Understanding Patient-Level Variables That Influence Lung Cancer-Screening Behavior and the Nurse's Role

Purpose: Lung cancer kills more people in the U.S. than breast, colorectal, pancreatic, and prostate cancers combined (American Cancer Society, 2016). Most die because they are diagnosed at an advanced stage with limited treatment options and a 1% five-year relative survival rate (American Cancer Society, 2016). Until recently, an effective screening test to identify lung cancer at an earlier stage did not exist. However, lung cancer screening with low-dose computed tomography is a recent U.S. Preventive Services Task Force Grade B recommendation for long-term smokers (Aberle et al., 2011; USPSTF 2014). Understanding variables that may or may not influence screening participation at the individual level is essential (Carpenter, 2010; Jonnalagadda et al., 2012). However, lung cancer screening also has potential harms which must be balanced against its benefits and may be weighed differently by different individuals. Shared decision-making is particularly important within contexts where one best solution does not exist (Makoul & Clayman, 2006). This is the case in lung cancer screening – where benefits are present, but risk and uncertainty exists and is patient specific. Nursing is uniquely poised to foster shared decision-making in lung cancer screening decisions through patient education, but we must first understand knowledge, risk perception, and health beliefs in the screening-eligible patient population in order to develop effective patient-level interventions that enhance shared decision-making in lung cancer screening, and subsequent screening behavior, in those at greatest risk. Therefore, the purposes of this study were to: (1) describe long-term smokers’ knowledge and perceptions of lung cancer, risk, and screening; and (2) examine relationships between individual health beliefs (risk, benefits, barriers, self-efficacy) and screening behavior.

Methods:  Descriptive, cross-sectional two-phase design using qualitative and quantitative data. Phase I: 4 focus groups (N=26) were recruited; 2 groups who recently completed lung cancer screening (n=12) and 2 groups who had never been screened (n=14). Data was collected via audio recordings and analyzed using thematic content analysis. Phase II: Guided by the Conceptual Model on Lung Cancer Screening Participation (Carter-Harris, Davis, & Rawl, 2016), a national convenience sample of screening-eligible individuals was recruited to collect data using survey methods (N=497). Data measured multiple variables including sociodemographic, health status characteristics and individual health beliefs.

Results: Phase I revealed low knowledge levels and confusion about risk factors and screening, and variables such as risk, benefits, barriers, self-efficacy, stigma, mistrust, fatalism, fear, and worry may be uniquely relevant in lung cancer screening. Using logistic regression in Phase II, we found perceived benefits (p<.001; OR=1.08, 95%CI (1.04, 1.14) and self-efficacy (p=.001; OR=1.06, 95%CI (1.02, 1.09) statistically significant, while perceived barriers was moderately significant (p=.054; OR=0.98, 95% CI (0.96, 1.00) with lung cancer screening behavior. Perceived benefits (p<.001) and self-efficacy (p=.019) maintained statistical significance with similar odds ratios, and barriers remained borderline significant (p=.081) when adjusted for other variables using multivariable logistic regression.

Conclusion:  Results from this study indicate individual health beliefs and other individual-level variables may be important in understanding lung cancer screening behavior in long-term smokers. Nursing is an integral component in the patient education process related to cancer screening and primary and secondary prevention. Nursing-delivered interventions tailored on salient variables and integrated into the primary care visit to support patient-provider discussions about, and decisions related to, lung cancer screening are needed to advance the science of this new screening option to support early detection of the world’s deadliest cancer.