The complicated ‘Yes’: Decision-making processes and receptivity to lung cancer screening among head and neck cancer survivors

https://doi.org/10.1016/j.pec.2018.04.012Get rights and content

Highlights

  • Qualitatively examines head and neck cancer survivors’ perspectives on lung cancer screening.

  • Survivors were receptive to lung cancer screening, minimizing potential harms.

  • They drew upon their head and neck cancer experiences as they considered screening.

  • Lung cancer screening discussions are complicated by head and neck cancer survivors’ history.

  • Specialty care settings might be more appropriate for screening discussions with this population.

Abstract

Objective

Shared decision making (SDM) is recommended when offering lung cancer screening (LCS)—which presents challenges with tobacco-related cancer survivors because they were excluded from clinical trials. Our objective was to characterize head and neck cancer (HNC) survivors’ knowledge, attitudes, and beliefs toward LCS and SDM.

Methods

Between November 2017 and June 2018, we conducted semi-structured qualitative interviews with 19 HNC survivors, focusing on patients’ cancer and smoking history, receptivity to and perceptions of LCS, and decision-making preferences

Results

Participants were receptive to LCS, referencing their successful HNC outcomes. They perceived that LCS might reduce uncertainty and emphasized the potential benefits of early diagnosis. Some expressed concern over costs or overdiagnosis, but most minimized potential harms, including false positives and radiation exposure. Participants preferred in-person LCS discussions, often ideally with their cancer specialist.

Conclusion and Practice Implications

HNC survivors may have overly optimistic expectations for LCS, and clinicians need to account for this in SDM discussions. Supporting these patients in making informed decisions will be challenging because we lack clinical data on the potential benefits and harms of LCS for cancer survivors. While some patients prefer discussing LCS with their cancer specialists, the ability of specialists to support high-quality decision making is uncertain.

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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