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. Author manuscript; available in PMC: 2024 Jan 1.
Published in final edited form as: Nurs Res. 2022 Oct 16;72(1):3–11. doi: 10.1097/NNR.0000000000000629

Lung Cancer Screening Knowledge, Attitudes and Practice Patterns Among Primary and Pulmonary Care Clinicians

Lisa Carter-Harris 1, Leah E Walsh 2, Elizabeth Schofield 3, Timothy J Williamson 4, Heidi A Hamann 5, Jamie S Ostroff 6
PMCID: PMC9772114  NIHMSID: NIHMS1843018  PMID: 36260526

Abstract

Background:

Lung cancer screening has the potential to identify lung cancer at an early stage when more treatment options exist. However, discussions with and referrals of screening-eligible patients remain unacceptably low. We need to better understand clinician knowledge, attitudes, and practice patterns to identify strategies to improve lung cancer screening uptake. Prior studies have focused on understanding these factors from physicians only. Nevertheless, many patients receive primary care from nurse practitioners and physician assistants where prevention and early detection conversations are most likely to occur. Therefore, we must engage the full range of clinicians treating screening-eligible patients.

Objectives:

To describe attitudes, beliefs and referral practice patterns, lung cancer screening knowledge, and concordance with lung cancer screening guidelines among nurse practitioners, physicians, and physician assistants in the U.S.

Methods:

Descriptive, cross-sectional study using survey methodology with clinical vignettes to examine clinician factors and concordance with U.S. Preventive Services Task Force (USPSTF) Lung Cancer Screening Guidelines.

Results:

Participants scored low on attitudes toward shared decision-making, high on the importance of shared decision-making in lung cancer screening, and low on barriers to lung cancer screening referral. In addition, midrange scores on empathy toward patients with smoking history were noted. Lung cancer screening knowledge was low regardless of clinician specialty; the most endorsed response when presented with a hypothetical patient was to refer for lung cancer screening using a chest X-ray.

Discussion:

Findings demonstrate that most clinicians are nonconcordant with USPSTF guidelines, erroneously believing a chest X-ray is appropriate for lung cancer screening. Clinicians must follow evidence-based practice guidelines, highlighting the need for targeted continuing education about lung cancer screening for clinicians who treat screening-eligible patients.

Keywords: lung cancer, primary care, screening, shared decision-making

Lung cancer screening with annual low-dose computed tomography (LDCT) has been a Grade B recommendation by the U.S. Preventive Services Task Force (USPSTF) for nearly a decade (USPSTF, 2022). Yet, compared to uptake of other types of recommended cancer screening, discussions with and referrals of screening-eligible patients remain abysmally low. Less than 5% of screening-eligible patients have been referred for lung cancer screening (Jemal & Fedewa, 2017), even though lung cancer kills more people in the U.S. than any other cancer (American Cancer Society, 2022). Screening has the potential to identify this deadly disease in high-risk patients at an early stage when more treatment options exist. A better understanding of clinician knowledge, attitudes, and practice patterns can help identify strategies to improve lung cancer screening uptake.

Clinicians’ lack of knowledge regarding screening efficacy, guidelines, and eligibility, clinician-perceived patient barriers (lack of awareness, stress, anxiety, cost), and potential for false positives have all been suggested as significant obstacles to lung cancer screening referrals (Carter-Harris et al., 2018; Ersek et al., 2016; Hoffman et al., 2015; Iaccarino et al., 2015; Lewis et al., 2015; Raz et al., 2016; Simmons et al., 2017). Despite being a covered preventive service under the Affordable Care Act and fully covered by Medicare with mandated shared decision-making prior to screening, discussions about lung cancer screening are unfortunately not occurring in the majority of the screening-eligible patient population. The decision to screen for lung cancer is not straightforward for the patient; it requires a discussion with an informed clinician, which adds additional layers to the already time-constrained clinical visit that contribute to the challenges of engaging eligible individuals in lung cancer screening. Although several decision tools have been developed and made available (Agency for Healthcare Research and Quality, 2016; Lau et al., 2015; Volk et al., 2014), lung cancer screening discussions and referrals occur infrequently (Carter-Harris et al., 2016; Jemal & Fedewa, 2017); this contributes to the low rates of lung cancer screening among those eligible (Jemal & Fedewa, 2017).

