Abstract
Background:
Lung cancer screening (LCS) with low-dose CT (LDCT) remains markedly underutilized. Prior studies suggest that perceptions regarding LCS may influence intention to undergo LDCT; however, little is known about these beliefs and behaviors in vulnerable populations. We examined LCS-related health beliefs and LDCT completion in an urban safety-net health care system.
Patients and Methods:
We surveyed English- and Spanish-speaking individuals between February 2017 and February 2019 who had been scheduled for, but had not yet undergone, an initial LDCT. Survey items were adapted from validated measures, including the Lung Cancer Screening Health Belief Scales and the Lerman Breast Cancer Worry Scales, to assess LCS-related beliefs and lung cancer–related worry. We examined associations between these factors and LDCT completion using 2-sample t tests and chi-square tests.
Results:
Among 447 eligible individuals, 411 participated in the survey (71% from racial/ethnic minoritized groups), of whom 339 (82%) completed the initial LDCT. Almost half believed that they were at risk for lung cancer in their lifetime, and >90% believed that LCS would help find lung cancer early. Higher self-efficacy scores and lower perceived barriers scores were associated with LDCT completion (P=.002 and P=.004, respectively). Perceived risk and benefit scores were not associated with LDCT completion. Individuals who did not complete the first LDCT were more likely to note fear of lung problems (33% vs 18%; P<.001), stigma related to lung cancer (33% vs 17%; P=.008), and worry affecting mood (77% vs 64%; P=.02).
Conclusions:
In a diverse, real-world LCS population, most patients believed that LCS facilitates early detection of lung cancer; however, approximately 20% did not complete the initial LDCT. Perceived fear, stigma, and negative emotional responses to a potential lung cancer diagnosis were associated with lower LDCT completion rates. These findings offer insight into potentially modifiable factors and future interventions to improve LCS uptake among eligible individuals.
Background
Since 2013, the US Preventive Services Task Force (USPSTF) and other professional organizations have endorsed annual lung cancer screening (LCS) with low-dose chest CT (LDCT) for high-risk adults, based on findings from the National Lung Screening Trial (NLST).1–3 Despite its proven mortality benefit, inclusion in clinical guidelines, and broad insurance coverage, LCS uptake remains low, with <20% of eligible individuals screened in 2022.4
Multiple factors influence LCS participation, including individual, provider, and health care system–related barriers.5,6 Broad initiatives, such as the American Cancer Society’s National Lung Cancer Roundtable, aim to improve provider awareness, address disparities, and enhance screening accessibility.7,8 Additionally, efforts to develop centralized LCS programs and mobile screening units are expanding, particularly to serve rural and underserved populations.9–12
As LCS programs continue to expand, understanding the factors that influence participation is essential. Health beliefs—including perceived risk, benefits, barriers, and self-efficacy—along with fear and worry, may influence screening decisions. In the context of lung cancer, additional perceptions such as stigma and blame from others, who may view tobacco-related diseases as self-inflicted, can further affect the decision to pursue screening.13 Although prior studies have examined the effects of lung cancer risk perceptions and worry on screening intentions,14 the extent to which these factors influence real-world adherence is not well understood. Given that approximately 40% of patients who initially agree to screening do not complete LDCT within 3 months,12,15 understanding the factors underlying this behavior is critically important.
Gaining insight into LCS-related perceptions can inform interventions aimed at improving screening uptake, particularly among racial and ethnic minoritized groups, who remain under-represented in screening trials, have lower screening rates, and experience disproportionately high lung cancer mortality.1,16,17 To address this gap, we examined attitudes and beliefs toward LCS in a diverse, real-world, safety-net population and assessed their association with initial LDCT completion.
Patients and Methods
Study Setting
This study was approved by the University of Texas Southwestern Medical Center Institutional Review Board (STU-2019-1388). We conducted this survey at Parkland Health, a safety-net health system serving a diverse, urban population. The LCS process at Parkland is decentralized; primary care and specialty clinicians across 16 community-based clinical sites order LDCT, which are performed at a central radiology facility on the main campus. Parkland has an electronic health record (EHR; Epic) order set for LDCT, which incorporates patient eligibility criteria, documents counseling and shared decision-making, and triggers Lung Imaging Reporting and Data System (Lung-RADS) result reporting.
