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CDP 11-227 – HSR&D Study

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CDP 11-227
Pulmonary Nodule Evaluation: Process and Feelings (CDA 09-025)
Christopher G. Slatore MD MS
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: October 2011 - September 2014

BACKGROUND/RATIONALE:
Almost 75% of Veterans have a history of tobacco use and combined with the rapidly increasing use of computed tomography (CT), there is an increased number of patients with incidental findings, often pulmonary nodules, that are suspicious for lung cancer. Many of these findings will be falsely positive but due to the lethality of lung cancer, the difficulty of sampling small lesions, and predicted rates of tumor growth, it is currently recommended to follow these incidental findings for up to two years. The psychosocial risks of lung cancer evaluation are unknown but it is quite likely that lung cancer evaluation is stressful. The behavioral risks of evaluation are also not known, including how adherent patients are with the process or how it impacts their most important risk for lung cancer development, tobacco use. Patient-clinician communication is a fundamental process in clinical care and is central to the delivery of high quality care. Most of the factors involved in lung cancer evaluation are not modifiable so improving patient-clinician communication is one of the few methods to decrease the distress felt by patients.

OBJECTIVE(S):
Aim 1: Using qualitative methods, explore Veterans' and clinicians' understanding, experiences, and perceptions of the process of prolonged lung cancer evaluation.

Aim 2: Prospectively evaluate Veterans who are undergoing lung cancer evaluation by examining psychosocial outcomes (e.g., anxiety and emotional distress), behavior (e.g., tobacco use, adherence to the diagnostic strategy), and perceptions of the clinician's communication.


METHODS:
I will first perform a qualitative study using grounded theory and standard coding techniques amongst patients undergoing lung cancer evaluation. Next, I will perform a qualitative study of clinicians as well. Lastly, I will design a prospective, longitudinal cohort study of patients undergoing lung cancer evaluation. For this step, I will utilize a survey, based on conceptual models and previous research, to adequately measure patients' feelings about communication, their mental health, quality of life, and smoking habits.

FINDINGS/RESULTS:
1. Patients with incidental pulmonary nodules often receive inadequate information about the causes of nodules, the individualized risk of lung cancer, and details about the follow-up plan.
2. Distress is common among these patients. Based on quantitative analyses, almost 50% of patients have at least mild distress. It is occasionally severe.
3. Patients often substantially overestimate the risk the nodule is lung cancer.
4. Satisfaction with the clinician's communication practices is associated with less distress. Satisfaction with knowledge about the nodule and lower self-perceived risk of lung cancer are not associated with distress.


IMPACT:
The process of lung cancer evaluation appears to be stressful for many Veterans and may be more so for those Veterans who report lower quality patient-centered communication. There are no previous data among Veterans about either the risks of this process or the methods to minimize these risks. This study will both measure the likely consequences of lung cancer evaluation and help identify modifiable factors in the patient-clinician relationship to help mitigate these effects. Thus, this study is highly relevant to VA's mission to provide the highest quality care to Veterans. Furthermore, VA has begun a lung cancer screening demonstration project. My CDA was funded largely on the premise that screening would be implemented and substantially increase the number of patients identified with incidental pulmonary nodules. Now that this process has started, the results of this work will be relevant for an even larger number of Veterans.

PUBLICATIONS:

