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

Disclosures

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

In This Article

Results

Physicians represented a range of practice settings, locations, and ages (Table 2). The majority of physicians were white male internists who practiced in a city with fewer than 500,000 people (Table 2). The results of our analyses indicated that seven factors influenced these physicians' decision whether to screen patients for lung cancer (Fig. 1). We describe each factor in detail below.

Figure 1.

Factors that influence physicians' decisions to order lung cancer screening

Perceived Effectiveness of Chest X-Rays and CT Scans for Lung Cancer Screening

Overall, physicians viewed CXR as an outdated and insensitive modality for lung cancer screening. While physicians reported using CXR to diagnose shortness of breath, persistent cough, and chest pain, most were aware that it lacks efficacy for lung cancer screening. Some physicians perceived CT scans as very efficacious in detecting small nodules in the lungs, yet participants had varying perceptions of its effectiveness as a screening test. Benefits and harms reported by physicians for CXR and CT scans are summarized in Table 3. Not all participants differentiated between the use of these procedures as screening tests (i.e., to detect disease in asymptomatic patients) and their use as diagnostic tests (i.e., to investigate symptoms). Their confusion regarding this terminology is reflected in the quote below:

… we picked up [a lung nodule] when I was getting a chest x-ray to screen for [diagnose] pneumonia on somebody and it showed the un-calcified nodule.

Physicians' Attitude Toward Clinical Guidelines or Recommendations Related to Lung Cancer Screening

One of the factors affecting physicians' decision to screen was their attitude toward clinical recommendations that address lung cancer screening. Although a few physicians were unaware of such recommendations, most, when asked, identified those published by the USPSTF and ACS. Among participants, two disparate views on lung cancer screening recommendations emerged. Some physicians used the lung cancer screening recommendations to direct their practices, while others used them to inform their decision-making but were not constrained by them. One of the reasons given for not following the recommendations consistently was the incorrect perception that the recommendations are based on a consensus of physicians' opinions rather than on actual evidence of their effectiveness. The following two comments illustrate the opposing ways in which focus group participants viewed the screening recommendations.

The federal government spends a tremendous amount of money in studying and publishing guidelines, which I use and which we're supposed to use, in trying to figure these things [whether to screen for lung cancer] out. It's called the United States Preventive Medicine [Services] Task Force and they come up with [recommendations for] routine screenings. Lung x-ray is not one of them.

However, the comments of another physician represent the opposing view:

You have to kind of break it down and think about it and remember, guidelines are guidelines. They're not law…I would really find it hard to say that an attorney could win a case saying that you didn't follow a guideline when it's very much that. It's a guideline. It's not saying it has to be this way or that way.

Physicians' Practice Experience

Focus group members who had observed adverse affects on patients who underwent diagnostic tests of what turned out to be benign lesions identified during lung cancer screening often held negative views about the utility of using chest X-rays and CT scans for such screening. As one physician holding such views stated:

…you get a lot of false positives… as [has] previously been mentioned, if you're doing CAT scans. And people wind up getting a lot of procedures with pretty significant morbidity/mortality for benign lesions. We don't really have good evidence-based medicine that says we're helping folks and, certainly, there's some pretty good evidence from the increased procedures that we hurt a lot of people.

Overall, the more experienced physicians were, the less likely they were to support lung cancer screening. One veteran physician described his experiences with lung cancer screening as follows:

I used to [screen for lung cancer with chest x-ray]…after getting so many false positives and then going through a whole bunch of CT scans…I really haven't had any [true] positive[s] and I've been in practice 19 years.

Physicians' Perception of Their Patients Risk for Lung Cancer

Although most physicians' reported that their decisions about screening patients for lung cancer were influenced by their perceptions of their patients' risk for lung cancer, how they determined that risk varied substantially. While family history, immune-compromised status, personal history of cancer, exposure to secondhand smoke, and pre-existing pulmonary disease (emphysema) were all cited by some physicians as being risk factors for lung cancer, smoking was the factor cited most often. One participant quipped, "it's cigarettes, cigarettes, cigarettes." A history of heavy cigarette smoking was defined by most participants as a history of smoking at least a pack a day for 20–40 years. Environmental risks such as exposure to asbestos, radon, and silica were also considered risk factors by many participants. As one physician said, "if [people have] worked in coal mines and other environments or occupations that put them at risk for inhalation of fumes, [such as] auto mechanics, [working at] gas stations…[this] put[s] them at more risk…

