) were willing to undergo lung cancer screening if it was recommended by their physician. Multivariable regression analysis found that knowledge of lung cancer screening, smoking status, chronic pulmonary disease, and belief in the efficacy of early detection of lung cancer were associated with willingness to screen.

CONCLUSIONS

Although a minority of individuals at high risk for lung cancer are aware of screening, the majority believe that early detection saves lives and would pursue screening if recommended by their primary care physician. Health systems may increase screening rates by improving patient and physician awareness of lung cancer screening.

Lung Screen Uptake Trial (LSUT): Randomized Controlled Clinical Trial Testing Targeted Invitation Materials

Rationale: Low uptake of low-dose computed tomography (LDCT) lung cancer screening, particularly by current smokers of a low socioeconomic position, compromises effectiveness and equity.Objectives: To compare the effect of a targeted, low-burden, and stepped invitation strategy versus control on uptake of hospital-based Lung Health Check appointments offering LDCT screening.Methods: In a two-arm, blinded, between-subjects, randomized controlled trial, 2,012 participants were selected from 16 primary care practices using these criteria: 1) aged 60 to 75 years, 2) recorded as a current smoker within the last 7 years, and 3) no prespecified exclusion criteria contraindicating LDCT screening. Both groups received a stepped sequence of preinvitation, invitation, and reminder letters from their primary care practitioner offering prescheduled appointments. The key manipulation was the accompanying leaflet. The intervention group's leaflet targeted psychological barriers and provided low-burden information, mimicking the concept of the U.K. Ministry of Transport's annual vehicle test ("M.O.T. For Your Lungs").Measurements and Main Results: Uptake was 52.6%, with no difference between intervention (52.3%) and control (52.9%) groups in unadjusted (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.82-1.16) or adjusted (OR, 0.98; 95% CI, 0.82-1.17) analyses. Current smokers were less likely to attend (adjusted OR, 0.70; 95% CI, 0.56-0.86) than former smokers. Socioeconomic deprivation was significantly associated with lower uptake for the control group only (P < 0.01).Conclusions: The intervention did not improve uptake. Regardless of trial arm, uptake was considerably higher than previous clinical and real-world studies, particularly given that the samples were predominantly lower socioeconomic position smokers. Strategies common to both groups, including a Lung Health Check approach, could represent a minimum standard.Clinical trial registered with www.clinicaltrials.gov (NCT02558101) and registered prospectively with the International Standard Registered Clinical/Social Study (N21774741).

Trial marketing in the Pan-Canadian Early Detection of Lung Cancer Study

BACKGROUND

Recruitment to clinical trials is suboptimal, increasing costs, and delaying the potential implementation of clinical advances. Among other barriers, the lack of marketing experience among trialists may limit recruitment. In this observational study, in the context of the Pan-Canadian Early Detection of Lung Cancer Trial, we assessed the value of a motivational survey of study participants in planning a tailored advertising campaign and analysed the value of individual components of advertising in generating telephone calls to the study and recruited subjects.

METHODS

The Pan-Canadian Early Detection of Lung Cancer Trial was a single arm study assessing risk modelling for lung cancer screening by low-dose computed tomography scan and autofluorescence bronchoscopy. Individuals were recruited to eight sites across Canada without a central marketing plan. On contact with the study, individuals reported how they heard about the study according to a predefined list. One site, the Juravinski Cancer Centre, worked with a marketing expert to develop a survey to assess participant motivations, source of study awareness, and personal habits. The survey was used to develop a media campaign for recruitment. Media events were collected from all sites. The primary analysis assessed the number of telephone contacts and recruited subjects associated with various media factors. Individual print media characteristics were assessed for their effect on recruitment.

RESULTS

At all sites, 7059 individuals contacted the study, and 2537 were eligible and recruited. Among 52 individuals completing the Juravinski Cancer Centre survey, motivation included concern for personal risk of lung cancer (71%), followed by desire to contribute to a cure (67%), followed by personal knowledge of a person with lung cancer (50%). Most reported hearing of the study from the newspaper (58%) despite no print ad yet being distributed. With survey input, a newsprint campaign was executed. The number of media events varied by site (median: 13, range: 3-28). Among all recruits, 56.4% reported referral by newspaper followed by family/friend (14%). Telephone contacts and recruited subjects per event varied significantly by site, while unpaid media events appeared superior to paid events. Print media characteristics associated with increased telephone contacts and recruitment included use of a rational appeal (vs a mixed rational-emotional), less use of white space, and larger headline font.

