Skip to main content
SpringerLink
Log in

Tackling Guideline Non-concordance: Primary Care Barriers to Incorporating Life Expectancy into Lung Cancer Screening Decision-Making—A Qualitative Study

  • Original Research: Qualitative Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Primary care providers (PCPs) are often the first point of contact for discussing lung cancer screening (LCS) with patients. While guidelines recommend against screening people with limited life expectancy (LLE) who are less likely to benefit, these patients are regularly referred for LCS.

Objective

We sought to understand barriers PCPs face to incorporating life expectancy into LCS decision-making for patients who otherwise meet eligibility criteria, and how a hypothetical point-of-care tool could support patient selection.

Design

Qualitative study based on semi-structured telephone interviews.

Participants

Thirty-one PCPs who refer patients for LCS, from six Veterans Health Administration facilities.

Approach

We thematically analyzed interviews to understand how PCPs incorporated life expectancy into LCS decision-making and PCPs’ receptivity to a point-of-care tool to support patient selection. Final themes were organized according to the Cabana et al. framework Why Don’t Physicians Follow Clinical Practice Guidelines, capturing the influence of clinician knowledge, attitudes, and behavior on LCS appropriateness determinations.

Key Results

PCP referrals to LCS for patients with LLE were influenced by limited knowledge of the life expectancy threshold at which patients are less likely to benefit from LCS, discomfort estimating life expectancy, fear of missing cancer at the point of early detection, and prioritization of factors such as quality of life, patient values, clinician-patient relationship, and family support. PCPs were receptive to a decision support tool to inform and communicate LCS appropriateness decisions if easy to use and integrated into clinical workflows.

Conclusions

Our study suggests knowledge gaps and attitudes may drive decisions to offer screening despite LLE, a behavior counter to guideline recommendations. Integrating a LCS decision support tool that incorporates life expectancy within the electronic medical record and existing clinical workflows may be one acceptable solution to improve guideline concordance and increase confidence in selecting high benefit patients for LCS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1

Similar content being viewed by others

Data Availability

The data that support the findings of this study are available on request from the corresponding author, LK. The data are not publicly available due to restrictions.

Abbreviations

LCS:

Lung cancer screening

USPSTF:

United States Preventive Services Task Force

LLE:

Limited life expectancy

PCPs:

Primary care providers

References

  1. Aberle DR, DeMello S, Berg CD, et al. Results of the Two Incidence Screenings in the National Lung Screening Trial. N Engl J Med 2013;369(10):920–931.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Koning H de, Meza R, Plevritis SK, et al. Benefits and Harms of Computed Tomography Lung Cancer Screening Strategies: A Comparative Modeling Study for the US Preventive Services Task Force. Ann Intern Med 2014;160(5):311-+.

  3. American Cancer Society lung cancer screening guidelines - Wender - 2013 - CA: A Cancer Journal for Clinicians - Wiley Online Library [Internet]. [cited 2022 Jul 13];Available from: https://acsjournals-onlinelibrary-wiley-com.ezproxy.bu.edu/doi/full/10.3322/caac.21172

  4. Mazzone PJ, Silvestri GA, Patel S, et al. Screening for Lung Cancer. Chest 2018;153(4):954–985.

    Article  PubMed  Google Scholar 

  5. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2021;325(10):962.

  6. Jaklitsch MT, Jacobson FL, Austin JHM, et al. The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. J Thorac Cardiovasc Surg 2012;144(1):33–38.

    Article  PubMed  Google Scholar 

  7. Wood DE, Kazerooni EA, Baum SL, et al. Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Cancer Netw JNCCN 2018;16(4):412–441.

  8. Administration VH. Lung Cancer Screening Saves Veterans Lives [Internet]. [cited 2022 Sep 27];Available from: http://www.va.gov/HEALTH/NewsFeatures/2018/March/LDCT-Screening-Enhances-Cancer-Care-for-Veterans.asp

  9. Howard DH, Richards TB, Bach PB, Kegler MC, Berg CJ. Comorbidities, smoking status, and life expectancy among individuals eligible for lung cancer screening. Cancer 2015;121(24):4341–4347.

    Article  PubMed  Google Scholar 

  10. Advani S, Braithwaite D. Optimizing selection of candidates for lung cancer screening: role of comorbidity, frailty and life expectancy. Transl Lung Cancer Res 2019;8(Suppl 4):S454–S459.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Tanner NT, Dai L, Bade BC, Gebregziabher M, Silvestri GA. Assessing the Generalizability of the National Lung Screening Trial: Comparison of Patients with Stage 1 Disease. Am J Respir Crit Care Med 2017;196(5):602–608.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Núñez ER, Caverly TJ, Zhang S, et al. Invasive Procedures and Associated Complications After Initial Lung Cancer Screening in a National Cohort of Veterans. CHEST 2022;162(2):475–484.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Eckstrom E, Feeny DH, Walter LC, Perdue LA, Whitlock EP. Individualizing cancer screening in older adults: a narrative review and framework for future research. J Gen Intern Med 2013;28(2):292–298.