Journal Articles

  1. Slatore CG, Wiener RS, Golden SE, Au DH, Ganzini L. Longitudinal Assessment of Distress among Veterans with Incidental Pulmonary Nodules. Annals of the American Thoracic Society. 2016 Nov 1; 13(11):1983-1991.
  2. Golden SE, Thomas CR, Deffebach ME, Sukumar MS, Schipper PH, Tieu BH, Kee AY, Tsen AC, Slatore CG, Early Stage Lung Cancer Comparative Effectiveness Research Consortium. "Even if I Don't Remember, I Feel Better". A Qualitative Study of Patients with Early-Stage Non-Small Cell Lung Cancer Undergoing Stereotactic Body Radiotherapy or Surgery. Annals of the American Thoracic Society. 2016 Aug 1; 13(8):1361-9.
  3. Isenberg JY, Quiñones AR, Slatore CG, Bryson WC, Thielke SM. Trends in cigarette smoking and cessation among Medicare managed care recipients, 2005-2012. Addictive Behaviors. 2016 Jul 1; 58:155-60.
  4. Freiman MR, Clark JA, Slatore CG, Gould MK, Woloshin S, Schwartz LM, Wiener RS. Patients' Knowledge, Beliefs, and Distress Associated with Detection and Evaluation of Incidental Pulmonary Nodules for Cancer: Results from a Multicenter Survey. Journal of Thoracic Oncology. 2016 May 1; 11(5):700-8.
  5. Moseson EM, Wiener RS, Golden SE, Au DH, Gorman JD, Laing AD, Deffebach ME, Slatore CG. Patient and Clinician Characteristics Associated with Adherence. A Cohort Study of Veterans with Incidental Pulmonary Nodules. Annals of the American Thoracic Society. 2016 May 1; 13(5):651-9.
  6. Simmons J, Gould MK, Iaccarino J, Slatore CG, Wiener RS. Systems-Level Resources for Pulmonary Nodule Evaluation in the United States: A National Survey. American journal of respiratory and critical care medicine. 2016 May 1; 193(9):1063-5.
  7. Golden SE, Wiener RS, Sullivan D, Ganzini L, Slatore CG. Primary Care Providers and a System Problem: A Qualitative Study of Clinicians Caring for Patients With Incidental Pulmonary Nodules. Chest. 2015 Dec 1; 148(6):1422-9.
  8. Wiener RS, Slatore CG, Gillespie C, Clark JA. Pulmonologists' Reported Use of Guidelines and Shared Decision-making in Evaluation of Pulmonary Nodules: A Qualitative Study. Chest. 2015 Dec 1; 148(6):1415-21.
  9. Iaccarino JM, Clark J, Bolton R, Kinsinger L, Kelley M, Slatore CG, Au DH, Wiener RS. A National Survey of Pulmonologists' Views on Low-Dose Computed Tomography Screening for Lung Cancer. Annals of the American Thoracic Society. 2015 Nov 1; 12(11):1667-75.
  10. Sullivan DR, Slatore CG. Advance Care Planning. Does It Benefit Surrogate Decision Makers in the Intensive Care Unit? Annals of the American Thoracic Society. 2015 Oct 1; 12(10):1432-3.
  11. Slatore CG, Au DH, Press N, Wiener RS, Golden SE, Ganzini L. Decision making among Veterans with incidental pulmonary nodules: a qualitative analysis. Respiratory medicine. 2015 Apr 1; 109(4):532-9.
  12. Slatore CG, Golden SE, Ganzini L, Wiener RS, Au DH. Distress and patient-centered communication among veterans with incidental (not screen-detected) pulmonary nodules. A cohort study. Annals of the American Thoracic Society. 2015 Feb 1; 12(2):184-92.
  13. Smith ME, Chiovaro JC, O'Neil M, Kansagara D, Quiñones AR, Freeman M, Motu'apuaka ML, Slatore CG. Early warning system scores for clinical deterioration in hospitalized patients: a systematic review. Annals of the American Thoracic Society. 2014 Nov 1; 11(9):1454-65.
  14. Sullivan DR, Ganzini L, Lopez-Chavez A, Slatore CG. Association of patient characteristics with chemotherapy receipt among depressed and non-depressed patients with non-small cell lung cancer. Psycho-oncology. 2014 Nov 1; 23(11):1318-22.
