Lung Cancer Screening: A Qualitative Study Exploring the Decision to Opt Out of Screening

Background: Lung cancer screening with annual low-dose computed tomography is relatively new for long-term smokers in the United States, and supported by a U.S. Preventive Services Task Force Grade B recommendation. As lung cancer screening programs are more widely implemented and providers engage patients about screening, it is critical to understand what influences a patient’s decision to screen, or not, for lung cancer. Understanding lung cancer screening behavior among high-risk smokers who opt out provides insight from the patient perspective about the shared decision-making process for lung cancer screening. The purpose was to explore screening-eligible patients’ decision to opt out of lung cancer screening after receiving a provider recommendation. This knowledge will inform intervention development to enhance shared decision-making processes between long-term smokers and their providers and decrease decisional conflict about lung cancer screening. Methods: Semi-structured qualitative telephone interviews were performed with 18 lung screening-eligible men and women who were members of an integrated, mixed-model health care system in Seattle, Washington, about their decision to opt out of lung cancer screening. Participants met lung cancer screening criteria for age, smoking and pack-year history. Audio-recorded interviews were transcribed verbatim. Two researchers with cancer screening and qualitative methodology expertise conducted data analysis using thematic content analytic procedures. Results: Participant mean age was 66 years (standard deviation: 6.5). Majority were female (61%), Caucasian (83%) or current smokers (61%). Five themes emerged: 1) Knowledge Avoidance; 2) Perceived Low Value; 3) False-Positive Worry; 4) Practical Barriers; and 5) Patient Misunderstanding. Conclusion: Many screening-eligible smokers opt out of lung cancer screening. The participants in our study provided new insights into why some patients make this choice. While there are known drawbacks to lung cancer screening, and it is not necessarily the best option for everyone who is eligible, it is known to be effective in early lung cancer detection among high-risk patients. Understanding why people decide not to screen will enhance future efforts to improve knowledge transfer from providers to patients about the risks and benefits of lung cancer screening and ultimately enhance shared decision-making about lung cancer screening