Challenges to treatment preparedness among lung cancer patients from a healthcare provider perspective: a mixed-method study

Abstract

We aim to (1) explore the main barriers to treatment faced by lung cancer patients, from a provider’s perspective, and (2) the existing support systems in addition to recommended mitigation strategies to enhance the preparedness process. Our study invol ves 50 surveys and 10 interview responses, in a mixed-method design. We conducted descriptive statistics and thematic analysis through a hybrid inductive-deductive approach. We based our analysis on the Optimal Care Pathways framework and Andersen’s Behavioral Model. The doctors identified challenges to patient readiness for treatment, such as a lack of knowledge about treatment options, emotional load, logistical barriers (e.g., transportation), and financial pressure. The providers mentioned some initiatives adopted to try to address these challenges, namely in-person instruction, printed materials, and transportation services provided by social workers. However, they emphasized the potential role of accessible digital tools to complement existing educational and support processes. Our results highlight the need to create educational protocols that are standardized yet phase-specific to address the challenges of each treatment phase. These suggestions may improve overall therapy results, decrease delays, and increase patient adherence.

Introduction

Despite decades of decreasing mortality rates, lung cancer remains a leading cause of cancer death in the US¹, with estimates of 226,650 new cases and 124,730 deaths in 2025 alone². Due to its asymptomatic nature, lung cancer is generally detected late, thus increasing the complexity of treatment planning³. The treatment journey for lung cancer patients involves a series of critical decisions made under the pressure of time and emotional distress, particularly among patients with an advanced stage of the disease. To ensure patients’ successful adherence to the treatment recommendations, it remains critical to engage with them early in the process⁴. However, many patients continue to experience disengagement due to unmet informational and other support needs⁴.

Frameworks such as the Health Belief Model, the Cancer Care Continuum, and the Shared Decision-Making Framework have frequently been applied to examine how individuals engage with care and make treatment-related decisions^5–7. However, these models often portray the treatment phase as a single, undifferentiated step, typically positioned between diagnosis and survivorship⁸. This limited framing tends to overlook the distinct and often complex experiences patients face during this period, particularly the processes of making informed decisions, preparing for treatment, and taking the first steps toward initiating care^9,10.

Emerging research suggests that disaggregating the treatment phase into multiple phases can contribute to the accurate identification of the challenges that patients face when transitioning from detection to treatment¹¹. Frameworks such as the Optimal Care Pathways (OCP), present a methodical approach to understanding this process by categorizing treatment into three interrelated stages: the “initial investigations and referral” phase, commonly referred to as the decision-making stage, the “staging and treatment planning” phase, also known as the preparation stage, and the “treatment initiation” phase, during which active therapeutic interventions are initiated¹². Although its own unique set of challenges characterizes each of these stages, there exists a paucity of research that investigates patient barriers within each distinct phase¹³.

To address this gap, our study adopts a mixed-methods approach to explore the barriers to lung cancer treatment from the perspective of healthcare professionals. The primary objectives of this research are to assess: (1) the principal challenges observed by providers throughout the treatment continuum; (2) the strategies currently employed to mitigate these challenges; and (3) the areas in which further enhancements are required to improve patient care.

Our analysis is based on two theoretical frameworks: the OCP framework and Andersen’s Model. The OCP framework provides a foundation for understanding treatment as a phased process, including the decision-making, preparation, and initiation phases. The Andersen’s Behavioral Model of Health Services offers a perspective to interpret healthcare access and outcomes as influenced by predisposing characteristics, enabling resources, and perceived or evaluated needs [14]. Together, these frameworks allow a more rigorous examination of the factors that may hinder a provider’s ability to guide patients through the complexities of lung cancer treatment effectively.

Results

The study involved 60 participants (50 surveys and 10 interviews), with 91.7% in the oncology specialty. The participants had an average of 5 years of practice (SD = 4) and saw about 126 patients per year (SD = 198). Table 1 summarizes the descriptive statistics. Interview participants also described several underlying contributors to these difficulties, including cognitive overload, emotional distress, and communication-related challenges such as language barriers.

