More than a third of U.S. veterans decline CT lung cancer screening

2019 12 09 17 23 7420 Veterans Affairs Va Seal 400

More than a third of U.S. veterans decline low-dose CT lung cancer screening, and shared decision-making conversations between veterans and their physicians may be a contributing factor, indicates research published August 16 in JAMA Network Open.

It's possible that these conversations may need some fine-tuning, wrote a team led by Dr. Eduardo Nuñez of Boston University.

"We found that the physician and site that offered lung cancer screening accounted for more variation in lung cancer screening decisions than did patient factors, suggesting a need to refocus shared decision-making conversations on the patient's individual circumstances and standardize [it] to minimize physician and facility variation," the group noted.

The U.S. Preventive Services Task Force (USPSTF) has recommended annual lung cancer screening with low-dose CT since 2013, and in March of last year, it expanded the pool of eligible individuals by lowering the starting age and smoking pack year history. But uptake remains spotty, particularly among racial and ethnic minorities, the study authors wrote.

The U.S. Centers for Medicare and Medicaid Services (CMS) has mandated that individuals eligible for lung cancer screening participate in a shared decision-making process with their physician. Some critics of this mandate say that it actually blocks lung cancer screening uptake because it emphasizes possible harms from the exam such as overdiagnosis, complications from additional procedures, and stress from inconclusive findings.

In any case, it's unclear how often eligible individuals decline lung cancer screening when offered it and why. Nuñez and colleagues sought to shed light on this question using data from the Veterans Health Administration (VHA), in part because the VHA has been an "early adopter" of lung cancer screening and tracks whether patients accept or decline screening through its electronic health record system and also because the VHA serves millions of people from a variety of geographic and socioeconomic backgrounds.

To this end, the group conducted a study that included data from 43,257 lung cancer screening-eligible U.S. veterans to whom the exam was offered by a physician at one of 30 VHA facilities across the country between January 2013 and February 2021. The study's main outcome was whether the veterans had declined the screening exam after discussing it with a physician. The mean age of the study participants was 65. Most (95.9%) were men, 84.2% were white, and 37.1% lived in a rural area. More than 70% of study participants were current smokers, 29.6% had chronic obstructive pulmonary disease, 24.5% had depression, and 23.6% were substance abusers.

Of the study cohort, 32% refused screening after discussing it with their physician, a result linked more to the physician and the facility at which the conversation occurred than by patient factors, the team found. The physician accounted for 19% of variation in an individual declining lung cancer screening, and the facility accounted for 36%.

The group did find that some patient factors influenced veterans to decline lung cancer screening:

  • Older age (between 70 and 80)
  • Living some distance away from a VA screening facility
  • Having spent significant time in long-term care
  • Having a higher comorbidity index score or conditions such as congestive heart failure, stroke, or schizophrenia

The factors that increased a veteran's likelihood of undergoing lung cancer screening included being younger and of Black or Latinx race, not having copays, and having more frequent use of VA health services.

Shared decision-making around lung cancer screening may be a good idea, but it needs to be refined, according to the authors.

"[Our work] suggests a need to improve the quality of patient-physician conversations about [lung-cancer screening] by incorporating the core aspects of shared decision-making: (1) discussing the individualized benefits and harms of the medical options (to receive screening or not) with regard to the patient's personal risk of lung cancer, (2) eliciting the patient's values and preferences regarding these options, and (3) choosing the option that best matches the patient's goals," they concluded.

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