In contrast to other cancer screenings (i.e., colorectal, breast), which use gender-, family history-, and/or age-based criteria for identifying screening eligibility, lung cancer screening is the only cancer screening that specifies a smoking history as part of the eligibility criteria (Centers for Medicare & Medicaid Services, 2015; National Lung Screening Trial Research Team, 2011). Individuals who smoke are a unique high-risk patient population who often report low engagement with cancer screening and preventive health services globally and perceived stigma from their health care clinicians (Stuber et al., 2008). This may deter both lung cancer screening discussions, subsequent referral, and adherence to screening recommendations. Many patients and clinicians express discomfort discussing smoking history due to stigma (Houghton et al., 2008; Wells et al., 2017), which might affect both clinicians’ and patients’ willingness to engage in a discussion about lung cancer screening.

Efforts to understand factors influencing clinician discussions of and referral for lung cancer screening have typically focused on patient-reported barriers (Coughlin et al., 2020). However, it is also essential to better understand barriers to discussions and subsequent referral from the clinicians’ perspectives to guide the development of effective clinical engagement strategies for high-risk patients that clinicians can integrate into their practice. Specifically, it is essential to study whether clinician-held negative attitudes and stigma towards individuals who currently smoke or formerly smoked may contribute to the low referral patterns for lung cancer screening. Additionally, clinicians may be hesitant to open the ‘Pandora’s box’ of possibilities that might occur after lung cancer screening, including false positive results, overdiagnosis, and incidental findings leading to a cascade of follow-up tests and treatments (National Lung Screening Trial Research Team, 2011). Moreover, the clinician must believe in the efficacy and relevance of lung cancer screening for their patient population. If they do not, the topic of lung cancer screening will remain silent during the clinical encounter.

Most prior studies have focused on understanding lung cancer screening practice patterns and attitudes from physicians only (either primary care, family physicians, or pulmonologists; Ersek et al., 2016; Hoffman et al., 2015; Iaccarino et al., 2015; Lewis et al., 2015; Raz et al., 2016; Simmons et al., 2017). While there was one study to understand barriers to lung cancer screening in primary care which included nurse practitioners (n = 5) and physician assistants (n = 3), nurse practitioners and physician assistants were underrepresented in the overall sample (n = 96). In addition, the study lacked theoretical grounding and was performed in one county (Coughlin et al., 2020). Many patients receive primary care from nurse practitioners and physician assistants, where conversations about presenting lung concerns and preventive health services specific to lung cancer screening are most likely to occur. In order to identify clinician barriers to discussions and subsequent screening referrals, we must engage a broad range of clinicians at a national level.

There is a dearth of research examining clinician concordance with lung cancer screening guidelines. Of the prior studies examining barriers to lung cancer screening referral, two examined propensities for guideline concordance (Coughlin et al., 2020; Iaccarino et al., 2015). One study—performed solely with pulmonologists—found that 24.9% had a propensity to under screen their screening-eligible patients (Iaccarino et al., 2015). The other study found underutilization of lung cancer screening in screening-eligible patients (Coughlin et al., 2020). Although clinicians are encouraged to engage in discussion with their screening-eligible patients about lung cancer screening, actual discussions and referrals for lung cancer screening are inconsistent. Our team analyzed the Health Information National Trends Survey (HINTS) data pre- and post-USPSTF guideline issuance in 2012 and 2014, respectively, and found unacceptably low discussion rates. Patient–clinician discussions about lung cancer screening were surprisingly lower in 2014 (10%) compared to 2012 (17%) before the USPSTF guidelines were issued (Carter-Harris et al., 2016). In additional analyses from the next iteration of HINTS in 2017, crude estimated rates of patient–clinician discussions regardless of smoking status remained low at 4.3% (Huo et al., 2019). Reasons for these changes in screening discussion patterns are unclear. They deserve focused attention to ensure that clinicians of varied disciplines who treat lung cancer, screening-eligible patients are informed, have a proper understanding, and implement evidence-based guidelines into their practice.

