Attitudes and Beliefs of Primary Care Providers in New Mexico About Lung Cancer Screening Using Low-Dose Computed Tomography
Attitudes and Beliefs of Primary Care Providers in New Mexico About Lung Cancer Screening Using Low-Dose Computed Tomography
ORIGINAL RESEARCH — Volume 12 — July 9, 2015
Richard M. Hoffman, MD, MPH; Andrew L. Sussman, PhD, MCRP; Christina M. Getrich, PhD; Robert L. Rhyne, MD; Richard E. Crowell, MD; Kathryn L. Taylor, PhD; Ellen J. Reifler, MPH; Pamela H. Wescott, MPP; Ambroshia M. Murrietta, MHS; Ali I. Saeed, MD; Shiraz I. Mishra, PhD, MBBS
Suggested citation for this article: Hoffman RM, Sussman AL, Getrich CM, Rhyne RL, Crowell RE, Taylor KL , et al. Attitudes and Beliefs of Primary Care Providers in New Mexico About Lung Cancer Screening Using Low-Dose Computed Tomography. Prev Chronic Dis 2015;12:150112. DOI: http://dx.doi.org/10.5888/pcd12.150112.
On the basis of results from the National Lung Screening Trial (NLST), national guidelines now recommend using low-dose computed tomography (LDCT) to screen high-risk smokers for lung cancer. Our study objective was to characterize the knowledge, attitudes, and beliefs of primary care providers about implementing LDCT screening.
We conducted semistructured interviews with primary care providers practicing in New Mexico clinics for underserved minority populations. The interviews, conducted from February through September 2014, focused on providers’ tobacco cessation efforts, lung cancer screening practices, perceptions of NLST and screening guidelines, and attitudes about informed decision making for cancer screening. Investigators iteratively reviewed transcripts to create a coding structure.
We reached thematic saturation after interviewing 10 providers practicing in 6 urban and 4 rural settings; 8 practiced at federally qualified health centers. All 10 providers promoted smoking cessation, some screened with chest x-rays, and none screened with LDCT. Not all were aware of NLST results or current guideline recommendations. Providers viewed study results skeptically, particularly the 95% false-positive rate, the need to screen 320 patients to prevent 1 lung cancer death, and the small proportion of minority participants. Providers were uncertain whether New Mexico had the necessary infrastructure to support high-quality screening, and worried about access barriers and financial burdens for rural, underinsured populations. Providers noted the complexity of discussing benefits and harms of screening and surveillance with their patient population.
Providers have several concerns about the feasibility and appropriateness of implementing LDCT screening. Effective lung cancer screening programs will need to educate providers and patients to support informed decision making and to ensure that high-quality screening can be efficiently delivered in community practice.
The National Lung Screening Trial (NLST) showed that lung cancer screening with low-dose computed tomography (LDCT) significantly reduced lung cancer deaths among heavy smokers compared with screening with chest x-ray (1). The US Preventive Services Task Force (USPSTF) subsequently issued a B recommendation supporting LDCT screening (2). The recommendation is important because the Affordable Care Act mandates first-dollar coverage for preventive services graded A or B by the USPSTF (3). In February 2015, the Centers for Medicare and Medicaid Services (CMS) proposed that evidence is sufficient to provide annual LDCT screening for patients and in centers meeting eligibility criteria (4). The American Lung Association (5) and American Cancer Society (6) also support LDCT screening. However, the American Academy of Family Physicians determined that the evidence was insufficient to recommend for or against lung cancer screening with LDCT (7).
Translating results of an efficacy trial conducted largely in academic medical centers into routine community practice may be challenging. Nearly all participants in the NLST were white, their socioeconomic status was higher than the general population, and they were adherent to recommended testing (1). US population data show marked racial/ethnic and socioeconomic disparities in lung cancer mortality, prevalence of smoking, stage at diagnosis, and adherence to cancer screening (8,9). New Mexico, the setting for our study, is a large, sparsely populated minority–majority state (non-Hispanic whites make up less than 50% of the population) characterized by low socioeconomic status and limited health care resources (10).
