Lung cancer CT screening: Psychological responses in the presence and absence of pulmonary nodules
Introduction
Lung cancer is the most commoncause of cancer-related deaths worldwide. [1] During 2014 approximately 46,400 individuals in the United Kingdom (UK) were diagnosed with lung cancer [2]. Despite the incidence of lung cancer decreasing [3], mortality rates remain high, with 1-year survival rates ranging from 71% when diagnosed at stage 1 to 16% at stage 4 [4].
The National Lung Screening Trial (NLST), showed serial computed tomography (CT) scanning was associated with a 20% reduction in lung cancer mortality. [5] However, screening has potential harms, such as radiation exposure, the detection of non-clinically relevant findings, over-diagnosis and psychosocial harms [[6], [7], [8], [9], [10], [11]]. It is therefore important to ensure acceptability to the population being screened [12], and that overall benefits outweigh the harms [13].
Assessments of the psychosocial impact of lung cancer screening are limited to studies using CT scanning. The NLST, Pittsburgh Lung Screening Study, and the UK Lung Cancer Screening (UKLS) Trial found increased anxiety in those with true positive screening results compared to those with negative results. The UKLS also found significantly higher cancer worry scale scores 2 weeks after receiving CT scan results in those referred for a repeat CT scan compared to those with negative results. However, absolute differences were small and not thought to be clinically important. [[14], [15], [16], [17]] Additionally, the Dutch-Belgian Randomized Lung Cancer Screening Trial (NELSON trial) and the Pittsburgh Lung Screening Study found increased lung cancer specific distress in those with an indeterminate result, which diminished over time [16,18,19].
As screening with CT scanning becomes more widespread, more people will be found to have incidental findings, such as pulmonary nodules. Pulmonary nodules are widely defined as round lesions within the lung, less than 3 cm in diameter and surrounded by normal lung tissue. [20,21] The NLST reported an incidence of pulmonary nodules of 25.9% in participants with a pack year history of at least 30 years [5]. Several studies used psychological measures to assess the negative impact of a diagnosis of pulmonary nodules [[22], [23], [24], [25]], finding increased emotional distress [22,23], frustration and fear [25] amongst those with nodules. Additionally, French individuals diagnosed with pulmonary nodules reported lower health-related quality of life (HRQoL) (measured using the SF36) compared to the French general population. [24]
Our study assesses short and mediumterm psychological responses amongst a sample of participants, with or without pulmonary nodule(s) identified on their first CT scan, within the Early Cancer Detection TestLung Cancer Scotland Study (ECLS Study). [26] This is a randomised controlled trial assessing the effectiveness of a blood test for lung cancer screening, measuring autoantibodies against seven antigens (Early CDT®-Lung test) [26,27]. A positive Early CDT®-Lung test is associated with a significantly increased risk of malignancy in the presence of pulmonary nodules 420 mm in diameter [28], and the consequent potential for adverse psychological effects. This study is therefore timely in assessing psychological impacts of this test and subsequent CT scanning.
Section snippets
Methods
This paper presents data on a sub-sample of participants in the ECLS study. Current or ex-smokers aged 50–75 years, with at least 20 pack-years, or fewer pack-years with a first-degree relative with lung cancer from Greater Glasgow and Clyde or Tayside, were randomised 1:1 to an Early CDT®-Lung test group or a non-screened control group. All trial participants were asked to complete a baseline questionnaire preceding awareness of group allocation. Those with positive Early CDT®-Lung tests were
Results
Three hundred and thirty eight Early CDT®-Lung test-positive ECLS trial participants took part in the psychological outcomes study, 269 (174 in the normal CT group and 95 in the nodule group) of whom were eligible to be included in the analyses presented in this paper (Fig. 1). Response rates to follow-up questionnaires were high. The analysis included 95% at 3 months and 94% at 6 months. All participants were aware of their CT scan result on completing the 3-month questionnaire.
Summary
This study demonstrates that a diagnosis of pulmonary nodules on a CT scan following an Early CDT®-Lung positive result for lung cancer screening does not result in an adverse psychological response in relation to affect, health anxiety, thought intrusion and illness perception compared to those who had a normal CT scan in both the short and medium-term. Although those in the nodule group had statistically significantly fewer avoidance behaviours than those in the normal CT group at 3 months
Funding
This study was carried out as part of a National Institute for Health Research (NIHR) School for Primary Care Research (SPCR) funded academic clinical fellowship. The views expressed are those of the author(s) and not necessarily those of the NIHR, the NHS or the Department of Health. The ECLS study was funded by the Scottish Executive and Oncimmune Ltd. The follow-up data collection was funded by University of Nottingham PhD studentships and by Oncimmune Ltd.
Ethical approval
Ethical approval was given by the East of Scotland Research Ethics Service as an amendment to the main ECLS study: REC reference 13/ES/0024, amendment number AM16.
Competing interests
The University of Dundee received funding from the Scottish Executive, the University of Glasgow received funding from the Scottish Executive and Oncimmune Ltd and the University of Nottingham received funding from Oncimmune Ltd to conduct this research. Marcia Clark was funded by an NIHR School for Primary Care Research Academic Clinical Fellowship and Laura Bedford and Ben Young were funded by University of Nottingham PhD studentships.
John Robertson reports grants from AstraZeneca, personal
Acknowledgements
We thank the ECLS trial staff for recruiting participants and collecting baseline data from the trial participants. We gratefully acknowledge the contribution to this study and publication made by the Tayside Clinical Trials Unit (TCTU).
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