Study Identifies Factors Associated with Refusal of Lung Cancer Screening When Offered by VA Physicians

BACKGROUND:
Lung cancer is the leading cause of cancer death worldwide, and lung cancer screening (LCS) has the potential to reduce mortality by approximately 20% in high-risk individuals. Since 2013, LCS has been recommended by the US Preventive Services Task Force, but fewer than 10% of eligible individuals have been screened. Little is known about how frequently patients decline LCS when it is offered, or factors associated with their decision. This retrospective cohort study sought to determine how frequently patients decline LCS when it is offered by a physician – and to define patient and facility-level factors associated with their decision. Using VA data, investigators identified 43,257 Veterans who were offered lung cancer screening by a VA physician between 2013 and 2021 at any of 30 VA facilities. The main outcome was documentation via clinical reminder that a Veteran declined LCS. Investigators also assessed patient demographics, VA priority status, and comorbidities.

FINDINGS:

• In this study cohort of more than 43,200 Veterans, approximately one-third (n=13,846) declined lung cancer screening following a discussion with their physician.
• The physician and facility offering LCS accounted for 19% and 36% of the variation in declining LCS, respectively. Rates of declining LCS varied from 4% to 62% across VA facilities.
• Older Veterans or those with serious comorbidities (e.g., mental health or cardiovascular conditions) were more likely to decline
• Groups that have long experienced worse lung cancer care and outcomes, including Black and Hispanic individuals and those receiving full VA benefits due to poverty, were more likely to accept This suggests that screening may be a pathway to improve long-standing disparities.

IMPLICATIONS:

• Variation in declining LCS was accounted for more by the facility and physician than by patient factors, suggesting a need to improve the quality of physician-patient discussions about LCS to increase the patient-centeredness of care.

LIMITATIONS:

• Investigators were unable to assess the quality of the conversation during which LCS was offered; for example, whether shared decision-making occurred.
• Investigators could not explore influences on patient decisions to decline LCS, i.e., lung cancer worry, perceptions of benefits vs harms of LCS, fatalism, or logistic barriers to accessing LCS.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 18-075). Drs. Núñez, Glickman, Miller, and Wiener, and Mses. Boudreau, Qian, and Zhang are part of HSR&D’s Center for Healthcare Organization & Implementation Research (CHOIR); Dr. Caverly is with HSR&D’s Center for Clinical Management Research (CCMR); and Dr. Slatore is part of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC).

Núñez E, Caverly T, Zhang S, Glickman M, Qian S, Boudreau J, Miller D, Slatore C, and Wiener R. Factors Associated with Declining Lung Cancer Screening after Discussion with a Physician in a Cohort of US Veterans. JAMA Network Open. August 16, 2022;5(8):e2227126.