Lung cancer is the leading cause of cancer-related death in Veterans and accounts for 18.8% of all cancers in VHA. It is potentially curable if found early, but lung tumors progress rapidly and most cases have long been diagnosed too late for cure. The situation may change dramatically with the implementation of low- dose CT scan screening, pursuant to findings from the National Lung Screening Trial (NLST). The Undersecretary for Health has ordered a demonstration project at 8 VA sites as a trial of lung cancer screening in VA, which is currently ongoing. The potential to improve Veterans' health through screening is enormous, although lung cancer screening will come with considerable challenges that need immediate attention. Adherence to follow-up CT is essential to effective lung cancer screening. The NLST demonstrated the efficacy of screening by ensuring near perfect adherence to serial CT scans. The effectiveness of screening in the VA will depend on ensuring Veterans' acceptance and continued adherence to screening protocols. This will be challenging. High resolution CT scans will detect many suspicious lung nodules, but few will turn out to be cancer. Suspicious nodules between 4 mm and 8 mm call for surveillance through repeated CT scans at 3-12 month intervals for a period of 2 years, with resumption of annual screening CT scans thereafter. More frequent surveillance, the uncertain significance of indeterminate nodules, and the high incidence of false positive findings will further complicate screening. Yet, non-adherence to either the surveillance of indeterminate nodules or annual CT scans will compromise the effectiveness of screening and may result in dangerous delays in diagnosis and treatment. Adherence to planned follow-up, including missed appointments and patient drop-out, will be problematic for Veterans. As lung cancer screening is implemented on a wide scale in the VHA, and outside the controlled settings of trials, we can expect adherence to these screening and surveillance protocols to be lower than adherence rates in screening trials and that Veterans will encounter multiple barriers to continued adherence. However, data to guide efforts to ensure high levels of adherence to lung cancer screening in the VHA are quite limited. Data relating to Veterans' perceptions of screening and their adherence to the process are urgently needed. However, as previous research has focused on patients' decisions to initiate lung cancer screening, little attention has been given to patients' persistence and adherence to continued surveillance when initial results are known and motivations may be on a new footing. We propose a Pilot study to characterize the decisions veterans make regarding adhering to follow-up screening and surveillance in lung cancer screening. We will conduct a qualitative study involving interviews with veterans who have initiated lung cancer screening through lung CT and clinical staff who are involved in their care. This study will accomplish the following 2 objectives: 1) Identify factors that lead to adherence and non-adherence. This will include characterizing Veterans' perceptions of lung cancer risk and the need for lung cancer screening, and the evaluation of Veterans' decision-making regarding lung cancer screening and adherence to follow- up and surveillance. 2) Characterize perceptions of clinical staff who are involved in coordinating lung cancer screening and in promoting/ensuring engagement with follow-up in clinics that have implemented screening. The focus will be to gain an understanding of strategies that have been employed for keeping Veterans engaged with screening and surveillance in order to inform future implementation of lung cancer screening across VHA.
We propose to characterize the decisions veterans make regarding adhering to follow-up screening and surveillance in lung cancer screening. The current implementation of lung cancer screening in VHA for veterans at high risk for lung cancer necessitates an investigation into patient decision-making, in addition to the perceptions of the screening and surveillance process by both veterans and the clinicians who coordinate their care. This research will address an important, yet understudied health care policy problem for the VHA. The findings from this research will be essential to understanding how to manage lung cancer screening programs in VHA in order to optimize adherence. We will produce a conceptual model to guide further, well informed, systematic research on adherence in lung cancer screening. The findings from this study will also have immediate utility in guiding the design of interventions for providers and patients that may improve patient adherence as lung cancer screening continues to be implemented throughout VHA.
