The complicated ‘Yes’: Decision-making processes and receptivity to lung cancer screening among head and neck cancer survivors
Introduction
Lung cancer is the leading cause of cancer-related deaths in the United States [1]. While 5-year survival is 65% for early-stage lung cancers, most lung cancers are diagnosed at advanced stage when survival is 16% [2]. The National Lung Screening Trial (NLST) found that lung cancer screening (LCS) with low-dose CT scans (LDCT) reduced lung cancer mortality by 20% compared to screening with chest radiographs [3]. Based in large part on the NLST results, in 2013 the US Preventive Services Task Force (USPSTF) issued a Grade B recommendation supporting LDCT screening of high-risk patients, including adults ages 55 to 80 years, with at least a 30-pack-year smoking history, who currently smoke or have quit within 15 years [4].
The National Comprehensive Cancer Network (NCCN) broadened eligibility criteria to include additional risk factors, including a history of head and neck cancer (HNC) [5]. The NCCN recommended considering screening these survivors beginning at age 50 if they had at least a 20-pack-year smoking history. Additionally, the Centers for Medicare & Medicaid Services (CMS) issued a national coverage determination for reimbursement, requiring clinicians to engage patients in shared decision making using a decision aid [6]. Survivorship guidelines from the American Cancer Society recommended that LCS discussions take place in the primary care setting [7].
However, there are multiple challenges to considering LCS discussions for HNC survivors. Little evidence exists that primary care providers can effectively hold LCS discussions with eligible patients without a cancer history [8], let alone among cancer survivors. Data suggest that primary care providers have limited awareness of lung cancer screening clinical trial results or professional society guidelines [9], [10], [11], [12], [13], [14]. In the past, studies have shown that primary care providers often fail to present balanced information regarding cancer-screening decisions for breast, colorectal, and prostate cancer. While decision aids can greatly facilitate these discussions, the available decision aids present NLST data, which may not be applicable to HNC survivors because cancer survivors were not eligible for the study [15]. Epidemiologic data suggest that early stage lung cancer has a greater mortality impact on HNC survivors than individuals with no prior cancer history, which might limit the mortality benefit of lung cancer screening for HNC survivors [16].
These issues call into question both how to conceptualize the overall benefits and risks of LCS for HNC survivors, and how and where to discuss LCS. Despite increased research into patient perceptions of LCS [10], [17], [18], [19], [20], [21], little is known about cancer survivors’ perceptions. We conducted a qualitative study to examine the knowledge, attitudes, and decision-making preferences about LCS among HNC survivors.
Section snippets
Subjects and settings
We recruited participants through the Otolaryngology Clinic at The University of Iowa Hospitals and Clinics (UIHC), an academic tertiary facility. Eligibility criteria included 1) diagnosis of HNC, including oral cavity, oropharyngeal, or laryngeal cancers, 2) being free of any known persistent or recurrent upper aerodigestive tract cancer at least one year after completion of cancer-directed therapy, and 3) having at least a 20-pack-year smoking history. Once identified as eligible by treating
Participant characteristics
All 19 participants had been treated for HNC with surgical resection, radiation, and/or chemotherapy. Three patients were current smokers, and 16 reported having quit. Of the former smokers, three had quit longer than 15 years before, and six reported quitting as a result of their diagnosis. Table 2 presents sociodemographic information and smoking histories.
Knowledge of screening and LCS
Many participants reported currently engaging in some screening, notably for prostate, colorectal, and/or breast cancer. However, most
Discussion
We addressed the broader screening recommendations for HNC survivors by conducting in-depth interviews regarding their cancer experiences and views about LCS. We found that survivors’ cancer experiences shaped LCS decision-making processes, including their health care priorities and their preferences for receiving and working through information about LCS. Given CMS’ reimbursement requirement for shared decision making, our findings have important implications for how health care providers
Funding
Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under the Award NumberUG1CA189823 (Alliance for Clinical Trials in Oncology NCORP Grant), U10CA180858, and by the National Center for Advancing Translational Sciences of the National Institutes of Health under the Award Number U54TR001356. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes
Conflict of interest
None
Personal information of patients
We confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
We thank the patients and providers who participated in the study for sharing their time, experiences, and expertise with us.
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