Documenting the perspectives of providers caring for racially/ethnically and socioeconomically diverse populations is necessary for planning screening implementation. However, few studies have evaluated physician attitudes and practices regarding LDCT lung cancer screening (11–14), and US studies were conducted before NLST results and screening recommendations were published. Therefore, we interviewed primary care clinicians practicing in New Mexico to characterize their knowledge, attitudes, and beliefs about LDCT lung cancer screening.
This study was conducted through the Research Involving Outpatient Settings Network, a network of health care providers. We thank the clinicians who participated in this study. We also thank Mary C. White, ScD, and Thomas B. Richards, MD, Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC). This research was supported by the University of New Mexico Prevention Research Center and was supported by CDC Cooperative Agreement no. U48DP001931-05S1. R.M.H. is supported by the Department of Veterans Affairs. R.M.H. designed and obtained funding for the study, oversaw the research, and drafted the manuscript for the article. A.L.S. helped design the study, oversaw and conducted the qualitative work and data analysis, and helped draft the article. C.M.G. helped conduct the qualitative work and data analysis, and helped draft the article. R.L.R. helped design the study and helped draft the article. R.E.C. helped design the study, assisted in patient recruitment, and helped draft the article. K.L.T., E.J.R., and P.H.W. helped design the study, particularly in developing interview guides, helped with qualitative data analysis, and helped draft the article. A.M.M. helped conduct the qualitative work and data analysis and helped draft the article. A.I.S. participated in the study and reviewed the manuscript. S.I.M. helped design and obtain funding for the study, oversaw the research, and drafted the article. The findings and conclusions in this article are those of the authors and do not necessarily represent the official views of the CDC.
Corresponding Author: Shiraz I. Mishra, PhD, MBBS, Professor, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM 87131. Telephone: 505-925-6085. Email: firstname.lastname@example.org. Dr Mishra is also affiliated with the University of New Mexico Cancer Center and the Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.
Author Affiliations: Richard M. Hoffman, University of New Mexico School of Medicine, University of New Mexico Cancer Center, Albuquerque Veterans Affairs Medical Center, Albuquerque, New Mexico; Andrew L. Sussman, Robert L. Rhyne, University of New Mexico Cancer Center and Department of Family Medicine and Community Medicine, Albuquerque, New Mexico; Christina M. Getrich, Department of Anthropology, University of Maryland, College Park, Maryland; Richard E. Crowell and Ali I. Saeed, University of New Mexico School of Medicine and University of New Mexico Cancer Center, Albuquerque, New Mexico; Kathryn L. Taylor, Georgetown Lombardi Comprehensive Cancer Center and Georgetown University Medical Center, Washington, DC; Ellen J. Reifler and Pamela H. Wescott, Healthwise, Boise, Idaho; Ambroshia M. Murrietta, Clinical and Translational Science Center, University of New Mexico Health Sciences Center, Albuquerque, New Mexico.
- Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, et al. . Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365(5):395–409. CrossRef PubMed
- Moyer VA; US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160(5):330–8. CrossRefPubMed
- Patient Protection and Affordable Care Act. Public Law 111–48 (2010).
- Centers for Medicare and Medicaid Services. Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N). Baltimore (MD): Centers for Medicare and Medicaid Services; 2015 . http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274. Accessed February 7, 2015.
- Samet JM, Crowell R, Estepar RSJ, Powe NR, Rand C, Rizzo AA, et al. Providing guidance on lung cancer screening to patients and physicians. Washington (DC): American Lung Association; 2012. http://www.lung.org/lung-disease/lung-cancer/lung-cancer-screening-guidelines/lung-cancer-screening.pdf. Accessed February 7, 2015.
- Wender R, Fontham ET, Barrera E Jr, Colditz GA, Church TR, Ettinger DS, et al. American Cancer Society lung cancer screening guidelines. CA Cancer J Clin 2013;63(2):107–17. CrossRefPubMed
- American Academy of Family Physicians. Clinical Preventive Service Recommendation. Lung cancer. 2013. http://www.aafp.org/patient-care/clinical-recommendations/all/lung-cancer.html. Accessed October 14, 2014.
- Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, et al. SEER cancer statistics review, 1975–2011. Bethesda (MD): National Cancer Institute; 2014.
- Bryan L, Westmaas L, Alcaraz K, Jemal A. Cigarette smoking and cancer screening underutilization by state: BRFSS 2010. Nicotine Tob Res 2014;16(9):1183–9. CrossRef PubMed
- State and County QuickFacts. US Census Bureau; 2014. http://quickfacts.census.gov/qfd/states/35000.html. Accessed October 31, 2014.
- Klabunde CN, Marcus PM, Silvestri GA, Han PK, Richards TB, Yuan G, et al. US primary care physicians’ lung cancer screening beliefs and recommendations. Am J Prev Med 2010;39(5):411–20. CrossRef PubMed
- Klabunde CN, Marcus PM, Han PK, Richards TB, Vernon SW, Yuan G, et al. Lung cancer screening practices of primary care physicians: results from a national survey. Ann Fam Med 2012;10(2):102–10. CrossRef PubMed
- Henderson S, DeGroff A, Richards TB, Kish-Doto J, Soloe C, Heminger C, et al. A qualitative analysis of lung cancer screening practices by primary care physicians. J Community Health 2011;36(6):949–56. CrossRef PubMed
- Couraud S, Girard N, Erpeldinger S, Gueyffier F, Devouassoux G, Llorca G, et al. . Physicians’ knowledge and practice of lung cancer screening: a cross-sectional survey comparing general practitioners, thoracic oncologists, and pulmonologists in France. Clin Lung Cancer 2013;14(5):574–80. CrossRef PubMed
- Sinclair-Lian N, Rhyne RL, Alexander SH, Williams RL. Practice-based research network membership is associated with retention of clinicians in underserved communities: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med 2008;21(4):353–5. CrossRef PubMed
- Borkan J. Immersion/crystallization. In: Crabtree B, Miller W, editors. Doing qualitative research. Thousand Oaks (CA): Sage Publications; 1999.
- Morse JM, Barrett M, Mayan M, Olson K, Spiers J. Verification strategies for establishing reliability and validity in qualitative research article. Int J Qual Methods 2002;1(2):2.
- Marinopoulos SS, Dorman T, Ratanawongsa N, Wilson LM, Ashar BH, Magaziner JL, et al. Effectiveness of continuing medical education. Evid Rep Technol Assess (Full Rep) 2007;(149):1–69.PubMed
- US Preventive Services Task Force. Talking with your patients about screening for lung cancer. http://www.uspreventiveservicestaskforce.org/Home/GetFileByID/796. Accessed October 31, 2014.
- King JS, Moulton BW. Rethinking informed consent: the case for shared medical decision-making. Am J Law Med 2006;32(4):429–501. PubMed
- Volk RJ. Promoting informed decisions about lung cancer screening. Patient-Centered Outcomes Research Institute; 2013. PCORI-CER-1306-03385. https://clinicaltrials.gov/ct2/show/NCT02282969. Accessed February 7, 2015.
- Doria-Rose VP, White MC, Klabunde CN, Nadel MR, Richards TB, McNeel TS, et al. Use of lung cancer screening tests in the United States: results from the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev 2012;21(7):1049–59. CrossRef PubMed
- Goulart BH, Bensink ME, Mummy DG, Ramsey SD. Lung cancer screening with low-dose computed tomography: costs, national expenditures, and cost-effectiveness. J Natl Compr Canc Netw 2012;10(2):267–75. PubMed
- Black WC, Gareen IF, Soneji SS, Sicks JD, Keeler EB, Aberle DR, et al. Cost-effectiveness of CT screening in the National Lung Screening Trial. N Engl J Med 2014;371(19):1793–802.CrossRef PubMed
- Villanti AC, Jiang Y, Abrams DB, Pyenson BS. A cost–utility analysis of lung cancer screening and the additional benefits of incorporating smoking cessation interventions. PLoS ONE 2013;8(8):e71379. CrossRef PubMed
- Kovalchik SA, Tammemagi M, Berg CD, Caporaso NE, Riley TL, Korch M, et al. Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med 2013;369(3):245–54.CrossRef PubMed