  15. Cooke CR, Feemster LC, Wiener RS, O'Neil ME, Slatore CG. Aggressiveness of intensive care use among patients with lung cancer in the Surveillance, Epidemiology, and End Results-Medicare registry. Chest. 2014 Oct 1; 146(4):916-23.
  16. Clark N, Fan VS, Slatore CG, Locke E, Whitson HE, Nici L, Thielke SM. Dyspnea and pain frequently co-occur among Medicare managed care recipients. Annals of the American Thoracic Society. 2014 Jul 1; 11(6):890-7.
  17. Slatore CG, Sullivan DR, Pappas M, Humphrey LL. Patient-centered outcomes among lung cancer screening recipients with computed tomography: a systematic review. Journal of Thoracic Oncology. 2014 Jul 1; 9(7):927-34.
  18. Zhang Z, Duckart J, Slatore CG, Fu Y, Petrik AF, Thorp ML, Cohen DM. Individuality of the plasma sodium concentration. American journal of physiology. Renal physiology. 2014 Jun 15; 306(12):F1534-43.
  19. Wiener RS, Gould MK, Slatore CG, Fincke BG, Schwartz LM, Woloshin S. Resource use and guideline concordance in evaluation of pulmonary nodules for cancer: too much and too little care. JAMA internal medicine. 2014 Jun 1; 174(6):871-80.
  20. Kahn JM, Gould MK, Krishnan JA, Wilson KC, Au DH, Cooke CR, Douglas IS, Feemster LC, Mularski RA, Slatore CG, Wiener RS, ATS Ad Hoc Committee on the Development of Performance Measures from ATS Guidelines. An official American thoracic society workshop report: developing performance measures from clinical practice guidelines. Annals of the American Thoracic Society. 2014 May 1; 11(4):S186-95.
  21. Slatore CG, Baumann C, Pappas M, Humphrey LL. Smoking behaviors among patients receiving computed tomography for lung cancer screening. Systematic review in support of the U.S. preventive services task force. Annals of the American Thoracic Society. 2014 May 1; 11(4):619-27.
  22. Zeliadt SB, Loggers ET, Slatore CG, Au DH, Hebert PL, Klein GJ, Kessler LG, Backhus LM. Preoperative PET and the reduction of unnecessary surgery among newly diagnosed lung cancer patients in a community setting. Journal of nuclear medicine : official publication, Society of Nuclear Medicine. 2014 Mar 1; 55(3):379-85.
  23. Slatore CG, Feemster LC, Au DH, Engelberg RA, Curtis JR, Uman J, Reinke LF. Which patient and clinician characteristics are associated with high-quality communication among veterans with chronic obstructive pulmonary disease? Journal of Health Communication. 2014 Feb 21; 19(8):907-21.
  24. Sullivan DR, Ganzini L, Duckart JP, Lopez-Chavez A, Deffebach ME, Thielke SM, Slatore CG. Treatment receipt and outcomes among lung cancer patients with depression. Clinical Oncology (Royal College of Radiologists (Great Britain)). 2014 Jan 1; 26(1):25-31.
  25. Slatore CG, Harber P, Haggerty MC, American Thoracic Society Respiratory Impairment and Disability Evaluation Group. An official American Thoracic Society systematic review: Influence of psychosocial characteristics on workplace disability among workers with respiratory impairment. American journal of respiratory and critical care medicine. 2013 Nov 1; 188(9):1147-60.
  26. Hunnibell LS, Slatore CG, Ballard EA. Foundations for lung nodule management for nurse navigators. Clinical Journal of Oncology Nursing. 2013 Oct 1; 17(5):525-31.
  27. Humphrey LL, Deffebach M, Pappas M, Baumann C, Artis K, Mitchell JP, Zakher B, Fu R, Slatore CG. Screening for lung cancer with low-dose computed tomography: a systematic review to update the US Preventive services task force recommendation. Annals of internal medicine. 2013 Sep 17; 159(6):411-20.