Study Population and Survey Administration
From February 2017 to February 2019, English- and Spanish-speaking patients who met the 2013 USPSTF criteria for LCS (age 55–77 years, ≥30 pack-years smoking history, and, for former smokers, having quit within the past 15 years) and for whom LDCT had been ordered but not yet performed were invited to complete a survey assessing demographics, smoking history, and perceptions of lung cancer risk and screening. Bilingual research assistants obtained consent from patients as part of a randomized study of telephone-based navigation for LCS18 and administered surveys by telephone prior to the first LDCT. Individuals who completed the survey received a $15 gift card in recognition of their time and effort.
Data Collection and Survey Instrument
LDCT performance was captured through an EHR-linked automated database. Adherence to LCS in this study was defined as initial LDCT completion among eligible individuals for whom the scan was already ordered by a clinician.
The survey assessed demographics (age, sex, race/ethnicity, marital status, educational background, and household income), health literacy and quality, LCS-related beliefs, perceptions of lung cancer risk, patient–provider communication, and smoking behaviors using a series of validated measures, including the Lung Cancer Screening Health Belief (LCSHB) Scales19 and the Lerman Breast Cancer Worry Scale.20
The LCSHB Scales assess perceived risk, benefits, and barriers to LCS, as well as self-efficacy. Items in the perceived risk, perceived benefits, and perceived barriers subscales use a 4-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree); items in the self-efficacy subscale use a 4-point scale, ranging from 1 (not at all confident) to 4 (very confident). Scale scores were calculated by summing the scores of all items in each subscale. Scale ranges were 2 to 8 for perceived risk, 2 to 8 for perceived benefits, 5 to 20 for perceived barriers, and 3 to 12 for self-efficacy for LCS.
The Lerman Breast Cancer Worry Scale is a validated instrument that addresses both the current levels of worry about developing cancer in the future (“worry frequency”) and the impact of this concern on mood and function (“worry impact”).20 Following previous adaptations,21,22 we replaced the term “breast” with “lung” to tailor the scale to LCS. Items were summed to create an index of lung cancer worry, with higher scores reflecting greater worry. The scale ranges were 1 to 4 for worry frequency and 3 to 12 for worry impact.
Statistical Analysis
Demographic data were described as means and standard deviations for continuous variables and frequencies and percentages for categorical variables. We used 2-sample t tests and chi-square tests to compare patient characteristics according to LDCT completion. Statistical significance was declared for 2-sided P<.05. All statistical analyses were performed using SAS 9.4 (SAS Institute Inc.).
Results
Among 447 invited individuals, 411 (92%) participated in the survey (Table 1). Mean patient age was 62 years, 45% were female, and 71% were racial/ethnic minorities (including 53% non-Hispanic Black). Fewer than 30% of participants had a postsecondary school education, and 84% reported an annual household income below the federal poverty level. Among survey participants, 339 (82%) completed the initial, previously ordered LDCT. As shown in Table 1, sociodemographic characteristics were not associated with completion of initial LDCT. Accordingly, they were not included as covariates in subsequent analyses.
Table 1.