Table 1.

Descriptive statistics of the sample

		Survey respondents		Interview respondents		All respondents
		N/mean	%/SD	N/mean	%/SD	N/mean	%/SD
Specialty	Oncology (N, %)	45	90%	10	100%	55	91.7%
	Pulmonology	3	6%	0	0%	3	5%
	Surgery	1	2%	0	0%	1	1.7%
	Other	1	2%	0	0%	1	1.7%
Years of practice (mean, SD)		4	4	7	5	5	4
Number of patients seen annually (mean, SD)		136	215	73	57	126	198

This upcoming section will present the challenges faced by patients. The challenges are clustered in decision-making-related challenges and preparedness and treatment initiation challenges.

Decision-making related challenges

The first predisposing factor-related challenge was difficulty understanding treatment options and prognosis

Survey respondents, 70% (N = 35), identified difficulty understanding treatment options as a major challenge during decision-making. However, most respondents (66%, N = 33) believed that informational resources were generally available to patients (Supplementary Table 1).

Interview participants described how the complexity of treatment regimens, prognostic uncertainty, emotional distress, and cognitive overload impaired patients’ ability to understand and process treatment-related information. Providers emphasized that although information may technically be available, patients frequently struggled to retain and comprehend it during emotionally overwhelming clinical encounters.

“I think patients also struggle with understanding the different types of treatments available and how and why we combine different modalities.” _ID 7

“These are, like, very—especially if we’re giving, like, many types—you know, a combination of medications and a regimen.” _ID 1

“It’s quite complicated to explain how much a treatment will improve their outcomes.” _ID 3

“I will say I occasionally struggle with patients with metastatic cancer, understanding how few treatments we really have in the grand scheme of things. And so I see them make decisions that I would not personally make because they underrate how dangerous their prognosis is.” _ID 7

“I think, for the decision making, sometimes it’s a challenge because there are… many treatment options, so trying to figure out which is the best one.” _ID 9

“For the patients in whom there are treatment decisions, it’s often very hard to convey the data as we think of it to patients.” _ID 7

“Because usually patients will get for them, like, 10% of what you’re explaining on their first visits.” — ID 3 “They didn’t fully understand what you were saying, or they forgot.” — ID 5 “Even sometimes they can mislead. Or you say… they focus just on that one, and they miss all the entire piece.” — ID 3

The second challenge was emotional overload impeding decision-making

Among survey respondents, 68% (N = 34) identified emotional distress as a barrier to decision-making.

Interview participants described diagnosis-related emotional overload as a major factor limiting patients’ ability to absorb information, evaluate treatment options, and participate in treatment decisions.

“I think in the beginning, it’s challenging in that it’s, like, a very emotionally distressing situation to get a new, you know, diagnosis of cancer, especially metastatic cancer.” — ID 1

“Balancing that with also making sure you can get all the […] information you need about the treatment that you’re about to start.” — ID 1

Under needs factors, the first challenge mentioned was managing Cancer Symptoms complicates decisions. None of the interviewed doctors mentioned cancer symptoms as a factor influencing patients’ decision-making, and only 32% (N = 16) of survey respondents believed it could affect their decisions.

Under enabling factors, the first challenge was financial Concerns Shape Perceptions

Sixty percent of survey respondents (N = 30) identified financial concerns as factors influencing treatment decision-making.

Interview participants described how insurance restrictions, economic uncertainty, and limited resources contributed to stress over treatment decisions and delays in access to care.

“They can’t figure out… their insurance issue. Sometimes they can’t get PET scans here because they can only see people in XX.” — ID 5

“There’s little resources to allocate to every patient.” — ID 4

Preparedness and treatment initiation challenges

Under predisposing factors, the first challenge mentioned was limited understanding of treatment options

Among survey respondents, 56% (N = 28) identified a lack of understanding of treatment processes as a challenge to treatment preparation. In contrast, only 34% (N = 17) identified inadequate side-effect education as a major barrier to beginning treatment.

