A Qualitative Analysis of Lung Cancer Screening Practices by Primary Care Physicians

Susan Henderson; Amy DeGroff; Thomas B. Richards; Julia Kish-Doto; Cindy Soloe; Christina Heminger; Elizabeth Rohan


J Community Health. 2011;36(6):949-956. 

In This Article

Abstract and Introduction


Lung cancer is the leading cause of cancer death in the United States, but no scientific organization currently recommends screening because of limited evidence for its effectiveness. Despite this, physicians often order screening tests such as chest X-rays and computerized tomography scans for their patients. Limited information is available about how physicians decide when to order these tests. To identify factors that affect whether physicians' screen patients for lung cancer, we conducted five 75-min telephone-based focus groups with 28 US primary care physicians and used inductive qualitative research methods to analyze their responses. We identified seven factors that influenced these physicians' decisions about screening patients for lung cancer: (1) their perception of a screening test's effectiveness, (2) their attitude toward recommended screening guidelines, (3) their practice experience, (4) their perception of a patient's risk for lung cancer, (5) reimbursement and payment for screening, (6) their concern about litigation, and (7) whether a patient requested screening. Because these factors may have conflicting effects on physicians' decisions to order screening tests, physicians may struggle in determining when screening for lung cancer is appropriate. We recommend (1) more clinician education, beginning in medical school, about the existing evidence related to lung cancer screening, with emphasis on the benefit of and training in tobacco use prevention and cessation, (2) more patient education about the benefits and limitations of screening, (3) further studies about the effect of patients' requests to be screened on physicians' decisions to order screening tests, and (4) larger, quantitative studies to follow up on our formative data.


Lung cancer accounts for the most cancer deaths in the United States, with over 203,000 new cases diagnosed each year.[1] In 2007, 158,680 Americans died from lung cancer, more than from prostate, breast, and colon cancer combined.[1] The prognosis of US lung cancer patients remains poor, with only 16% surviving 5 years from the time of diagnosis.[2] Although screening for other types of cancer, including breast, cervical, and colorectal, has been shown to be effective, evidence concerning the effectiveness of lung cancer screening in reducing lung cancer-associated morbidity and mortality rates is less clear.[3,4] In 2004, the United States preventive services task force (USPSTF) changed its rating for evidence of lung cancer screening's usefulness from "D" (fair evidence against its usefulness) to "I" (inconclusive evidence).[4] Other organizations' clinical guidelines for the use of computerized tomography (CT) scanning as a population-based screening tool vary (Table 1). The American Cancer Society (ACS) distinguishes between mass screening and individual screening and recommends that decisions about individual screening be shared by physicians and their patients. Advocacy groups such as the Lung Cancer Alliance (LCA) encourage discussion with one's physician about the benefits of a baseline CT in any smoker over age 50 or smokers with a greater than 10-pack-year history.[5]

The results of randomized trials concerning the utility of CT scans for lung cancer screening have been inconsistent. For example, results of a study by Bach et al.[6] showed no evidence that CT screening was associated with lower mortality rates, whereas results from another study showed that CT screening of "high-risk patients" defined as 10-pack-year or higher smokers did produce favorable results.[7] These recent studies follow the highly publicized results published by Henschke in 2006 showing a 92% survival rate after 5 years among people found to have stage 1 lung cancer through CT screening.[8] Ethical issues have called into question those study results.[9] In addition, preliminary results from the Prostate, Lung, Colorectal, and Ovarian (PLCO) trial showed a significantly larger number of early stage cancers identified in people screened by chest X-ray than in those who were not,[10] and preliminary findings from the National Lung Screening Trial (NLST), a study sponsored by the National Cancer Institute (NCI), showed a small decrease in mortality rates associated with use of low-dose CT scans.[11,12]

Physicians' decisions about ordering screening tests for lung cancer have been found to be sometimes inconsistent with recommendations. Results of a 2010 study, for example, showed that 67% of primary care physicians recommended lung cancer screening for asymptomatic patients who were current smokers, former smokers who had quit within the previous year, or nonsmokers whose spouses smoked.[13] The study, however, did not attempt to determine why physicians do or do not use chest X-rays or CT scans for lung cancer screening. We conducted this formative study to better understand the factors influencing physicians' decisions about screening patients for lung cancer.