Characteristics of Survey Respondents and Lung Cancer Screening Adherence
| Characteristic | Overall Population n (%) |
Completion of Ordered LDCT | P Value | |
|---|---|---|---|---|
| Yes n (%) |
No n (%) |
|||
| Total patients, N | 411 | 339 | 72 | |
| Age, mean [SD], y | 62 [5] | 62 [5] | 61 [5] | .52 |
| Sex | .16 | |||
| Female | 186 (45) | 148 (44) | 38 (53) | |
| Male | 225 (55) | 191 (56) | 34 (47) | |
| Race/Ethnicity | .90 | |||
| Non-Hispanic Black | 217 (53) | 177 (52) | 40 (56) | |
| Non-Hispanic White | 118 (29) | 98 (29) | 20 (28) | |
| Other including Hispanic | 73 (18) | 61 (18) | 12 (17) | |
| Declined to answer/missing | 3 (0) | 3 (1) | 0 (0) | |
| Education | .17 | |||
| Less than high school diploma | 141 (34) | 110 (32) | 31 (43) | |
| High school diploma | 149 (36) | 124 (37) | 25 (35) | |
| Additional vocational or higher education | 121 (29) | 105 (31) | 16 (22) | |
| Health literacy (self-rated) | .35 | |||
| Very good/good | 287 (70) | 240 (71) | 47 (65) | |
| Okay/Poor/Very poor | 124 (30) | 99 (29) | 25 (35) | |
| Marital status | .64 | |||
| Never married | 80 (20) | 69 (20) | 11 (15) | |
| Married or living as married | 88 (21) | 70 (21) | 18 (25) | |
| Widowed/Separated/Divorced | 238 (58) | 196 (58) | 42 (58) | |
| Other | 5 (1) | 4 (1) | 1 (1) | |
| Annual household income, USD | .73 | |||
| <$15,000 | 239 (58) | 193 (57) | 46 (64) | |
| $15,000 to <$35,000 | 108 (26) | 92 (27) | 16 (22) | |
| ≥$35,000 | 23 (6) | 19 (6) | 4 (6) | |
| Don’t know/not sure | 41 (10) | 35 (10) | 6 (8) | |
| Quality of health (self-rated) | .27 | |||
| Excellent/Very good | 31 (8) | 26 (8) | 5 (7) | |
| Good/Fair | 266 (65) | 225 (66) | 41 (57) | |
| Poor/Very poor | 90 (22) | 71 (21) | 19 (26) | |
| Don’t know/not sure | 24 (6) | 17 (5) | 7 (10) | |
Abbreviation: LDCT, low-dose CT.
Table 2 displays health beliefs and lung cancer screening adherence among survey respondents. Almost half believed that they were at risk for lung cancer in their lifetime, and nearly 40% believed they were likely to get lung cancer in the next 10 years. Almost all respondents (>90%) believed that LCS would help find lung cancer early, and more than three-quarters believed a lung scan would help them worry less about lung cancer. As shown in Supplementary Table S1 (available in the supplementary materials), composite scores for perceived lung cancer risk (4.8 vs 4.8; P=.72) and perceived LCS benefit (6.2 vs 6.4; P=.16) were not significantly associated with LDCT completion.
Table 2.
Health Beliefs and Lung Cancer Screening Adherence
| Overall Population (n=411) n (%) |
Completion of Ordered LDCT | P Value | ||
|---|---|---|---|---|
| Yes (n=339) n (%) |
No (n=72) n (%) |
|||
| Perceived risk of lung cancer | ||||
| It’s likely that I will get lung cancer sometime in my lifetime | .99 | |||
| Agree or strongly agree | 187 (45) | 154 (45) | 33 (46) | |
| Disagree or strongly disagree | 216 (53) | 178 (53) | 38 (53) | |
| Declined to answer/missing | 8 (2) | 7 (2) | 1 (1) | |
| It’s likely that I will get lung cancer in the next 10 years | .78 | |||
| Agree or strongly agree | 160 (39) | 128 (38) | 32 (44) | |
| Disagree or strongly disagree | 243 (59) | 204 (60) | 39 (54) | |
| Declined to answer/missing | 8 (2) | 7 (2) | 1 (1) | |
| Perceived benefits of lung cancer screening | ||||
| Having a lung scan will help find lung cancer early | .86 | |||
| Agree or strongly agree | 387 (94) | 319 (94) | 68 (94) | |
| Disagree or strongly disagree | 17 (4) | 14 (4) | 3 (4) | |
| Declined to answer/missing | 7 (2) | 6 (2) | 1 (1) | |
| Having a lung scan will help me not worry as much about lung cancer | .40 | |||
| Agree or strongly agree | 319 (78) | 265 (78) | 54 (75) | |
| Disagree or strongly disagree | 83 (20) | 66 (19) | 17 (24) | |
| Declined to answer/missing | 9 (2) | 8 (2) | 1 (1) | |
| Perceived barriers for lung cancer screening | ||||