Interview participants described how patients frequently struggled to understand treatment logistics, treatment flow, expected timelines, and side-effect management. Providers emphasized that although information was discussed during visits, many patients began treatment without fully understanding what the process would involve or how to manage treatment-related symptoms.

Healthcare providers noted that one factor influencing whether patients start their treatment is their understanding of the prescribed options, as a lack of clarity reduces their confidence in proceeding.

“So that can sometimes be, like, a barrier to really understanding what’s going on and what the plan for treatment is.” — ID 1

“But even for a patient who… has a lot of support, there’s a lot that goes into treatment. I think understanding, like, the logistics of how things work in the very beginning can be difficult.” — ID 1

“It can be, like, a very long treatment day… I guess just, like, understanding the flow and logistics of getting treatment.” — ID 1

“Also, I think communicating side effects can be challenging because there are so many of them… it doesn’t cover all of the possibilities.” — ID 1

“They frequently ask me about managing side effects about the therapy.” — ID 2

The second challenge was fear or anxiety about treatment

Emotional distress and psychological burden were commonly identified by survey respondents as barriers affecting treatment readiness and engagement.

Interview participants described fear, denial, and emotional overload as major barriers affecting patients’ ability to psychologically prepare for treatment initiation. Providers noted that some patients struggled to emotionally process the diagnosis before beginning treatment.

Providers described the emotional burden of beginning treatment as an important factor contributing to fear, hesitation, and treatment-related distress. Some patients had difficulty accepting the diagnosis, while others experienced psychological distress that disrupted their treatment planning:

“It’s a very emotionally distressing situation to get a new, you know, diagnosis of cancer, especially metastatic cancer.” — ID 1

“Before treatment, the biggest thing is… patients wrapping their heads around… the seriousness of the diagnosis.” — ID 7

“There’s an understanding issue. Patients often don’t fully understand what they’re getting into… there may be some element of denial.” — ID 5

Under enabling factors, the first challenge was logistical issues (e.g, transportation, scheduling)

Among survey respondents, 68% (N = 34) identified logistical barriers as challenges affecting treatment initiation. Additionally, 80% (N = 40) highlighted transportation and scheduling-related burdens as major barriers to maintaining treatment continuity.

Interview participants described transportation difficulties, scheduling burdens, mobility limitations, and long treatment visits as major obstacles to treatment initiation and continuity of care.

“Patients often face logistical difficulties when they follow a specific therapy. For example, travel is difficult for them.” — ID 2

“Often it is logistical, getting to the appointment… brain metastases… can’t drive… missed every scan and every visit because his access ride never showed up.” — ID 5

“Transportation, I think coming in, particularly the ones that have to come in more regularly… is another big challenge.” — ID 9

The second challenge was financial concerns

Among survey respondents, 64% (N = 32) identified financial issues as barriers affecting treatment initiation.

Interview participants described insurance restrictions, limited institutional resources, and financial stress as contributors to treatment delays and difficulties accessing diagnostic and treatment services.

“They can’t figure out… their insurance issue. Sometimes they can’t get PET scans here because they can only see people in New Jersey.” — ID 5

“There’s little resources to allocate to every patient.” — ID 4

The third challenge was limited support systems

Among survey respondents, 58% (N = 29) identified lack of caregiver or social support as a challenge affecting treatment initiation.

Interview participants described how patients without caregivers or family support often struggled to understand treatment plans, navigate appointments, and cope with emotional distress during treatment initiation.

“Especially if the patient is alone… it can be especially challenging to really understand what’s going on while also… navigating all the emotional stuff.” — ID 1

“We find that… if the patient is alone… it can be especially challenging.” — ID 1

The last challenge was the language barriers

Among survey respondents, 62% (N = 31) identified language and communication barriers as obstacles affecting treatment initiation.