CONCLUSION

A survey of trial candidates provides useful information regarding personal motivation, media use, and lifestyle. Unpaid media events appear superior in generating recruitment, while print media may be superior to radio and television in selecting eligible recruits. The utility of individual print media characteristics appears to differ from the commercial advertising literature. Further research on marketing in clinical trials is encouraged to improve recruitment ( ClinicalTrials.gov registration: NCT00751660, https://clinicaltrials.gov/ct2/show/NCT00751660 ).

Evaluation of a health service adopting proactive approach to reduce high risk of lung cancer: The Liverpool Healthy Lung Programme

OBJECTIVES

This Liverpool Healthy Lung Programme is a response to high rates of lung cancer and respiratory diseases locally and aims to diagnose lung cancer at an earlier stage by proactive approach to those at high risk of lung cancer. The objective of this study is to evaluate the programme in terms of its likely effect on mortality from lung cancer and its delivery to deprived populations.

METHODS

Persons aged 58-75 years, with a history of smoking or a diagnosis of chronic obstructive pulmonary disease (COPD)² according to general practice records were invited for lung health check in a community health hub setting. A detailed risk assessment and spirometry were performed in eligible patients. Those with a 5% or greater five-year risk of lung cancer were referred for a low dose CT³ scan.

RESULTS

A total of 4 566 subjects attended the appointment for risk assessment and 3 591 (79%) consented to data sharing. More than 80% of the patients were in the most deprived quintile of the index of multiple deprivation. Of those attending, 63% underwent spirometry and 43% were recommended for a CT scan. A total of 25 cancers were diagnosed, of which 16 (64%) were stage I. Comparison with the national stage distribution implied that the programme was reducing lung cancer mortality by 22%.

CONCLUSIONS

Community based proactive approaches to early diagnosis of lung cancer in health deprived regions are likely to be effective in early detection of lung cancer.

Attitudes towards lung cancer screening in a population sample

Background

Lung cancer is the leading cause of cancer death worldwide. Routine UK lung cancer screening is not yet available, thus understanding barriers to participation in lung screening could help maximize effectiveness if introduced.

Methods

Population‐based survey of 1007 adults aged 16 and over in Wales using random quota sampling. Computer‐assisted face‐to‐face interviews included demographic variables (age, gender, smoking, social group), four lung cancer belief statements and three lung screening attitudinal items. Determinants of lung screening attitudes were examined using multivariable regression adjusted for age, gender, social group and previous exposure to lung campaign messages.

Results

Avoidance of lung screening due to fear of what might be found was statistically significantly associated with negative lung cancer beliefs including fatalism (aOR = 8.8, 95% CI = 5.6‐13.9, P ≤ 0.001), low perceived value of symptomatic presentation (aOR = 2.4, 95% CI = 1.5‐3.9, P ≤ 0.001) and low treatment efficacy (aOR = 0.3, CI = 0.2‐0.7, P ≤ 0.01).

Low perceived effectiveness of lung screening was significantly associated with fatalism (aOR = 6.4, 95% CI = 3.5‐11.7, P ≤ 0.001), low perceived value of symptom presentation (aOR = 4.9, 95% CI = 2.7‐8.9, P ≤ 0.001) and low treatment efficacy (aOR = 0.1, 95% CI = 0.1‐0.3, P ≤ 0.001). In contrast, respondents who thought lung screening could reduce cancer deaths had positive beliefs about lung cancer (aOR = 0.4, 95% CI = 0.2‐0.7, P ≤ 0.001) and its treatment (aOR = 6.1, 95% CI = 3.0‐12.6, P ≤ 0.001).

Conclusion

People with negative beliefs about lung cancer may be more likely to avoid lung screening. Alongside the introduction of effective early detection strategies, interventions are needed to modify public perceptions of lung cancer, particularly for fatalism.