| I might put off having a lung scan because I don’t have any lung problems or symptoms | .49 | |||
| Agree or strongly agree | 103 (25) | 83 (24) | 20 (28) | |
| Disagree or strongly disagree | 301 (73) | 250 (74) | 51 (71) | |
| Declined to answer/missing | 7 (2) | 6 (2) | 1 (1) | |
| I might put off having a lung scan because I don’t know enough about it | .25 | |||
| Agree or strongly agree | 142 (35) | 110 (32) | 32 (44) | |
| Disagree or strongly disagree | 262 (64) | 223 (66) | 39 (54) | |
| Declined to answer/missing | 7 (2) | 6 (2) | 1 (1) | |
| I might put off having a lung scan because I would rather not know if I have any lung problems | <.001 | |||
| Agree or strongly agree | 84 (20) | 60 (18) | 24 (33) | |
| Disagree or strongly disagree | 320 (78) | 273 (81) | 47 (65) | |
| Declined to answer/missing | 7 (2) | 6 (2) | 1 (1) | |
| I might put off having a lung scan because I worry about being blamed for having smoked | .008 | |||
| Agree or strongly agree | 83 (20) | 59 (17) | 24 (33) | |
| Disagree or strongly disagree | 319 (77) | 274 (81) | 45 (63) | |
| Declined to answer/missing | 9 (2) | 6 (2) | 3 (4) | |
| I might put off having a lung scan because I worry about finding something wrong | .10 | |||
| Agree or strongly agree | 155 (38) | 120 (35) | 35 (49) | |
| Disagree or strongly disagree | 249 (61) | 213 (63) | 36 (50) | |
| Declined to answer/missing | 7 (2) | 6 (2) | 1 (1) | |
| Self-efficacy for lung cancer screening | ||||
| How sure are you that you can find transportation to get to and from your appointment to have a lung scan? | <.001 | |||
| Somewhat sure or very sure | 337 (82) | 285 (84) | 52 (72) | |
| Not too sure or not at all sure | 67 (16) | 48 (14) | 19 (26) | |
| Declined to answer/missing | 7 (2) | 6 (2) | 1 (1) | |
| How sure are you that you can get enough information about having a lung scan? | .02 | |||
| Somewhat sure or very sure | 325 (79) | 275 (81) | 50 (69) | |
| Not too sure or not at all sure | 78 (19) | 57 (17) | 21 (29) | |
| Declined to answer/missing | 8 (2) | 7 (2) | 1 (1) | |
| How sure are you that you can have a lung scan even if you don’t know what to expect? | <.001 | |||
| Somewhat sure or very sure | 312 (76) | 263 (78) | 49 (68) | |
| Not too sure or not at all sure | 92 (22) | 70 (21) | 22 (31) | |
| Declined to answer/missing | 7 (2) | 6 (6) | 1 (1) | |
Abbreviation: LDCT, low-dose CT.
The survey identified various barriers to LCS: 38% noted that they might put off an LDCT because they worried about finding something wrong; 35% felt that they did not know enough about LCS; 25% thought they did not have lung problems or symptoms; 20% preferred not to know if they had lung problems; and 20% worried about being blamed for having smoked (Table 2). Specifically, fear and stigma related to lung cancer diagnosis was significantly associated with not completing the initial LDCT (P<.001 and P=.008, respectively). Overall, patients who did not complete the initial LDCT had significantly higher perceived barrier scores (11.7 vs 10.3; P=.002) (Supplementary Table S1).
Most respondents conveyed higher levels of self-efficacy to complete LCS. Specifically, 82% of all patients believed (“very sure” or “somewhat sure”) they could secure transportation to their imaging appointment; 79% believed they could obtain enough information about the lung scan; 76% believed they could proceed with the scan even if they did not know what to expect (Table 2). Of note, patients who did not complete the ordered LDCT were more likely to express uncertainty about securing transportation to their radiology appointments (26% vs 14%; P<.001), obtaining enough information about having a lung scan (29% vs 17%; P=.02), and having a lung scan even if they did not know what to expect (31% vs 21%; P<.001). Patients who did not complete the initial LDCT also had significantly lower self-efficacy scores (9.5 vs 10.2; P=.004) (Supplementary Table S1).