Interview participants emphasized that language and cultural barriers complicated access to care, understanding of instructions, and continuity of treatment.

“When you have this type of population—African American, Spanish, sometimes Asian—and some of them don’t speak the language, it’s already hard enough for them to make it all the way to the office.” — ID 6

Under need factors, the first challenge was comorbidities and treatment-related toxicities

This topic was not directly assessed in the survey component.

An additional theme emerging uniquely from the interview data was the role of comorbidities and treatment-related toxicities in delaying treatment initiation. Providers described how complex medical conditions, multiple medications, and treatment-related burdens increased the need for individualized preparation and coordination.

“They struggle with the treatment… and the next is the struggle with the treatment toxicity.” — ID 10

“Older patients who take a lot of other medications… that can probably make it more challenging.” — ID 1

Current mitigation efforts

As shown in Supplementary Table 2, numerous efforts have been made to address these challenges and improve how patients are informed and supported.

Survey respondents reported several strategies currently used to support patient preparedness. In-person consultations (N = 46, 92%) and printed educational materials (N = 31, 62%) were the most commonly used approaches, followed by online resources (N = 18, 36%). Educational videos were minimally used (N = 2, 4%).

Interview participants described existing mitigation efforts focused on improving treatment understanding, addressing logistical barriers, reducing emotional burden, managing symptoms and side effects, and maintaining patient follow-up and outreach.

Under improving understanding of treatment, providers described structured onboarding processes involving initial treatment discussions and nurse-led educational follow-up visits.

“So I guess in terms of how it works when we see them for the first time… we go over the treatment plan, what it’s going to look like.” — ID 1

“And then one of the nurses will follow up and do a teaching visit… explaining how to manage the medications at home.” — ID 1

Under addressing logistical barriers, and to tackle access issues, especially related to transportation and scheduling, clinics worked with social workers and care coordinators to help patients facing these logistical challenges.

“And we have social workers who work with us. They try to set up rides for people… especially if they’re older or they’re alone.” — ID 1

Under reducing emotional burden, several participants emphasized the importance of psychosocial support in alleviating the emotional stress associated with treatment. These supports include referrals to counseling, access to social workers, and encouragement to join support groups or other resources for patients.

“We also ask if they want to speak with a social worker to talk through their feelings… especially if they seem overwhelmed.” — ID 1

Under managing symptoms and side effects, proactive counseling and education about expected side effects are used to prepare patients, helping them avoid unmanaged symptoms and encouraging timely reporting of complications.

“We try to go over the common side effects right at the beginning, so they know what to expect and when to call us.” — ID 1

Under enhancing follow-up and outreach, recognizing that some patients may disengage or miss visits, clinics have established proactive outreach systems to ensure continuous care. This includes call-back routines and targeted follow-ups for patients who miss appointments.

“So if a patient, like, doesn’t show up for their chemo, we usually call them the same day to see what happened and try to get them rescheduled.” — ID 1

“I think we’re very good about, like, proactively reaching out to patients who don’t respond or show up for appointments.” — ID 1

Recommendations for enhancing preparedness for treatment

Survey respondents prioritized emotional and psychological support services (N = 37), logistical support (N = 36), and more detailed educational materials (N = 33) as key areas requiring improvement.

Interview participants emphasized the need for more formalized and standardized educational procedures, stronger communication strategies, caregiver involvement, proactive patient engagement systems, and digital tools that complement in-person education.