Physicians' Reimbursement for Screening

A few physicians reported that they could easily secure reimbursement for chest X-rays by either reporting that patients were smokers or that they had symptoms such as a persistent cough. Most, however, reported having more difficulty obtaining such reimbursement for CT. One physician said that she commonly referred patients to a local facility offering $99 full-body CT scans as a means of screening them for lung cancer. Even though these scans were not designed to screen for lung cancer specifically, she suggested they were a more affordable option for patients who had to pay for screening:

I know that they're not the ideal screening test, but I've never had a problem having those [CXRs] covered [by insurers]. But to do a spiral CT, those won't get covered and people aren't willing to pay [the several hundred dollars charged by the hospital or facility performing the CT].

Physicians' Concerns about Litigation

Even when they believed a patient was at low risk for lung cancer, some physicians reported ordering chest X-rays or CT scans to protect themselves against potential future lawsuits, especially if the patient requested lung cancer screening. As one physician said:

I may send …[patients] for a chest x-ray mainly for legal reasons, not to discover the tumor, because some of them eventually will develop lung cancer, no doubt. And they may come after you as a physician and say, "Oh, I saw you a long time ago and you knew I was a smoker. How do you know that I did not have lung cancer back then?"

Patients' Request for Screening

Patient requests for screening is another factor that influences physicians' screening decisions. Regardless of physicians' knowledge about screening efficacy, when faced with a patient request, physicians said that they frequently comply and order a screening test. Some suggested that patients who were smokers and particularly anxious about their risk for lung cancer (i.e., "the worried well") were more likely to request screening. Others described patients requesting chest X-rays to test for lung cancer because lung cancer had been diagnosed recently in a friend or relative. One physician mentioned that several of her patients requested lung cancer screening shortly after news reports of lung cancer being diagnosed in a celebrity and that she complied with their requests. Some physicians said they ordered a screening test as a means to relieve patient anxiety, including one who described the rationale for doing so as follows:

I've had several [patients asking to be screened for lung cancer]… especially if they've had a relative who just died from lung cancer and they themselves are heavy smokers. They're kind of hoping against hope… They'll come say, "Doc, can I have a chest x-ray? My uncle just died from lung cancer. I know I'm a smoker. I know I need to stop smoking. Could you just please do a chest x-ray?"

Physician Struggle

Although we initially separated focus group participants into two groups (screeners and non-screeners) on the basis of their preliminary descriptions of their use of screening tests, we found little difference between the groups in how they described their use of these tests during the focus group sessions. Physicians who had identified themselves as "screeners" sometimes did not routinely screen, and those who had identified themselves as "non-screeners" sometimes did. This finding reflects a concept that we define as "physician struggle," meaning that physicians' may make decisions about screening their patients that are contradictory to their beliefs about screening as they weigh the factors noted above. While some of these factors are complimentary, often they are contradictory. For example, one physician knew that professional recommendations do not support lung cancer screening, but he debated the merits of screening considering other factors in his decision:

Everybody [the other physicians in the focus group] seems to struggle with the same thing I do: when to get chest x-rays and when not and how to screen…it's basically proven that routine chest x-rays are not effective.

Some physicians reported that despite the scientific evidence, they would use chest X-rays to screen patients who were "heavy" smokers if the patients had insurance that would reimburse them for the test. Similarly, several physicians described ordering screening tests for patients who requested them, sometimes because of their fear of potential litigation. Others, however, expressed reluctance to order tests because of the unnecessary, invasive follow-up procedures that patients with false-positive results would have to endure. This reluctance was described by one physician as follows:

…since it [screening] isn't currently recommended and…since there are significant economic consequences even for the insured patient, I wouldn't do it [screen] routinely in the asymptomatic patient unless they specifically request it…I think you have to warn the patients about the fallout that comes from having the scan done in terms of [finding] inconsequential nodules, [doing] repeat scans, biopsies, bronchoscopy…

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