As shown in Table 3, almost half of all respondents expressed “somewhat” or “a lot” of worry about getting lung cancer at some point, although this concern was not significantly associated with LDCT completion (P=.35). However, if respondents reported that such worry affected their mood, they were significantly less likely to complete the LDCT (P=.02). Furthermore, as shown in Supplementary Table S1, those who reported the greatest effect of worry on their mood and function (higher “worry impact score”) had the lowest LDCT completion rates (P=.05).
Table 3.
Lung Cancer Worry and Lung Cancer Screening Adherence
| Overall Population (n=411) n (%) |
Completion of First LDCT | P Value | ||
|---|---|---|---|---|
| Yes (n=339) n (%) |
No (n=72) n (%) |
|||
| Worry frequency | ||||
| How worried are you about getting lung cancer someday? | .35 | |||
| A lot | 95 (23) | 82 (24) | 13 (18) | |
| Somewhat | 88 (21) | 70 (21) | 18 (25) | |
| A little | 100 (24) | 86 (25) | 14 (19) | |
| Not at all | 120 (29) | 95 (28) | 25 (35) | |
| Declined to answer/missing | 8 (2) | 6 (2) | 2 (3) | |
| Worry impact a | ||||
| How much does your worry affect your mood? | .02 | |||
| A lot | 46 (16) | 42 (17) | 4 (9) | |
| Somewhat | 69 (24) | 52 (21) | 17 (36) | |
| A little | 78 (27) | 63 (26) | 15 (32) | |
| Not at all | 88 (30) | 80 (33) | 8 (17) | |
| Declined to answer/missing | 10 (3) | 7 (3) | 3 (6) | |
| How much does your worry affect your ability to perform daily activities? | .10 | |||
| A lot | 32 (11) | 29 (12) | 3 (6) | |
| Somewhat | 36 (12) | 27 (11) | 9 (19) | |
| A little | 59 (20) | 46 (19) | 13 (28) | |
| Not at all | 153 (53) | 134 (55) | 19 (40) | |
| Declined to answer/missing | 11 (4) | 8 (3) | 3 (6) | |
| When you worry about lung cancer, how difficult is it to control these worries? | .51 | |||
| A lot | 36 (12) | 28 (11) | 8 (17) | |
| Somewhat | 41 (14) | 33 (14) | 8 (17) | |
| A little | 82 (28) | 70 (29) | 12 (26) | |
| Not at all | 122 (42) | 106 (43) | 16 (34) | |
| Declined to answer/missing | 10 (3) | 7 (3) | 3 (6) | |
Abbreviation: LDCT, low-dose CT.
Excludes participants who answered “Not at all” to the question “How worried are you about getting lung cancer someday?” (n=120), resulting in sample sizes of n=291 for the overall population, n=244 for those who completed first LDCT, and n=47 for those did not complete first LDCT.
Although all study participants were previously referred by their clinical team for LCS through placement of an LDCT order, only 251 of 411 (61%) recalled speaking with their physician about having an LDCT for LCS (Table 4). Among respondents who did report such a discussion, 40% asked further clarifying questions, 42% let the doctor know what they liked/disliked about the scan, 55% asked their doctor to explain the scan/procedures in greater detail, and 74% felt free to express concerns and worries about the process. These responses were not associated with LDCT completion.
Table 4.