Conceptual Underpinnings

The current study was guided by the Modified Diagnostic Evaluation Model (DEM; Myers et al., 1999), which integrates theoretical perspectives from the Health Belief Model (HBM), Theory of Reasoned Action (TRA), and Social Cognitive Theory (SCT). Perceived benefits of and barriers to lung cancer screening for clinicians are derived from the HBM (Guerra et al., 2007). Clinician behavioral intention stems from the TRA, which posits that behavioral intention is the most important determinant of actual behavior; intention is predicted by associated factors such as attitudes (in this context, clinicians’ perceived benefits and barriers to lung cancer screening and their perceptions of patients with a current or former smoking history). SCT addresses how behavior, personal factors (cognitive, beliefs, stigma), and environmental influences (such as characteristics of the clinician’s practice) interact. All three models focus on individual motivational factors which drive behavior. The Modified DEM guided the selection of measures to ensure the primary constructs were assessed from the clinician’s perspective in lung cancer screening. The Modified DEM allows us to determine the degree of congruence between intended self-reported clinician recommendation/referral for lung cancer screening and current USPSTF lung cancer screening guidelines by incorporating the influence of several patient characteristics through clinical vignettes (see Figure 1).

Figure 1.

Figure 1.

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Modified Diagnostic Evaluation Model (adapted from Myers et al. 1999)

Methods

Study Design

We used a cross-sectional study design to examine barriers to discussions and subsequent screening referrals for lung cancer screening-eligible patients amongst primary care and pulmonary clinicians (nurse practitioners, physicians, and physician assistants). We observed—by applying the survey methodology—clinician factors (attitudes and beliefs about shared decision-making in general as well as specific to lung cancer screening, practice characteristics, lung cancer screening referral patterns, empathy toward patients with a smoking history, and knowledge of and concordance with USPSTF lung cancer screening guidelines). We aimed to (a) describe attitudes, beliefs, and referral practice patterns, and (b) describe lung cancer screening knowledge and assess concordance with lung cancer screening guidelines using clinical vignettes among primary care and pulmonary clinicians (nurse practitioners, physicians, physician assistants) treating lung cancer, screening-eligible patients in the United States. We hypothesized that clinician attitudes, beliefs, and knowledge would predict concordance with USPSTF lung cancer screening guidelines.

Sample and Setting

Participants were recruited nationally from December 2019 to May 2020 using a targeted advertisement of demographic information and keywords in Facebook users’ profiles or interest lists. Facebook can “target” an advertisement by demographics and keywords listed in each Facebook user’s profile or interest list. A Facebook user’s interest list includes a wide range of details a user can indicate when setting up and/or maintaining their profiles that they have an interest in or identify with, such as occupation, educational degree, occupational specialization, industry sector, groups, hobbies, lifestyle choices, behaviors, points of view, and specific organizations, to name a few. This allowed us to purposively sample people who were nurse practitioners, physicians, or physician assistants by targeting our advertisement on Facebook using the following keywords: nurse practitioner, advanced registered nurse practitioner, advanced practice provider, ARNP, APRN, American Academy of Nurse Practitioners, American Nurses Credentialing Center, Physician Assistant, PA, PA-C, Physician, Doctor, Medical Doctor, MD, DO, American Medical Association, Internal Medicine, Family Medicine, Internist, Pulmonary, Pulmonology, Pulmonologist. The advertisement was only presented to those Facebook users meeting one or more of these criteria. Guided by social media researchers’ safety and monitoring guidelines for (Russomanno et al., 2019), our approach included design and close monitoring of the Facebook targeted advertisement to ensure all methodologic and ethical standards were upheld. In addition, a screening survey was employed that included verification of professional license to ensure participants met inclusion criteria.

Data were collected using Research Electronic Data Capture (REDCap), and participants were compensated with a $50 gift card after completing the 30-min survey. The participant incentive was not included in any recruitment materials to limit responses solely for financial incentives. Eligibility criteria included: (a) having an active license as a physician, nurse practitioner, or physician assistant; (b) working in an outpatient, primary care, or pulmonary setting in the U.S.; and (c) providing health care to patients aged 55 years and older given lung cancer screening is a recommendation for an older patient population. It should be noted that data were collected prior to the updated USPSTF lung cancer screening guidelines in May 2021, which lowered the age criteria from 55 to 50 years. This research was approved by the Memorial Sloan Kettering Cancer Center’s Institutional Review Board.

