Lung cancer is the leading cause of cancer-related death in Veterans and accounts for 18.8% of all cancers in VHA. It can be cured in many cases if found early, but lung tumors progress rapidly and most cases have been diagnosed too late for cure. The Undersecretary for Health has ordered a demonstration project at 8 VA sites as a trial of lung cancer screening in VA, which is currently ongoing. The potential to improve Veterans' health through screening is enormous, although lung cancer screening has challenges that need immediate attention.
Adherence to follow-up CT is essential to effective lung cancer screening. The effectiveness of screening in the VA will depend on ensuring Veterans' acceptance and continued adherence to screening protocols. More frequent surveillance, the uncertain significance of indeterminate nodules, and the high incidence of false positive findings further complicates screening. Yet, non-adherence to either the surveillance of indeterminate nodules or annual CT scans can compromise the effectiveness of screening and can result in dangerous delays in diagnosis and treatment.
Adherence to planned follow-up, including missed appointments and patient drop-out, will likely be problematic for Veterans. As lung cancer screening is implemented on a wide scale in the VHA, and outside the controlled settings of trials, we can expect adherence to these screening and surveillance protocols to be lower than adherence rates in screening trials and that Veterans will encounter multiple barriers to continued adherence. However, data to guide efforts to ensure high levels of adherence to lung cancer screening in the VHA are quite limited.
The objectives of this study were to:
1)Identify factors that lead to adherence and non-adherence. This included characterizing Veterans' perceptions of lung cancer risk and the need for lung cancer screening, and the evaluation of Veterans' decision-making regarding lung cancer screening and adherence to follow-up and surveillance.
2)Characterize perceptions of clinical staff who are involved in coordinating lung cancer screening and in promoting/ensuring engagement with follow-up in clinics that have implemented screening.
We conducted a qualitative study involving interviews with 32 veterans who initiated lung cancer screening through lung CT and 15 clinical staff who were involved in their care. Semi-structured, in-depth interviews with veterans addressed their experiences with initiating lung cancer screening, including the process of completing the initial CT scan and experiences with any subsequent CT scans. Interviews with clinicians at each of the above sites who are responsible for coordinating the tracking and scheduling of follow-up CT scans as part of lung cancer screening and surveillance addressed how they communicate with patients, how follow-up appointments were scheduled, and their impressions of lung cancer screening and the appropriateness of the screening process.
Analysis followed a grounded thematic approach. Interview transcripts were coded by attaching key words to text that was judged to have significance. Coding was performed by multiple researchers with extensive qualitative training, who met frequently to assess the coding categories that emerged and to achieve consistency in coding. After initial coding, additional coding activities involved inspecting relevant codes, individually, in order to draw conclusions from the data, followed by verification of these conclusions by returning to the transcripts to assess their fit with the data.
Through the analysis of interviews with patients who had lung cancer screening, and providers involved in the ordering, scheduling, and tracking of screening exams and results, we found that adherence to surveillance in lung cancer screening can be influenced by both patient and clinical factors. Patients vary in their understanding of the screening process, the importance of receiving additional CT scans, and their intention to persist with the screening protocol.
One of the most important factors that influenced whether a patient returned for a follow-up CT was simply knowing that it was required for the providers to recommend and conduct the screening. For those patients who were not adherent, many were not aware of the recommendation to receive further annual screening or surveillance. This may be an artifact of discrepancies between patient understanding and provider recommendations. In addition to information entered into CPRS from radiology using established screening recommendations based upon the findings of the screening CT, screening coordinators at each site also keep track of patient screening. Upon inspection of how the screening status of patients correlates between CPRS classification, screening coordinator classification, and patient understanding, there was concordance across these three indicators in only 45% of cases. As a result of these discrepancies, patients and providers were not of the same understanding in regard to the need for, or timing of, follow-up CTs. In fact, 30% of respondents were simply unaware that additional imaging was recommended. That is, they didn't know they were supposed to come back.
Other factors patients cited for non-adherence were a refusal to continue, difficulty making appointments, dissatisfaction with the screening process, or lack of interest in continuing.
Despite the lack of concordance between patient understanding and recommendations in clinical records, providers expressed confidence in the ability to track and follow patients who had initiated lung cancer screening. While screening coordinators indicated that this was a difficult process, and that there were numerous ways patients could fall through the cracks, physicians expressed confidence that patients at their site were being tracked adequately and that this was not a problem at their site.
Some sites were more rigorous in tracking patients than others, and these sites experienced greater adherence to surveillance with their patients.
Veterans expressed, in general, interest and motivation in persisting with screening and surveillance for Lung Cancer Screening. Veterans understood the value of screening, and were interested in additional imaging, but were often not aware of the screening process and what expectations were for follow-up.
This study is the necessary first step to defining the factors that enable or impede Veterans' continued adherence to lung cancer screening protocols, ultimately toward earlier detection of lung cancer and prevention of early mortality. We have enhanced our understanding of continued adherence and its behavioral determinants in the lung cancer setting. Poor adherence to a screening process can severely compromise its effectiveness in achieving timely detection of cancer and thus reduction of mortality. As we begin to implement mandatory lung cancer screening in the VA, we need to build on this understanding of patients' engagement with screening as well as the clinical factors that contribute to non-adherence. The results of this study will inform subsequent research to assess the adequacy of methods for tracking patients who are undergoing lung cancer screening and the factors that inform patients' ability and intention to persist with lung cancer screening.
- McCullough MB, Gillespie C, Petrakis BA, Jones EA, Park AM, Lukas CV, Rose AJ. Forming and activating an internal facilitation group for successful implementation: A qualitative study. Research in social & administrative pharmacy : RSAP. 2017 Sep 1; 13(5):1014-1027.