“They often don’t understand their scans or how decisions are made… visuals might help.” — ID 10

“That’s where probably technology approaches may facilitate and improve the understanding of patients.” — ID 3

“The figure of the caregiver… is very, very important.” — ID 2

“You have to try to engage people at the level they’re at… and their family members.” — ID 7

Additionally, clinicians emphasized the importance of “building trust early” and recommended systems that encourage patients to “proactively reach out with questions or symptoms” without fearing they are “bothering” providers. They suggested this could include patient navigators or dedicated check-in calls, especially for those at risk of disengagement. Lastly, they proposed structural changes to reduce practical barriers to care, such as “offering parking vouchers as not everyone gets them consistently” and “ensuring access to transportation services to simplify appointment logistics.”

Discussion

This mixed-methods study uses the Optimal Care Pathways Framework and Andersen’s Behavioral Model to identify the barriers healthcare providers see as critical to lung cancer patients’ readiness for treatment. It also aims to examine current strategies and those needed to overcome these challenges. Table 2 summarizes the barriers to lung cancer treatment preparedness and the solutions aligned with the two frameworks.

Table 2.

Summary table of the lung cancer treatment preparedness barriers and solutions

OCP Phase	Andersen Model Factor	Key Barriers Identified	Current mitigation efforts	Recommended Solutions
Decision Making	Predisposing	- Limited understanding of treatment options and prognosis- Emotional overload at diagnosis	In-person consultations; printed educational materials; nurse-led discussions and teaching visits	- Early, structured education sessions- Teach-back techniques- Involving caregivers in discussions
	Enabling	- Financial uncertainty and insurance confusion- Transportation barriers	Social worker involvement; transportation coordination; referral assistance	- Financial navigation support- Coordination with social workers and transportation services
	Need	- Difficulty retaining information- Misinterpretation of risk	Repeated explanations during clinical visits; provider clarification during consultations	- Repetition of key messages across visits- Use of visual aids and multilingual materials
Preparation	Predisposing	- Ongoing anxiety/fear- Unclear logistics (e.g., schedule, expectations)	Initial onboarding discussions; nurse-led orientation and follow-up visits	- Standardized onboarding protocols- Nurse-led orientation and follow-up calls
	Enabling	- Lack of caregiver or support network- Language barriers	Family involvement during visits; interpreter support when available	- Family-inclusive appointments- Culturally and linguistically tailored resources
	Need	- Treatment side effects not well explained- Unanswered questions	Side-effect counseling; medication and symptom education sessions	- Proactive side effect counseling- Expanded consultation time or patient navigation services
Initiation	Predisposing	- Fear of treatment toxicities- Continued misunderstanding of the treatment plan	Emotional support referrals; reassurance and counseling during visits	- Use of patient-centered education tools (videos, infographics)- Encourage a question-asking culture
	Enabling	- Logistical issues (scheduling, travel)- Gaps in continuity of care	Appointment reminders; outreach calls for missed visits; transportation coordination	- Streamlined scheduling systems- Appointment reminders and follow-up outreach
	Need	- Comorbidities complicating treatment start- Delays due to missed appointments	Individualized follow-up; symptom monitoring and rescheduling support	- Individualized care planning- Risk flagging and proactive rescheduling strategies

Our findings show that newly diagnosed lung cancer patients face two main challenges as they prepare for treatment, including decision-making and starting treatment issues. These challenges are classified into predisposing, enabling, and need factors based on Andersen’s Behavioral Model¹⁴.

During decision-making, predisposing factors such as patients’ difficulty understanding treatment options, goals, and outcomes, as well as emotional burden, were reported to impair patients. This result reflects prior research on the unmet needs of newly diagnosed lung cancer patients in decision-making situations^15,16. Some researchers attribute this challenge to complex decision-making processes, while others link it to the lack of prerequisites for shared decision-making^17,18. In fact, a study by Mokhles et al. showed that lung cancer patients who experience decisional conflict are more likely to feel that they were not adequately informed about the options available¹⁹. In. Additionally, the finding on the emotional burden corroborates findings from Nguyen et al. that acute anxiety at diagnosis negatively impacts patients’ capacity to retain information and to make informed decisions²⁰. Enabling factors, namely financial and logistical constraints, were mentioned to erode decision confidence further, echoing findings from previous studies on the out-of-pocket costs, insurance coverage, and transportation issues that cancer patients face, which impact their decisions^21,22.