Variables and Measures

To address the aims and guided by the Modified Diagnostic Evaluation Model, self-reported data were collected to assess personal characteristics (age, gender, race, years in practice, specialty, board certification, professional role), clinician attitudes and beliefs, knowledge and concordance with USPSTF lung cancer screening guidelines, practice characteristics, and barriers to lung cancer screening referral, clinician behavior. We did not study social norms—defined as the perceptions of standard practice and conformity to standard practice. Table 1 presents the study’s constructs, associated measures, and Cronbach’s alphas.

Table 1.

Measures

Overarching Construct Variable Measure # of items Cronbach’s alpha
Clinician Attitudes and Beliefs Attitudes Toward Shared Decision-Making in General General Shared Decision-Making Attitudes Scale (Forcino et al., 2018) 11 .81
Importance of Shared Decision-Making in Lung Cancer Screening Importance of Shared Decision-Making in Lung Cancer Screening Scale (investigator-developed informed by literature) 5 .76
Perceptions About Smoking Empathy Toward Patients with a Smoking History Scale (Lewis et al., 2015) 11 .89
Barriers Barriers to Referral Barriers to Lung Cancer Screening Referral Scale (investigator-developed informed by literature) 7 .84
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Clinician Attitudes and Beliefs

We assessed clinician attitudes and beliefs, such as perceptions about shared decision-making in general, the importance of shared decision-making in lung cancer screening, and perceptions about individuals who currently smoke or formerly smoked. Clinician attitudes toward shared decision-making, in general, were assessed with 11 items adapted from a General Shared Decision-Making Attitudes Survey with 4-point Likert-type response options consisting of 1 = Strongly Disagree to 4 = Strongly Agree (Forcino et al., 2018). Higher mean scale scores were reflective of unfavorable attitudes toward shared decision-making. Using an investigator-developed questionnaire, we also assessed if clinicians thought shared decision-making was influential in lung cancer screening with five items with a 4-point Likert-type response option (1 = Strongly Disagree to 4 = Strongly Agree). Empathy toward patients who qualify for lung cancer screening—specifically individuals with either a current or former smoking status was assessed with 11 items adapted from the literature (Lewis et al., 2015).

Practice Characteristics

Practice characteristics were self-reported by participants to include practice size, number of patients seen daily, access to lung cancer screening, percentage of patients aged 55 years and older in their personal practice, practice setting, and population characteristics.

Barriers to Lung Cancer Screening Referral

Barriers to referring screening-eligible patients for lung cancer screening were assessed with seven items using a 4-point Likert-type response option scale (1 = Strongly Disagree to 4 = Strongly Agree) developed by the investigators and informed by the literature (Kanodra et al., 2016; Wang et al., 2019).

Knowledge and Clinician Behavior

Knowledge of and concordance with USPSTF lung cancer screening guidelines were assessed using questions adapted from the National Cancer Institute’s National Survey of Primary Care Physicians’ Cancer Screening Recommendations & Practices Lung Cancer Screening Questionnaire (National Cancer Institute, Healthcare Delivery Research Program, n.d.). In order to assess clinician behavior, we created six brief vignettes that described a patient’s age and smoking status; we asked participants to indicate what imaging they would use to screen for lung cancer, if any, to better understand knowledge levels about lung cancer screening eligibility. The vignettes served as a proxy for behavior in the absence of being able to observe clinical encounters directly. Each vignette had the following four nonexclusive response options: LDCT of the chest, chest X-ray, no screening, not sure. Two vignettes included descriptions of individuals who qualified for lung cancer screening. Four vignettes included descriptions of individuals who did not qualify for lung cancer screening. The participants’ answers were recoded to indicate whether the clinician’s recommendation was concordant or discordant with current USPSTF lung cancer screening guidelines.

Sample Size Justification and Power Analysis

A total of 545 participants were enrolled in the study. The a priori alpha level was equal to .05. Power analysis was conducted using PASS software, version 2022. Based on our sample size, the study is appropriately powered for thoroughly testing the associations in the aims, with at least 80% power. Specifically, assuming that the baseline proportion of clinicians who are concordant with USPSTF lung cancer screening guidelines is between 20% and 50% for testing the effect of a continuous predictor with an odds ratio (OR) of 1.4, or a binary independent variable with a 25%–75% prevalence and OR = 2, using a multiple logistic regression model.