Physician Communication About Lung Cancer Screening
| Overall Population (n=411) n (%) |
Completion of First LDCT | P Value | ||
|---|---|---|---|---|
| Yes (n=339) n (%) |
No (n=72) n (%) |
|||
| Occurrence of LDCT discussion | ||||
| Has your doctor ever talked with you about having a lung scan to check for lung cancer? | .31 | |||
| Yes | 251 (61) | 209 (62) | 42 (58) | |
| No | 127 (31) | 100 (29) | 27 (38) | |
| Don’t know/not sure | 14 (3) | 13 (4) | 1 (1) | |
| Declined to answer/missing | 19 (5) | 17 (5) | 2 (3) | |
| Content of LDCT discussion a | ||||
| I asked the doctor to explain the lung scan and procedures in greater detail | .32 | |||
| Agree or strongly agree | 156 (55) | 133 (56) | 23 (51) | |
| Disagree or strongly disagree | 118 (42) | 99 (41) | 19 (42) | |
| Declined to answer/missing | 10 (4) | 7 (3) | 3 (7) | |
| I asked the doctor for recommendations for getting a lung scan | .97 | |||
| Agree or strongly agree | 150 (53) | 127 (53) | 23 (51) | |
| Disagree or strongly disagree | 124 (44) | 105 (44) | 19 (42) | |
| Declined to answer/missing | 10 (4) | 7 (3) | 3 (7) | |
| I asked the doctor a lot of questions about my options for getting a lung scan | .56 | |||
| Agree or strongly agree | 115 (40) | 95 (40) | 20 (44) | |
| Disagree or strongly disagree | 159 (56) | 137 (57) | 22 (49) | |
| Declined to answer/missing | 10 (4) | 7 (3) | 3 (7) | |
| I let the doctor know what I like and dislike about the lung scan option | .43 | |||
| Agree or strongly agree | 120 (42) | 99 (41) | 21 (47) | |
| Disagree or strongly disagree | 153 (54) | 132 (55) | 21 (47) | |
| Declined to answer/missing | 11 (4) | 8 (3) | 3 (7) | |
| I felt free to express any concerns and worries I might have about my lung scan | .51 | |||
| Agree or strongly agree | 210 (74) | 179 (75) | 31 (69) | |
| Disagree or strongly disagree | 64 (23) | 53 (22) | 11 (24) | |
| Declined to answer/missing | 10 (4) | 7 (3) | 3 (7) | |
Abbreviation: LDCT, low-dose CT.
Excludes participants who answered “No” to the question “Has your doctor ever talked with you about having a lung scan to check for lung cancer?” (n=127), resulting in a sample sizes of n=284 for the overall population, n=239 forthose who completed first LDCT, and n=45 for those who did not complete first LDCT.
Discussion
Despite the USPSTF’s recommendation published more than a decade ago and its proven mortality benefit, LCS with LDCT remains widely underutilized across the United States.1,2,4 Uptake is even lower among racially and ethnic minoritized groups, particularly Black/African Americans, who disproportionately develop and die of lung cancer.16,23
To better understand factors influencing LCS participation, we examined health beliefs in a racially diverse population, more than half of whom were Black. In this study of >400 individuals treated within an urban safety-net health care system, we identified numerous attitudes and emotions associated with initial LDCT completion, including fear and stigma surrounding a lung cancer diagnosis, perceived self-efficacy for LCS, and the extent to which worry about lung cancer affects mood.
In the context of cancer screening, perceived barriers represent an individual’s estimation of the level of challenge associated with screening participation.24 In this study, at least 20% of participants indicated that they might put off LCS because they don’t know enough about the process, worry about being blamed for having smoked, or worry about finding something wrong. Indeed, survey respondents with higher perceived barriers scores were less likely to complete initial LDCT. Similar to prior reports,13 we found that smoking-related stigma was a significant barrier to LCS. Study participants who did not complete the ordered LDCT were twice as likely to have concerns about being blamed for having smoked than those who did undergo the scan. Evidence shows that stigma related to lung cancer adversely affects patients not only at the screening phase but also throughout the lung cancer care continuum.25,26
Fear of a lung cancer diagnosis emerged as another major barrier to LCS, with approximately one-fifth of patients in this study indicating they may put off LDCT because they prefer not to know whether they have any lung problems. Although prior qualitative studies have shown that fear of lung cancer diagnosis and fatalistic beliefs can influence LCS preferences among screening-eligible individuals,27,28 our findings demonstrate that such concerns also affect LCS behavior. Multilevel efforts to mitigate both stigma and fear within LCS conversations are underway and should continue to be prioritized.29
Factors influencing self-efficacy—the confidence that one can perform the tasks related to arranging and completing the screening process—may present a prime opportunity to modify LCS uptake. We found that patients who subsequently completed the ordered LDCT had higher LCS self-efficacy scores in terms of securing transportation, acquiring the necessary knowledge about LCS, and undergoing LDCT without knowing what to expect. Consistent with these findings, a recent mixed-methods study among LCS-eligible individuals found that self-efficacy predicted LCS behavior. Participants with higher perceived self-efficacy for LCS reported lower levels of cancer fatalism and lung cancer–related fear, were highly influenced by their social networks, and had received a provider recommendation to undergo screen.30