In the preparation phase, inadequate education about expectations and anxiety persisted as predisposing factors impacting patients’ readiness to begin therapies, while enabling factors, such as limited support systems and logistical hurdles, continued to obstruct patients’ access^23,24. Our results expand on Cone et al.‘s insights into patients’ confusion about treatment logistics and its impact on treatment initiation of treatment^25,26. Lastly, need factors, including comorbidities and toxicity concerns, are likely to delay treatment initiation, which underscores physical health burdens as drivers of delayed treatment initiation, beyond what has been shown in previous research¹⁴. Overall, our results confirm existing barriers in cancer care, but also expand to lung cancer treatment settings, where some of the challenges are underrecognized and warrant targeted attention.

Providers in this study shared various strategies already used to support patient preparedness, reflecting established best practices, such as face-to-face consultations, printed materials, and reduced reliance on online resources and educational videos. Although these methods have been successful in various settings, our study participants acknowledged that some gaps remain. Extended in-person education, especially when delivered by patients, has been shown to improve patients’ knowledge about and preparedness for lung cancer screening, as well as enhance other cancer patients’ understanding of their condition, which our study expands to include treatment readiness^27–29. To overcome logistical challenges, some social workers and care coordinators facilitate transportation support. Previous studies have demonstrated that this approach is effective in reducing no-show and adherence rates^30,31. While these approaches may show potential strengths in various settings, their adoption by some providers and social workers often only tackles immediate access issues. For instance, individual counseling sessions typically address only the most common problems. Also, non-consistent, standardized protocols provided to guide health systems in overcoming logistical challenges may limit access to care to people who have access to such resources only. Referring patients to counseling and support groups has also been used in some cases to reduce treatment anxiety, based on the literature on mental health support³². Printed educational materials were also provided in some settings. However, one-off consultations and printed educational materials may not be very accessible to patients with low health literacy and patients from different backgrounds^16,33,34. Furthermore, due to low digital literacy and limited technology exposure, some technology-based educational interventions provided by certain providers may not yield optimal results³⁵.

To address these barriers, participants emphasized the importance of more formalized educational processes that provide consistent treatment preparation while remaining adaptable to patients’ literacy levels, language needs, and cultural contexts. Adopting teach-back techniques could also honor all patients’ understanding and self-efficacy^36–38. Teach-back is a communication method used in healthcare to confirm that a patient truly understands the information explained to them^36–38. Although our participants did not suggest it, adding training tools and materials into electronic health record templates and patient portals could help health systems support patient education³⁹.

Moreover, it remains important to train care teams on the consistent delivery of health-related messages, in a proactive manner to help address logistical and financial challenges that patients face when starting treatment and relying on patient navigators could strengthen the quality of messages conveyed³¹. Although providers reported limited current use of digital educational tools and acknowledged barriers related to health and digital literacy, several interview participants described potential value in digital interventions as complementary supports to reinforce in-person education and improve accessibility outside clinical visits. Prior research suggests that such approaches may support information retention and patient engagement when appropriately adapted to patient literacy, language, and accessibility needs⁴⁰. Some apparent discrepancies between survey and interview findings may reflect differences between access to information and its comprehension or retention. Although providers generally perceived informational resources as available, interview participants emphasized that emotional distress, cognitive overload, and treatment complexity may still impair patients’ ability to process and retain information during clinical encounters. Taken together, the findings suggest that improving treatment preparedness may require combining structured educational workflows, psychosocial support, and accessible supplemental technologies, rather than relying on a single intervention.

This study has several limitations that should be considered when interpreting the findings. First, the study relied on voluntary participation and network-based recruitment methods, including professional outreach, organizational dissemination, and clinician contacts. Because invitations were distributed through multiple direct and indirect channels, the exact number of individuals who received the study invitation could not be determined, and a formal response rate could not be calculated. Consequently, the sample should not be interpreted as statistically representative of all healthcare providers involved in lung cancer care.