    Article  PubMed  Google Scholar 

  14. Bade B, Gwin M, Triplette M, Wiener RS, Crothers K. Comorbidity and life expectancy in shared decision making for lung cancer screening. Semin Oncol 2022;S0093775422000574.

  15. Wolf AMD, Oeffinger KC, Shih TY-C, et al. Screening for lung cancer: 2023 guideline update from the American Cancer Society. CA Cancer J Clin [Internet] [cited 2023 Nov 6];n/a(n/a). Available from: https://onlinelibrary.wiley.com/doi/abs/10.3322/caac.21811

  16. Rustagi AS, Byers AL, Keyhani S. Likelihood of Lung Cancer Screening by Poor Health Status and Race and Ethnicity in US Adults, 2017 to 2020. JAMA Netw Open 2022;5(3):e225318.

    Article  PubMed  PubMed Central  Google Scholar 

  17. What Goes into Patient Selection for Lung Cancer Screening? Factors Associated with Clinician Judgments of Suitability for Screening [Internet]. [cited 2024 Jan 15];Available from: https://www.atsjournals.org/doi/epdf/10.1164/rccm.202301-0155OC?role=tab

  18. Jonas DE, Reuland DS, Reddy SM, et al. Screening for Lung Cancer With Low-Dose Computed Tomography: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. Agency for Healthcare Research and Quality (US); 2021 [cited 2022 Sep 29]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568573/

  19. Jemal A, Fedewa SA. Lung Cancer Screening With Low-Dose Computed Tomography in the United States—2010 to 2015. JAMA Oncol 2017;3(9):1278–1281.

    Article  PubMed  PubMed Central  Google Scholar 

  20. National Cancer Institute. Lung Cancer Screening [Internet]. 2023 [cited 2024 Jan 15]. Available from: https://progressreport.cancer.gov/detection/lung_cancer

  21. Harris RP, Wilt TJ, Qaseem A, High Value Care Task Force of the American College of Physicians. A value framework for cancer screening: advice for high-value care from the American College of Physicians. Ann Intern Med 2015;162(10):712–717.

  22. Black WC, Gareen IF, Soneji SS, et al. Cost-Effectiveness of CT Screening in the National Lung Screening Trial. N Engl J Med 2014;371(19):1793–1802.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Wiener, Renda, Sliwinski, Samantha, Boudreau J, et al. Organization of Lung Cancer Screening Programs and Coordinator Roles in the Veterans Health Administration: Implications for Quality of Care. Acad Health 2023;

  24. Wang L, Porter B, Maynard C, et al. Predicting risk of hospitalization or death among patients receiving primary care in the Veterans Health Administration. Med Care 2013;51(4):368–373.

    Article  PubMed  Google Scholar 

  25. Austin PC, Walraven C van, Wodchis WP, Newman A, Anderson GM. Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a general adult population cohort in Ontario, Canada. Med Care 2011;49(10):932–939.

    Article  PubMed  Google Scholar 

  26. Tammemägi MC, Ruparel M, Tremblay A, et al. USPSTF2013 versus PLCOm2012 lung cancer screening eligibility criteria (International Lung Screening Trial): interim analysis of a prospective cohort study. Lancet Oncol 2022;23(1):138–148.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Green AK, Bach P. Model-Based Eligibility for Lung Cancer Screening: Where Theory Meets Practice. Ann Intern Med 2018;168(3):223–224.

    Article  PubMed  Google Scholar 

  28. Elwyn G, Scholl I, Tietbohl C, et al. “Many miles to go …”: a systematic review of the implementation of patient decision support interventions into routine clinical practice. BMC Med Inform Decis Mak 2013;13 Suppl 2:S14.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Rivera MP, Tanner NT, Silvestri GA, et al. Incorporating Coexisting Chronic Illness into Decisions about Patient Selection for Lung Cancer Screening. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med. 2018;198(2):e3–e13.

  30. Núñez ER, Caverly TJ, Zhang S, et al. Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019. JAMA Netw Open 2021;4(7):e2116233.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Kinsinger LS, Anderson C, Kim J, et al. Implementation of Lung Cancer Screening in the Veterans Health Administration. JAMA Intern Med 2017;177(3):399–406.

    Article  PubMed  Google Scholar 

  32. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups | EQUATOR Network [Internet]. [cited 2024 Jan 16];Available from: https://www.equator-network.org/reporting-guidelines/coreq/

  33. Bourgeault I, Dingwall R, De Vries R. The SAGE Handbook of Qualitative Methods in Health Research [Internet]. 1 Oliver’s Yard, 55 City Road, London EC1Y 1SP United Kingdom: SAGE Publications Ltd; 2010 [cited 2022 Dec 21]. Available from: https://methods.sagepub.com/book/sage-hdbk-qualitative-methods-in-health-research

  34. Guest G, Bunce A, Johnson L. How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability. Field Methods 2006;18(1):59–82.