Data Analysis

Descriptive statistics were used to characterize participants’ characteristics (i.e., sociodemographic variables) and measures of attitudes and beliefs, barriers to lung cancer screening referral, practice characteristics, and knowledge of and concordance with USPSTF lung cancer screening guidelines, overall and stratified by clinician type. For USPSTF lung cancer screening concordance, the proportion of participants who answered each item correctly is reported, along with the percent who endorsed the “not sure” option. We then calculated a sum score for number of items answered concordantly with USPSTF lung cancer screening guidelines. Next, we ran a series of analyses of variance tests and Pearson correlations to assess correlation with clinician characteristics, attitudes and beliefs, barriers to lung cancer screening referral, and practice characteristics. In this study, the overarching conceptual model—DEM—has been modified to incorporate hypothetical patient characteristics as an additional predictor of clinical intention for recommendation for lung cancer screening (see Figure 1). We used SAS software (version 9.4) to conduct statistical analyses.

Results

Personal and Practice Characteristics

In total, 545 clinicians (37% nurse practitioners, 29% physicians, and 34% physician assistants) responded to the survey. The largest proportion of respondents was in general internal medicine (41%), followed by family practice (33%), and then by clinicians identifying both pulmonology and internal medicine as their specialty (27%). Most respondents indicated they had LDCT of the chest available (87%) and that their facility provides lung cancer screening (87%). One quarter (25%) of respondents reported a daily patient count of 10 or fewer, half (53%) reported seeing between 11 and 20 patients daily, and the remainder (22%) had a daily patient count of more than 20. The sample contained more female clinicians than male (60% vs. 38%) and contained moderate numbers of rural (11%), Hispanic (8%), Black (9%), and Asian (6%) clinicians. The sample ranged in age from 22 to 71 years, with a mean age of 40 years (SD = 8.4) and mean years in practice of 9.4 years (SD = 7.2). Complete sample characteristics are reported in Table 2.

Table 2.

Participant sociodemographics by professional role (N = 545)

All NP
(n = 200)		 MD or DO
(n = 157)		 PA
(n = 188)
Main practice area
 General Internal Medicine 221 (40.6%) 89 (44.5%) 57 (36.3%) 75 (39.9%)
 Family Practice 178 (32.7%) 76 (38.0%) 32 (20.4%) 70 (37.2%)
 Pulmonology 146 (26.8%) 35 (17.5%) 68 (43.3%) 43 (22.9%)
Low-dose computed tomography of the chest available at your facility?
 Yes 474 (87.0%) 172 (86.0%) 139 (88.5%) 163 (86.7%)
Approx. daily patient volume
 1–10 135 (24.8%) 48 (24.0%) 42 (26.7%) 45 (23.9%)
 11–20 286 (52.4%) 101 (50.5%) 77 (49.0%) 108 (57.4%)
 >21 121 (22.2%) 50 (25.0%) 37 (23.6%) 34 (18.1%)
Practice Geographic Classification
 Urban 221 (40.6%) 82 (41.0%) 78 (49.7%) 61 (32.5%)
 Suburban 220 (40.4%) 85 (42.5%) 39 (24.8%) 96 (51.1%)
 Rural 61 (11.2%) 24 (12.0%) 14 (8.9%) 23 (12.2%)
Gender
 Male 209 (38.4%) 52 (26.0%) 77 (49.0%) 80 (42.6%)
 Female 328 (60.2%) 145 (72.5%) 77 (49.0%) 106 (56.4%)
Hispanic/Latino
 Yes 46 (8.4%) 17 (8.5%) 12 (7.6%) 17 (9.0%)
Race
 White 428 (78.5%) 152 (76.0%) 131 (83.4%) 145 (77.1%)
 Black 49 (9.0%) 23 (11.5%) 6 (3.8%) 20 (10.6%)
 Asian 40 (7.3%) 13 (6.5%) 14 (8.9%) 13 (6.9%)
 American Indian 5 (0.9%) 3 (1.5%) 1 (0.6%) 1 (0.5%)
 Hawaiian/Alaska Native 3 (0.6%) 2 (1.0%) 0 (0%) 1 (0.5%)
 Other 7 (1.3%) 3 (1.5%) 1 (0.6%) 3 (1.6%)
 2 or more 8 (1.5%) 2 (1.0%) 2 (1.3%) 4 (2.1%)
What percentage of your adult patients are age 55 or older? [0 – 100] (n=542) 55.8 (20.4) 55.2 (20.5) 59.5 (21.3) 53.4 (19.3)
Age [22 – 71] (n=540) 39.7 (8.4) 39.4 (8.4) 41.9 (8.6) 38.1 (8.0)
# Years in Practice [1 – 40] (n=540) 9.4 (7.2) 8.8 (6.6) 12.3 (8.4) 7.7 (6.1)
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Aim 1. Describe attitudes, beliefs, and referral practice patterns