Second, the sample was predominantly composed of oncology providers, which may limit the transferability of findings to other specialties involved in lung cancer treatment and supportive care. In addition, although participants represented providers involved in lung cancer care across clinical settings in the United States, we did not systematically collect information regarding the socioeconomic, demographic, rurality, or institutional characteristics of the patient populations served by participants. As a result, we were unable to fully assess how patient population characteristics or regional care contexts may have influenced provider-reported barriers and perspectives.

Third, although the study employed a mixed-methods design, the quantitative component was primarily descriptive and intended to contextualize and complement the qualitative findings rather than provide statistically generalizable estimates. Differences between survey and interview findings may partially reflect variation in provider experiences, clinical workloads, or interpretation of treatment preparedness challenges. Furthermore, several themes emerged uniquely through the interviews and were not directly assessed within the survey component.

Despite these limitations, the selected mixed-methods design was considered appropriate for the exploratory objectives of the study, which aimed to understand healthcare provider perspectives regarding barriers affecting treatment preparedness among lung cancer patients. Combining descriptive survey data with semi-structured interviews enabled both broader contextualization of provider perspectives and deeper exploration of treatment-related challenges across the treatment continuum. Several methodological steps were also taken to improve the credibility and interpretability of the findings. The study used triangulation between quantitative and qualitative data sources, included providers from multiple clinical roles, applied independent coding and consensus-based analytical procedures, and used thematic saturation to guide qualitative sampling. In addition, the qualitative analysis followed a hybrid inductive–deductive thematic approach informed by Andersen’s Behavioral Model and the Optimal Care Pathways framework, allowing both theory-informed categorization and the emergence of additional provider-reported themes. Nevertheless, the findings should be interpreted within the context of the study design, sample composition, and exploratory nature of the analysis.

Methods

This study used a mixed-methods design to explore healthcare providers’ perceptions of the challenges patients with lung cancer face during the treatment preparation and initiation phases.

This study employed a qualitatively dominant mixed-methods design in which semi-structured interviews served as the primary analytical component, while descriptive survey data were used to contextualize and triangulate provider perspectives regarding treatment preparedness challenges. The qualitative and quantitative findings were integrated during interpretation to identify areas of convergence, divergence, and complementarity across the two data sources⁴¹. Our study was reviewed and approved by the Institutional Review Board at Columbia University (IRB Protocol# AAAV4003).

We utilized Andersen’s Behavioral Model of Health Services Use to guide both the development of data-collection tools (survey and interview guides) and the analysis of patients’ treatment-preparedness challenges and potential interventions in the context of lung cancer treatment (see Supplementary Table 3). In this study, Andersen’s Behavioral Model was adapted to examine provider-observed factors that influence treatment preparedness and engagement across the lung cancer treatment continuum. Although Andersen’s Behavioral Model originally conceptualizes predisposing factors as characteristics that exist prior to illness and influence healthcare utilization, this study adapted the framework to examine provider-observed factors that influence treatment preparedness and engagement after diagnosis. Within this context, predisposing factors were operationalized as patient-level cognitive, emotional, or experiential characteristics that influence patients’ ability to understand, prepare for, and engage with treatment-related processes. Predisposing-related factors were operationalized as patient-level cognitive, emotional, or experiential characteristics influencing preparedness behaviors; enabling-related factors as structural or resource-related facilitators and barriers affecting treatment access and continuity; and need-related factors as clinically perceived or evaluated care-related concerns requiring additional support or coordination⁴². Figure 1 summarizes the conceptual framework of the study.

Fig. 1.

Conceptual framework of the study.