    Article  Google Scholar 

  35. Powell AA, Bloomfield HE, Burgess DJ, Wilt TJ, Partin MR. A conceptual framework for understanding and reducing overuse by primary care providers. Med Care Res Rev MCRR 2013;70(5):451–472.

    Article  PubMed  Google Scholar 

  36. Breslau ES, Gorin SS, Edwards HM, Schonberg MA, Saiontz N, Walter LC. An Individualized Approach to Cancer Screening Decisions in Older Adults: A Multilevel Framework. J Gen Intern Med 2016;31(5):539–547.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Wong L. Data Analysis in Qualitative Research: A Brief Guide to Using Nvivo. Malays Fam Physician Off J Acad Fam Physicians Malays 2008;3(1):14–20.

    Google Scholar 

  38. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101.

    Article  Google Scholar 

  39. Strauss AL. Qualitative Analysis for Social Scientists. Cambridge University Press; 1987.

  40. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282(15):1458–1465.

    Article  CAS  PubMed  Google Scholar 

  41. Caverly TJ, Cao P, Hayward RA, Meza R. Identifying Patients for Whom Lung Cancer Screening Is Preference-Sensitive: A Microsimulation Study. Ann Intern Med 2018;169(1):1–9.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Schoenborn NL, Boyd CM, Pollack CE. Physician Attitudes About Using Life Expectancy to Inform Cancer Screening Cessation in Older Adults-Results From a National Survey. JAMA Intern Med 2022;182(11):1229–1231.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Wilt TJ, Harris RP, Qaseem A, High Value Care Task Force of the American College of Physicians. Screening for cancer: advice for high-value care from the American College of Physicians. Ann Intern Med 2015;162(10):718–725.

  44. Leung KMYB, Hopman WM, Kawakami J. Challenging the 10-year rule: The accuracy of patient life expectancy predictions by physicians in relation to prostate cancer management. Can Urol Assoc J 2012;6(5):367–374.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Enns JP, Pollack CE, Boyd CM, Massare J, Schoenborn NL. Discontinuing Cancer Screening for Older Adults: a Comparison of Clinician Decision-Making for Breast, Colorectal, and Prostate Cancer Screenings. J Gen Intern Med 2022;37(5):1122–1128.

    Article  PubMed  Google Scholar 

  46. Schoenborn NL, Massare J, Park R, Boyd CM, Choi Y, Pollack CE. Assessment of Clinician Decision-making on Cancer Screening Cessation in Older Adults With Limited Life Expectancy. JAMA Netw Open 2020;3(6):e206772.

    Article  PubMed  PubMed Central  Google Scholar 

  47. White N, Reid F, Harris A, Harries P, Stone P. A Systematic Review of Predictions of Survival in Palliative Care: How Accurate Are Clinicians and Who Are the Experts? PLoS ONE 2016;11(8):e0161407.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ 2000;320(7233):469–472.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Clément-Duchêne C, Carnin C, Guillemin F, Martinet Y. How Accurate Are Physicians in the Prediction of Patient Survival in Advanced Lung Cancer? The Oncologist 2010;15(7):782–789.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Ahmed SU, Burke M, McGuire M, et al. A Novel Curriculum on Using Life Expectancy to Inform Cancer Screening in Older Adults. J Am Geriatr Soc 2021;69(2):524–529.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Cheung LC, Berg CD, Castle PE, Katki HA, Chaturvedi AK. Life-Gained-Based Versus Risk-Based Selection of Smokers for Lung Cancer Screening. Ann Intern Med 2019;171(9):623–632.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Fagerlin A, Caverly T. screenLC.com [Internet]. 2023;Available from: https://screenlc.com/. Accessed 2/25

  53. Schoenborn NL, Lee K, Pollack CE, et al. Older Adults’ Views and Communication Preferences About Cancer Screening Cessation. JAMA Intern Med 2017;177(8):1121–1128.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Verduzco-Aguirre HC, Gomez-Moreno C, Chavarri-Guerra Y, Soto-Perez-de-Celis E. Predicting Life Expectancy for Older Adults with Cancer in Clinical Practice: Implications for Shared Decision-making. Curr Oncol Rep 2019;21(8):68.