Clinician Attitudes and Beliefs

Respondents scored relatively low (χ = 2.5, SD = 0.5) on the General Shared Decision-Making Attitudes Scale and relatively high (χ = 3.0, SD = 0.5) on the Importance of Shared Decision-Making in Lung Cancer Screening Scale. Respondents scored average on the Empathy Toward Patients with a Smoking History Scale (χ = 2.7, SD = 0.6), although 14% of the sample had a score of 3 or above, indicating an average rating of “Agree” across all statements which reflected irritation and frustration with patients who continue to smoke.

Importance of shared decision-making in lung cancer screening was negatively correlated with barriers to lung cancer screening referral (r = −.15, p < .001). While clinicians believe both lung cancer screening and shared decision-making are important (M = 15.1 [SD = 2.6]; minimum–maximum 5–20), participants reported moderately unfavorable attitudes toward performing shared decision-making in general (M = 27.4 [SD = 5.6]; minimum-maximum 11–44).

Barriers to Lung Cancer Screening Referral

Respondents scored relatively low (χ = 2.1, SD = 0.6) on the Barriers to Lung Cancer Screening Referral Scale. Participants also reported moderate levels of perceived barriers to referring their patients for lung cancer screening (M = 14.9 (SD = 4.5); range of 7–28), and barriers to shared decision-making were positively correlated with barriers to lung cancer screening (r = .48, p < .001).

Aim 2. Describe lung cancer screening knowledge and assess concordance with lung cancer screening guidelines

Knowledge and Clinician Behavior

Lung cancer screening knowledge was surprisingly low among clinicians who treat lung cancer, screening-eligible patients, regardless of specialty. Response distributions for each vignette are shown in Table 3. More than one third (39%) of respondents answered none of the six vignettes correctly, with another approximately one third (31%) answering only one correctly. Only 5% of respondents answered more than half of the vignettes correctly. For each vignette, the most endorsed response (ranging from 39%–52%) was to refer the hypothetical patient for lung cancer screening using a chest X-ray, which was an incorrect response for all vignettes.

Table 3.

Response distributions for each vignette item.

LDCT Only LDCT & X-ray X-ray Only No Screening
A) A 60-year-old with a 30 pack-year history who quit smoking 5 years ago. (n = 535) 147 (27%) 93 (17%) 251 (47%) 34 (6%)
B) A 60-year-old who has never smoked who has a 30-year exposure to secondhand smoke from a chain-smoking spouse. (n = 536) 119 (22%) 61 (11%) 280 (52%) 70 (13%)
C) A 60-year-old with a 30 pack-year history who quit 20 years ago. (n = 533) 132 (25%) 60 (11%) 224 (42%) 110 (21%)
D) A 50-year-old former smoker with a 30 pack-year history who quit 1 year ago. (n = 532) 165 (31%) 100 (19%) 199 (37%) 60 (11%)
E) A 75-year-old former smoker with a 40 pack-year history who quit 10 years ago. (n = 524) 139 (27%) 87 (17%) 236 (45%) 53 (10%)
F) A 48-year-old current smoker with a 40 pack-year history. (n = 529) 129 (24%) 126 (24%) 207 (39%) 54 (10%)
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Note. LDCT = low-dose computed tomography; Bold indicates correct response.