Cancer worry is a complex factor in screening decisions, sometimes motivating participation and other times acting as a barrier.22 Its influence on LCS, however, remains unclear. In this study, approximately three-fourths of participants reported some level of worry about developing lung cancer, with one-quarter experiencing high worry. Importantly, worry was associated with lower LDCT completion when it negatively affected mood. Similar patterns have been observed in breast cancer screening, where mild worry can motivate screening, but excessive worry—especially when it disrupts daily life—serves as a significant deterrent.31
Because screening barriers, self-efficacy, and lung cancer worry may be modifiable variables, our findings have implications for future interventions to improve LCS uptake. Although many clinicians may already address LCS risks and benefits in shared decision-making conversations, tailoring such discussions to acknowledge fear, stigma, and worry might help address these salient, but often silent, barriers. Among the respondents who recalled speaking to their clinician about LCS, more than half said they did not express their likes and dislikes about getting a scan during this discussion, and almost one-fourth reported not feeling comfortable expressing concerns and worries about LCS, suggesting a need to further examine and optimize communication about LCS. Incorporating dedicated LCS navigators early in these shared decision-making discussions—to facilitate joint dialogue and identify and address barriers to screening—may improve adherence.32 Furthermore, interventions such as the “Lung Cancer Stigma Communications Assessment Tool” may help identify, remove, and replace potentially stigmatizing language and imagery from patient materials on LCS.29
Limitations of the current study include the single-center setting and restriction to English- and Spanish-speaking individuals. The relatively small size of the LDCT noncompletion cohort may have limited the statistical power to detect associations with LDCT completion observed in prior studies, such as those related to race and age.33,34 However, this finding may also reflect distinct patterns within a safety-net population, where patients often share similar socioeconomic and educational backgrounds. Additionally, the reasons for LDCT noncompletion were not available. Strengths include the overall size of the study population, which included a large proportion of patients from groups disproportionately impacted by lung cancer (ie, racial and ethnic minoritized groups, individuals with incomes below the federal poverty level, and uninsured/underinsured individuals), as well as the ability to correlate LCS-related health beliefs with LDCT completion and not just intention.
Conclusions
The decision to undergo LCS represents a complex consideration that can be influenced by patient, provider, and system-level characteristics. In this study in an urban, safety-net population, nearly all patients believed that LCS would help find lung cancer early. Nevertheless, almost one-fourth did not complete the ordered LDCT. Perceived fear, stigma, and worry affecting mood were associated with reduced likelihood of LDCT completion. These findings have implications for future interventions to improve LCS uptake.
Supplementary Material
Supplementary material: Supplementary material associated with this article is available online at https://doi.org/10.6004/jnccn.2025.7091. The supplementary material has been supplied by the author(s) and appears in its originally submitted form. It has not been edited or vetted by JNCCN. All contents and opinions are solely those of the author. Any comments or questions related to the supplementary materials should be directed to the corresponding author.
Supplementary material is published online at https://doi.org/10.6004/jnccn.2025.7091
Funding:
This work was supported by the Cancer Prevention Research Institute of Texas (CPRIT; RP160030, PP190052, and PP230041 to H.A. Hamann, S.J. Craddock Lee, and D.E. Gerber). Additional support was received through the Biostatistics Shared Resource in the Harold C. Simmons Comprehensive Cancer Center (5P30 CA142543) and UT Southwestern Center for Patient-centered Outcomes Research (R24 HS022418).
Footnotes
Disclosures: Dr. Bhalla has served in a consulting/advisory role for AstraZeneca, Bristol Myers Squibb, EMD Serano, Merus, Mirati, and Novocure. Dr. Gerber has disclosed receiving research funding from AstraZeneca, BerGenBio, Karyopharm, Novocure; has served in a consulting/advisory role for BeiGene, Catalyst, Daiichi-Sankyo, Elevation Oncology, Jansen, Mirati, Regeneron, Sanofi; is a shareholder in Gilead, Medtronic, and Walgreens; has pending U.S. patents 16/487,335, 17/045,482, 63/386,387, 63/382,972, 63/382,257; and is cofounder and Chief Medical Officer, OncoSeer Diagnostics, Inc. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.
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