The patient voice: Insights into lung cancer screening

From the Triplette Group, Clinical Research Division

“Lung cancer screening is the “new kid on the block” for cancer screening, only being recommended by the USPSTF [US Preventive Service Taskforce] since 2013. However, it’s also an incredibly powerful tool, and the number needed to screen to save one life is far lower than other standard screening modalities. In the 9 years since this recommendation, myself and others who have studied screening have found that implementation of screening along the entire continuum of care has been quite poor. Less than 10% of the 16 million adults eligible for lung cancer screening in the US have been screened,” discussed Dr. Matthew Triplette, an Assistant Professor in Fred Hutch’s Clinical Research Division, when asked to speak about his recent research examining adherence to lung cancer screening. Globally, lung cancer is the most common cause of cancer related mortality, often detected at an advanced stage as a person may not experience symptoms that might trigger alarm and reporting to a doctor. To address this, lung cancer screening has recently been made available to more eligible patients in the United States as disease detected at an earlier stage has a greater chance of survival for patients. However, as Dr. Triplette stated, lung cancer screening options remain underutilized, a critical issue that needs to be addressed to aid in reducing the lung cancer related mortality burden.

Led by a medical student, Anna Holman, Dr. Triplette and colleagues designed a study comprised of qualitative interviews that aimed to determine patient experiences and insights into adherence to lung cancer screening regimens. Thoughtfully, their study design incorporated a balance of patients who adhered to lung cancer screening recommendations, as well as patients who did not. This enabled the researchers to gather insight into both sides of the spectrum. Patients who attended the multicenter University of Washington/Seattle Cancer Care Alliance Lung Cancer Screening program were invited to participate. Describing their study, recently published in Chest, Dr Triplette said “in an earlier study, my group found that even among those screened once, less than half returned for timely annual screening. This result has since been duplicated in several other sites. This study is really answering the question of why? Why do some people come back for screening and some people don’t? That kind of question is best approached through qualitative work like in this study. From talking to patients, we found pretty uniformly that awareness was a key issue. Patients need to be aware that asymptomatic annual screening is important and need to be reminded by providers and programs when they are due. For some patients, unique barriers like transportation and cost issues also need to be addressed.”

Access barriers, including transportation and medical insurance costs, contribute to poor adherence to lung cancer screening.
Access barriers, including transportation and medical insurance costs, contribute to poor adherence to lung cancer screening. Image provided by Dr. Triplette.

The authors rigorously prepared a semi-structured set of interview topics and questions designed to gather patient perspectives and 40 eligible patients participated. The authors performed thematic analysis on the interview data and derived several common interview themes provided by patients that can inform their next research ventures. They noted that the majority of study participants, those who adhered and those who did not, reported that the screening experience was an overall positive one. The study participants reported they would most likely seek out lung cancer screening because their doctor suggested it, not out of their own accord, emphasizing the importance of practitioner referrals in this setting. The responses received suggested a poor understanding among patients about the lack of symptoms associated with lung cancer. Further, among patients who did not adhere to the lung cancer screening, significant barriers to screening existed. Participants described how uncertainty surrounding medical insurance coverage and affordability of the screening was a real concern, as well as detailing the difficulties faced attending multiple appointments because of lack of available transportation options. These data suggest that access to screening remains a serious issue for patients at high risk for lung cancer.

The authors and study participants suggest that utilizing the skillset of a patient navigator as part of the screening process would greatly help patients adhere to and better understand screening requirements and timelines. A patient navigator is a person who helps to “navigate” a patient through the healthcare system; they can aid in making appointments, transport to and from hospital visits, and provide support throughout diagnosis and treatment. “This research, along with other studies, shows that more intensive contact between the screeners (program, providers, etc.) and those who are being screened is an important component of maintenance of screening care. Other centers take this evidence to mean screening needs to be centralized—taken out of the hands of primary care providers and instead managed by a central lung cancer screening program. While there are benefits to this approach, patients also heavily emphasize they trust and rely on their primary care provider for medical shared decision making. Instead, as leaders in lung cancer screening programs, I think we can support patients in our system by providing them with a navigator—someone who can reach out to the patient and guide them through the complex screening process. I am now studying patient navigation as an approach to screening, particularly for patient populations that face health disparities”, described Dr. Triplette.

Dr. Triplette finished by describing the role of the Fred Hutch/University of Washington/Seattle Children's Cancer Consortium in supporting his ongoing research, “The consortium is incredibly helpful as I conduct my research. I rely on groups like the Office of Community Outreach and Engagement (OCOE) to help with recruitment of patients and tailoring of study materials. I also rely on shared resources like the Collaborative Data Services program for my assessments and data collection.”

This work was funded by the American Thoracic Society.

Fred Hutch/University of Washington/Seattle Children's Cancer Consortium members Dr. Kristina Crothers, Dr. Allison Cole and Dr. Matthew Triplette contributed to this work.

Holman A, Kross E, Crothers K, Cole A, Wernli K, Triplette M. Patient Perspectives on Longitudinal Adherence to Lung Cancer Screening. Chest. 2022 Feb 8:S0012-3692(22)00223-9. doi: 10.1016/j.chest.2022.01.054. Epub ahead of print. PMID: 35149081.