Nearly three fourths (73%) of clinicians answered incorrectly when presented with a vignette that depicted a screening-eligible patient; only 14% of clinicians responded correctly on both such vignettes. Further, item-level knowledge scores revealed that the correct response rates were poor, ranging from only 10% to 27% correct across vignettes. Overwhelmingly, most clinicians regardless of specialty were nonconcordant with USPSTF guidelines regarding their decisions to refer the patient for lung cancer screening and what test to order. For both screening-eligible vignettes, 27% of clinicians answered correctly that the hypothetical patient should be referred for lung cancer screening with LDCT of the chest. Of note, 17% of clinicians responded that the patient should be screened using LDCT of the chest in addition to a chest X-ray (which is not an approved method to screen for lung cancer). Very few respondents endorsed the “not sure” option in any of the scenarios (range of 2% to 4% per item).

The only practice or clinician characteristic that was significantly associated with the total sum knowledge score across vignettes was whether the clinicians’ facilities provide lung cancer screening (p = .03); clinicians at such facilities scored an average of 0.43 points higher than clinicians at facilities without in-house lung cancer screening services. Further, in testing item-level scores on the General Shared Decision-Making Attitudes Scale with the total knowledge score, it was observed that several item-level scores were weakly but significantly correlated to the total knowledge score (Table 4). The item assessing empathy toward patients with a smoking history was positively correlated (r = .09, p =.04) with knowledge, such that respondents who answered more than half (M = 2.91, SD = 0.5) of the vignettes correctly had the highest mean empathy score, followed by those who answered 2 to 3 correctly (M = 2.76, SD = 0.6).

Table 4.

Correlations of attitude scale scores to vignette knowledge score

Scale Vignette Knowledge Score r
(p-value)
0
n = 215		 1
n = 170		 2–3
n = 135		 4–6
n = 25
General Shared Decision-Making Attitudes Scale 2.49 (0.6) 2.49 (0.5) 2.55 (0.5) 2.64 (0.4) 0.08 (0.08)
Importance of Shared Decision-Making in Lung Cancer Screening Scale 3.08 (0.6) 3.03 (0.5) 2.88 (0.5) 3.08 (0.4) −0.09 (0.03)
Barriers to Lung Cancer Screening Referral Scale 2.08 (0.7) 2.10 (0.6) 2.22 (0.6) 2.13 (0.3) 0.05 (0.25)
Empathy Toward Patients with a Smoking History Scale 2.67 (0.7) 2.65 (0.6) 2.76 (0.6) 2.91 (0.5) 0.09 (0.04)
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Discussion

We sought to describe lung cancer screening knowledge and assess concordance with lung cancer screening guidelines using clinical vignettes among clinicians (nurse practitioners, physicians, physician assistants) treating lung cancer screening-eligible patients in the U.S. The findings demonstrate that an overwhelming majority of clinicians’ decisions on lung cancer screening in response to hypothetical clinical vignettes were nonconcordant with USPSTF guidelines. Specifically, the most frequently selected screening decision in response to each of the six vignettes was to refer the hypothetical patient for lung cancer screening using a chest X-ray, which was an incorrect response for all scenarios. For four of the vignettes, the hypothetical patient should not have been referred for lung cancer screening, which indicates that the referral and practice patterns of the clinicians in this study tended toward over-prescribing lung cancer screening. Additionally, a chest X-ray is not an approved method for lung cancer screening, indicating that the clinicians in the current study tended to select a method most used for lung cancer screening that is not concordant with USPSTF guidelines.

Many clinicians continue to erroneously believe that a chest X-ray is appropriate for lung cancer screening, which is concerning because when a chest X-ray is ordered to screen for lung cancer, there is high probability of missing early-stage, more treatable tumors of the lung. It is critical clinicians follow evidence-based practice guidelines, and this study highlights the need for targeted continuing education about lung cancer screening for clinicians who treat screening-eligible patients. A very small proportion of respondents indicated “not sure” in response to the clinical vignettes, which suggests that many clinicians might have been confident in their answers and could be unaware that their incorrect responses were not concordant with USPSTF guidelines. As health systems continue implementing lung cancer screening programs, it is vital to promote continuing education on the updated evidence-based guidelines and the importance of shared decision-making for nurse practitioners, physicians, and physician assistants who treat lung cancer, screening-eligible patients.