  28. Slatore CG, Press N, Au DH, Curtis JR, Wiener RS, Ganzini L. What the heck is a "nodule"? A qualitative study of veterans with pulmonary nodules. Annals of the American Thoracic Society. 2013 Aug 1; 10(4):330-5.
  29. Colt HG, Murgu SD, Korst RJ, Slatore CG, Unger M, Quadrelli S. Follow-up and surveillance of the patient with lung cancer after curative-intent therapy: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May 1; 143(5 Suppl):e437S-54S.
  30. Slatore CG, Hansen L, Ganzini L, Press N, Osborne ML, Chesnutt MS, Mularski RA. Communication by nurses in the intensive care unit: qualitative analysis of domains of patient-centered care. American Journal of Critical Care : An Official Publication, American Association of Critical-Care Nurses. 2012 Nov 1; 21(6):410-8.
  31. Brasky TM, Baik CS, Slatore CG, Alvarado M, White E. Prediagnostic nonsteroidal anti-inflammatory drug use and lung cancer survival in the VITAL study. Journal of Thoracic Oncology. 2012 Oct 1; 7(10):1503-12.
  32. Brasky TM, Baik CS, Slatore CG, Potter JD, White E. Non-steroidal anti-inflammatory drugs and small cell lung cancer risk in the VITAL study. Lung cancer (Amsterdam, Netherlands). 2012 Aug 1; 77(2):260-4.
  33. Cecere LM, Slatore CG, Uman JE, Evans LE, Udris EM, Bryson CL, Au DH. Adherence to long-acting inhaled therapies among patients with chronic obstructive pulmonary disease (COPD). COPD. 2012 Jun 1; 9(3):251-8.
  34. Slatore CG, Cecere LM, Letourneau JL, O'Neil ME, Duckart JP, Wiener RS, Farjah F, Cooke CR. Intensive care unit outcomes among patients with lung cancer in the surveillance, epidemiology, and end results-medicare registry. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2012 May 10; 30(14):1686-91.
  35. Slatore CG, Goy ER, O'hearn DJ, Boudreau EA, O'Malley JP, Peters D, Ganzini L. Sleep quality and its association with delirium among veterans enrolled in hospice. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2012 Apr 1; 20(4):317-26.
  36. Zeliadt SB, Sekaran NK, Hu EY, Slatore CC, Au DH, Backhus L, Wu DY, Crawford J, Lyman GH, Dale DC. Comparison of demographic characteristics, surgical resection patterns, and survival outcomes for veterans and nonveterans with non-small cell lung cancer in the Pacific Northwest. Journal of Thoracic Oncology. 2011 Oct 1; 6(10):1726-32.
  37. Brasky TM, Lampe JW, Slatore CG, White E. Use of glucosamine and chondroitin and lung cancer risk in the VITamins And Lifestyle (VITAL) cohort. Cancer Causes & Control : Ccc. 2011 Sep 1; 22(9):1333-42.
  38. Cecere LM, Littman AJ, Slatore CG, Udris EM, Bryson CL, Boyko EJ, Pierson DJ, Au DH. Obesity and COPD: associated symptoms, health-related quality of life, and medication use. COPD. 2011 Aug 2; 8(4):275-84.
  39. Reinke LF, Slatore CG, Uman J, Udris EM, Moss BR, Engelberg RA, Au DH. Patient-clinician communication about end-of-life care topics: is anyone talking to patients with chronic obstructive pulmonary disease? Journal of palliative medicine. 2011 Aug 1; 14(8):923-8.
  40. Slatore CG, Gould MK, Au DH, Deffebach ME, White E. Lung cancer stage at diagnosis: Individual associations in the prospective VITamins and lifestyle (VITAL) cohort. BMC cancer. 2011 Jun 7; 11:228.
  41. Reinke LF, Slatore CG, Udris EM, Moss BR, Johnson EA, Au DH. The association of depression and preferences for life-sustaining treatments in veterans with chronic obstructive pulmonary disease. Journal of pain and symptom management. 2011 Feb 1; 41(2):402-11.
Journal Other