Participants and recruitment

We recruited healthcare professionals involved in the treatment and care of lung cancer patients from cancer treatment centers and hospitals across the United States, including oncologists, pulmonologists, surgeons, nurses, radiation therapists, and related oncology care professionals. Purposive sampling strategies were adopted to ensure a diverse composition of our sample. Eligible participants were required to have at least one year of experience interacting with lung cancer patients and familiarity with treatment-related decision-making, preparation, or initiation processes. The data collection process happened between October 5^th, 2024, and January 15^th, 2025. We were able to recruit 50 healthcare professionals to complete the survey and conduct 10 90-minute semi-structured interviews with 10 additional participants.

Recruitment strategies for participants included email outreach, contact with established physician networks, and outreach to cancer foundations and related organizations. Participants who consented to participate were able to choose to complete the online survey, participate in an interview, or do both. Survey links were sent via REDCap. Semi-structured interviews were conducted via Zoom by the first author, who has prior experience in qualitative interviewing and cancer-related health services research. Interviews were audio-recorded and professionally transcribed verbatim for analysis. The survey and interview guide were developed based on the study objectives, Andersen’s Behavioral Model, and the Optimal Care Pathways framework. The instruments were iteratively refined by the research team to ensure alignment with treatment-preparedness concepts and provider experiences (see Supplementary Table 3 for the survey and interview questions). Because recruitment relied on professional outreach networks, organizational dissemination, and voluntary participation, an exact response rate could not be calculated across all recruitment channels.

Data analysis

We began with descriptive statistics to summarize the survey responses (frequencies, percentages, means, and medians) and provide an overview of response patterns across the main variables. We then followed a rigorous, systematic approach to analyzing the qualitative data. After transcribing the data verbatim via Zoom, one team member reviewed the interviews and transcripts to verify accuracy (SE). Each interview was systematically coded using a hybrid inductive–deductive approach⁴³. Initial open coding identified emerging concepts, while a predefined coding framework aligned with the research objectives guided subsequent analysis. We then employed thematic analysis, similar to prior research¹⁶, to group related codes into broader themes and highlight key patterns across the transcripts. Two members of the research team independently reviewed and coded the transcripts. Coding discrepancies were discussed iteratively until consensus was achieved. The coding process combined inductive theme generation with deductive framework-guided categorization. Thematic saturation was reached by the seventh interview, as no substantially new themes emerged in subsequent interviews. The study followed established qualitative reporting principles to improve methodological transparency and analytical rigor. The qualitative analysis was informed by Braun and Clarke’s thematic analysis approach and followed a hybrid inductive–deductive coding strategy. The deductive component was guided by Andersen’s Behavioral Model and the Optimal Care Pathways framework, while the inductive component allowed additional themes to emerge from the interview data. The qualitative component was reported in accordance with established qualitative reporting guidance, including SRQR and COREQ, to improve transparency and completeness.

Survey findings were analyzed descriptively and primarily used to contextualize the qualitative themes emerging from the interviews. Areas where the survey and interview findings aligned were interpreted as reinforcing key provider-observed barriers, whereas divergent findings were examined to better understand differences in provider interpretation, clinical experience, or dimensions of treatment preparedness.

Ethics approval and consent to participate

This study involving human participants was reviewed and approved by the Institutional Review Board at Columbia University (IRB Protocol #AAAV4003). All participants provided informed consent prior to participation. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants prior to their participation in the study.

Author contributions

Data Analysis: SE. Conceptualization: SE. Funding: SE, AM, SF. Initial Draft of the Manuscript: SE. Editing and Validation of the final version of the manuscript: SE, MY, AM, and SF.

Data availability

The data supporting the findings of this study are not publicly available due to the study still being ongoing and the data still being used to answer other questions that satisfy the grant purposes, but may be made available upon reasonable request to the corresponding author. Access will be granted for research purposes only and in accordance with institutional data-sharing policies.

Competing interests

The authors declare no competing interests.

Supplementary information

The online version contains supplementary material available at 10.1038/s44401-026-00129-5.