    Article  PubMed  Google Scholar 

  55. Schoenborn NL, Janssen EM, Boyd CM, Bridges JFP, Wolff AC, Pollack CE. Preferred Clinician Communication About Stopping Cancer Screening Among Older US Adults: Results From a National Survey. JAMA Oncol 2018;4(8):1126–1128.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Schonberg MA, Kistler CE, Pinheiro A, et al. Effect of a Mammography Screening Decision Aid for Women 75 Years and Older: A Cluster Randomized Clinical Trial. JAMA Intern Med 2020;180(6):831–842.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Kukhareva PV, Li H, Caverly TJ, et al. Implementation of Lung Cancer Screening in Primary Care and Pulmonary Clinics: Pragmatic Clinical Trial of Electronic Health Record-Integrated Everyday Shared Decision Making Tool and Clinician-Facing Prompts. Chest 2023;S0012-3692(23)00641–4.

    Google Scholar 

  58. Lewis JA, Samuels LR, Denton J, et al. National Lung Cancer Screening Utilization Trends in the Veterans Health Administration. JNCI Cancer Spectr 2020;4(5):pkaa053.

  59. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143(5 Suppl):e93S-e120S.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Reynolds A. New Measure Coming for Lung Cancer Screening [Internet]. NCQA. 2022 [cited 2024 Feb 22];Available from: https://www.ncqa.org/blog/new-measure-coming-for-lung-cancer-screening/

Download references

Funding

This study was funded by VA HSR&D IIR 18-075 (PI: Wiener) and supported in part with resources from the VA Boston Healthcare System, the VA Bedford Healthcare System and the VA Ann Arbor Healthcare System.

Author information

Authors and Affiliations

  1. Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA and VA Bedford Healthcare System, Bedford, MA, USA

    Lauren Kearney MD, Rendelle E. Bolton PhD, MPH, Eduardo R. Núñez MD, MS, Jacqueline H. Boudreau MPH, Samantha Sliwinski MPH, Abigail N. Herbst MPH & Renda Soylemez Wiener MD, MPH

  2. The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA

    Lauren Kearney MD, Eduardo R. Núñez MD, MS & Renda Soylemez Wiener MD, MPH

  3. The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA

    Rendelle E. Bolton PhD, MPH

  4. Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA

    Eduardo R. Núñez MD, MS

  5. VA Ann Arbor Healthcare System, Ann Arbor, MI, USA

    Tanner J. Caverly MD, MPH

  6. National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC, USA

    Tanner J. Caverly MD, MPH & Renda Soylemez Wiener MD, MPH

  7. University of Michigan School of Medicine, Ann Arbor, MI, USA

    Tanner J. Caverly MD, MPH

Authors
  1. Lauren Kearney MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rendelle E. Bolton PhD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eduardo R. Núñez MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jacqueline H. Boudreau MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Samantha Sliwinski MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Abigail N. Herbst MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Tanner J. Caverly MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Renda Soylemez Wiener MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Study concept and design: Bolton, Nunez, Boudreau, Herbst, Sliwinski, Wiener. Acquisition of data: Bolton, Nunez, Boudreau, Sliwinski, Herbst. Analysis and interpretation of data: Kearney, Bolton, Wiener. Drafting of the manuscript: Kearney. Critical revision of the manuscript for important intellectual content: Bolton, Nunez, Boudreau, Sliwinski, Herbst, Caverly, Wiener. Obtained funding: Wiener. Study supervision (guarantor): Wiener.

Corresponding author

Correspondence to Lauren Kearney MD.

Ethics declarations

Conflict of Interest:

Dr. Caverly has an open-source license for a free, web-based tool to support shared decision-making for lung cancer screening (Decision Precision, screenLC.com). He receives no payments or royalties. Dr. Wiener serves as Associate Documents Editor (paid) for the American Thoracic Society, as well as in several unpaid leadership roles related to lung cancer screening policy for professional societies including the American Thoracic Society, American College of Chest Physicians, American College of Radiology, and American Cancer Society National Lung Cancer Round Table.

Disclaimer:

This work does not necessarily represent the views of the Department of Veteran Affairs or the US government.

IRB Approval:

VA Boston Healthcare System #1590535-14.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Prior Presentations

Kearney LE, Bolton R, Nunez ER, Boudreau, JH, Sliwinski S, Herbst A, Caverly T, Wiener RS. Exploring provider conceptualization of limited life expectancy in the context of lung cancer screening and the acceptability of a prediction tool in clinical practice: a qualitative study. [Poster]. American Thoracic Society, Washington DC, United States. https://www.atsjournals.org/doi/abs/10.1164/ajrccmconference.2023.207.1_MeetingAbstracts.A6309.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 24 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kearney, L., Bolton, R.E., Núñez, E.R. et al. Tackling Guideline Non-concordance: Primary Care Barriers to Incorporating Life Expectancy into Lung Cancer Screening Decision-Making—A Qualitative Study. J GEN INTERN MED (2024). https://doi.org/10.1007/s11606-024-08705-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11606-024-08705-x

KEY WORDS

Search

Navigation