  1. Wiener RS, Slatore CG. Real-world evidence about potential psychosocial harms of lung cancer screening. JAMA internal medicine. 2014 Aug 1; 174(8):1416.
  2. Lareau S, Moseson E, Slatore CG. Exacerbation of COPD. American journal of respiratory and critical care medicine. 2014 Mar 15; 189(6):P11-2.
  3. Humphrey LL, Deffebach M, Pappas M, Zakher B, Slatore CG. Screening for lung cancer with low-dose computed tomography. Annals of internal medicine. 2014 Feb 4; 160(3):212.
  4. Wiener RS, Slatore CG. Framing discussions about CT scan screening for lung cancer so that patients see the whole picture. Chest. 2013 Dec 1; 144(6):1749-50.
  5. Drake MG, Slatore CG. American Thoracic Society Patient Information Series: Smoking Marijuana and the Lungs. American journal of respiratory and critical care medicine. 2013 Jun 1; 187(11):5-6.
  6. Slatore CG, Wiener RS, Cooke CR. Reply to F. Vincet, et al and Reply to S. Alibhai re Intensive Care Unit Outcomes among Patients with Lung Cancer in the SEER-Medicare Registry. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2012 Oct 10; 30(29):3652-3653.
HSR&D Publication

  1. Smith MEB, Chiovaro JC, O'Neil ME, Kansagara D, Quinones AR, Freeman M, Motuapuaka M, Slatore CG. Early Warning Scoring Systems: A Systematic Review. 2014 Jan 1; 1(1).
  2. Humphrey LL, Deffebach M, Pappas M, Baumann C, Artis K, Mitchell JP, Zakher B, Slatore CG. Screening for Lung Cancer: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 105. 2013 Jul 1; 13-05196-EF(1).
Center Product

  1. Slatore CG. Lung Cancer Screening Implementation: A Serial Discussion (Podcast). American Thoracic Society; 2016 Jul 29. Available from: https://www.thoracic.org/about/ats-podcasts/lung-cancer-screening-implementation-a-serial-discussion.php.
Conference Presentations