Barriers to referring patients for lung cancer screening were significantly associated with barriers to shared decision-making. In addition, our findings demonstrated that clinicians believe shared decision-making is essential in the context of lung cancer screening but do not necessarily have a positive attitude toward performing shared decision-making. This may be related to the ever-increasing expectations clinicians encounter during well care and preventive care visits without a corresponding increase in time for the appointment—which may place increased stress on the clinician and clinical workflow. Implementing evidence-based, decision-making tools that facilitate effective brief shared decision-making (Caverly et al., 2021) may reduce the perceived barriers to shared decision-making and referring patients for lung cancer screening. Additionally, computer-tailored, decision aids—such as LungTalk—may be useful to prepare at-risk, screening-eligible patients for discussing lung cancer screening with their clinicians by providing key baseline patient education before a visit (Carter-Harris et al., 2020).

Strengths and Limitations

To our knowledge, this study represents the first U.S. national survey examining attitudes, beliefs, and knowledge of lung cancer screening and shared decision-making across varied primary care and pulmonary care clinician groups who treat screening-eligible patients, including nurse practitioners, physicians, and physician assistants. In addition, we enrolled a relatively equal number across the three clinician groups allowing a diverse multidisciplinary representation of perspectives. However, our sample was derived from an online panel of respondents and may not represent the entire U.S. population of these professionals, allowing for possible selection bias. Another limitation of this study is that it was not originally intended for respondents to select multiple choices in response to the vignettes; therefore, it is unknown how clinicians would have responded if forced to select only one option on the knowledge items. Though, the pattern of responses (that resulted from the nonmutually exclusive response options) highlights an important issue in that a substantial proportion of clinicians who believe a chest X-ray is an appropriate method for lung cancer screening (either on its own or in addition to LDCT of the chest).

Clinical Implications

Lung cancer screening referrals remain influenced by low knowledge of the guidelines—which is appropriate for referral—and the recommended imaging test for screening for lung cancer despite the USPSTF guidelines being released nearly one decade ago. While clinicians’ positive attitudes and beliefs are reassuring, lung cancer screening is falling short of reaching its full potential for those at greatest risk because of knowledge gaps that lead to inappropriate referrals. These inappropriate referrals also can burden the health care system’s resources when ineligible patients are referred. Results from this study highlight both the gaps in clinician knowledge around lung cancer screening and the need for targeted educational efforts and implementation strategies that support the patient–clinician discussion and referral of appropriate lung cancer screening-eligible patients.

Conclusion

Nearly 1 decade after the official lung cancer screening guideline was released by the USPSTF, most clinicians are nonconcordant with guidelines and inaccurately believe that a chest X-ray is appropriate for lung cancer screening. Targeted clinician interventions to support practice using evidence-based guidelines are critical as one piece of the puzzle to address low screening utilization among at-risk people.

Acknowledgement:

Research reported in this publication was supported by the American Lung Association Social-Behavioral Research Grant. The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Lung Association.

Ethical Conduct of Research:

This submission is the authors’ own original work, which has not been previously published elsewhere. This paper is not currently being considered for publication elsewhere. The paper reflects the authors’ own research and analysis in a truthful and complete manner. The paper properly credits the meaningful contributions of co-authors and co-researchers. The results are appropriately placed in the context of prior and existing research. All sources used are properly disclosed. All authors have been personally and actively involved in substantial work leading to the paper and will take public responsibility for its content. In addition, this study was reviewed and approved by the Institutional Review Board of Memorial Sloan Kettering Cancer Center prior to any research activities commencing.

Footnotes

The authors have no conflicts of interest to report.

Contributor Information

Lisa Carter-Harris, Department of Psychiatry & Behavioral Sciences Memorial Sloan Kettering Cancer Center New York, NY.

Leah E. Walsh, Memorial Sloan Kettering Cancer Center New York, NY.

Elizabeth Schofield, Memorial Sloan Kettering Cancer Center New York, NY.

Timothy J. Williamson, Memorial Sloan Kettering Cancer Center New York, NY.

Heidi A. Hamann, Department of Psychology University of Arizona Tucson, AZ.

Jamie S. Ostroff, Department of Psychiatry & Behavioral Sciences Memorial Sloan Kettering Cancer Center New York, NY.

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