  1. Slatore CG. Lung Cancer Screening and Nodule Evaluation. Paper presented at: American Thoracic Society Annual International Conference; 2016 May 16; San Francisco, CA.
  2. Slatore CG. SBRT vs. Surgery for Patients with Early Stage Lung Cancer: An Observational Comparative Effectiveness Study. Paper presented at: American Society for Radiation Oncology Annual Meeting; 2015 Oct 20; San Antonio, TX.
  3. Slatore CG. Screening in the VA with Low Dose Chest CT Scans. Presented at: American Thoracic Society Annual International Conference; 2014 May 21; San Diego, CA.
  4. Sullivan DR, Pappas M, Humphrey LL, Slatore CG. A systematic review of the psychosocial impact of lung cancer screening with computed tomography on patients. Paper presented at: American Thoracic Society Annual International Conference; 2014 May 21; San Diego, CA.
  5. Moseson EM, Golden SE, Slatore CG. Adherence to Fleischner Society guidelines among Veterans with pulmonary nodules in a clinical registry. Paper presented at: American Thoracic Society Annual International Conference; 2014 May 19; San Diego, CA.
  6. Slatore CG. Implementation of Lung Cancer Screening in the United States. Presented at: American Thoracic Society Annual International Conference; 2014 May 19; San Diego, CA.
  7. Slatore CG. Comparative Effectiveness: Treatments, Research, and Practice. Presented at: American Thoracic Society Annual International Conference; 2014 May 19; San Diego, CA.
  8. Slatore CG, Golden SE, Wiener RS, Ganzini LK, Au DH. Pulmonary nodule detection: association of patient-clinician communication with distress. Paper presented at: American Thoracic Society Annual International Conference; 2014 May 19; San Diego, CA.
  9. Wiener RS, Slatore CG. Attitudes of VA pulmonologists towards implementation of low dose CT screening for lung cancer: results of a national survey. Poster session presented at: American Thoracic Society Annual International Conference; 2014 May 19; San Diego, CA.
  10. Slatore CG. Implementation of Lung Cancer Screening: A Toolbox for Clinicians and Researchers. Presented at: American Thoracic Society Annual International Conference; 2014 May 18; San Diego, CA.
  11. Slatore CG. Defining the Relevant Quality Metrics for Lung Cancer Screening. Presented at: American Thoracic Society Annual International Conference; 2014 May 18; San Diego, CA.
  12. Slatore CG. Implementation of Lung Cancer Screening. Presented at: American Thoracic Society Annual International Conference; 2014 May 17; San Diego, CA.
  13. Slatore CG. Lung Cancer Screening: My Year of Living Semi-Dangerously. Paper presented at: Oregon Thoracic Society Annual Meeting; 2014 Feb 16; Sunriver, OR.
  14. Cooke CR, Feemster LC, Wiener RS, Slatore CG. Care Unit Utilization Among Patients With Lung Cancer in the SEER-Medicare Registry. Presented at: American Thoracic Society Annual International Conference; 2013 May 19; Philadelphia, PA.
  15. Slatore CG. Dollars and Sense: Identifying the Costs, Utilization, and Burden of Respiratory Disease Management. Paper presented at: American Thoracic Society Annual International Conference; 2013 May 19; Philadelphia, PA.
  16. Sullivan DR, Duckart JP, Slatore CG. Chemotherapy Utilization In Advanced Non-Small Cell Lung Cancer Patients With Depression. Presented at: American Thoracic Society Annual International Conference; 2013 May 19; Philadelphia, PA.
  17. Slatore C, Au DH, Curtis J, Press N, Weiner R, Ganzini L. What the (Heck) Is A Nodule? A Qualitative Study Of Veterans' Reactions To Finding An Incidental Pulmonary Nodule. Poster session presented at: American Thoracic Society Annual International Conference; 2013 May 17; Philadelphia, PA.
  18. Slatore CG, Helfand M. Patient-Centered Juggernaut: The Right Move for Clinical Care, Policy and Research? Paper presented at: American Thoracic Society Annual International Conference; 2013 May 13; San Francisco, CA.
  19. Slatore CG, Zeliadt SB, Backhus LM, Kessler LG, Hu E, Au DH. A Comparative Effectiveness Study of Pre-operative PET Imaging and the Reduction of Unnecessary Lung Cancer Surgery. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.
  20. Wiener RS, Gould MK, Slatore C, Kneeland T, Hickey E, Welch HG, Schwartz LM, Woloshin S. Evaluation of potentially malignant pulmonary nodules in the VA system: resource use and adherence to guideline recommendations. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.
  21. Slatore CG. Implementing Lung Cancer Screening in the Real World. Presented at: National Lung Cancer Partnership Annual Conference; 2012 Jun 1; Chicago, IL.
  22. Slatore CG, Wiener RS. Implementing Lung Cancer Screening: Moving from RCT’s to the Real World. Paper presented at: American Thoracic Society Annual International Conference; 2012 May 22; San Francisco, CA.
  23. Slatore CG, Cecere LM, LeTourneau J, O'Neil ME, Duckart JP, Soylemez-Wiener R, Farjah F, Cooke CR. Intensive Care Unit Outcomes among Patients with Lung Cancer in the SEER-Medicare Registry. Presented at: American Thoracic Society Annual International Conference; 2011 May 20; San Francisco, CA.
  24. Sullivan DR, Duckart JP, Slatore CG. Lung Cancer Outcomes Among Patients With Depression. Presented at: American Thoracic Society Annual International Conference; 2011 May 20; San Francisco, CA.
  25. Reinke LF, Slatore CG, Uman J, Udris E, Moss BR, Engelberg RA, Au DH. Patient-Clinician Communication About End-of-Life Care Topics. Presented at: American Thoracic Society Annual International Conference; 2011 May 16; Denver, CO.
  26. Cecere LM, Slatore CG, Uman JE, Evans LE, Udris EM, Bryson CL, Au DH. Factors Associated with Adherence to Long-Acting Inhaled Therapies Among Patients with COPD. Presented at: American Thoracic Society Annual International Conference; 2011 May 15; Denver, CO.
  27. Slatore CG, Gould MK, Au DH, Deffebach ME, White E. Lung Cancer and Stage at Diagnosis: Associations in the VITamins And Lifestyle (VITAL) Study. Presented at: American Thoracic Society Annual International Conference; 2011 May 15; Denver, CO.
  28. Brasky TM, Lampe JW, Slatore CG, White E. Long-term use of glucosamine and chondroitin and lung cancer risk in the VITamins And Lifestyle (VITAL) cohort. Presented at: American Association for Cancer Research Annual Meeting; 2011 Apr 4; Orlando, FL.


DRA: Aging, Older Veterans' Health and Care, Cancer, Lung Disorders
DRE: Treatment - Observational
Keywords: Career Development
MeSH Terms: none