Attitudes about low-dose computed tomography screening for lung cancer: a survey of American Thoracic Society Clinicians.

To the Editor: The National Lung Screening Trial (NLST) demonstrated a 20% reduction in lung cancer mortality with annual low-dose computed tomography (LDCT) screening among high-risk individuals (1). Yet LDCT screening can also cause harm. Although several organizations recommend screening (although in different populations) (2–4), others do not (5). With both Medicare and private insurers set to begin coverage in 2015, LDCT screening is expected to disseminate widely into practice. Whether implementation is successful, appropriate, and cost-effective will depend on clinicians’ attitudes and behaviors regarding screening (6). To address this issue, we surveyed an international sample of practicing clinicians who see patients with pulmonary disease. Methods We surveyed clinician (MDs, NPs, PAs) members of the American Thoracic Society (ATS) Clinical Problems and Respiratory Cell and Molecular Biology Assemblies (the parent assemblies of the Section of Thoracic Oncology) who regularly see outpatients. ATS sent three emails between March and April 2014 inviting participation in an anonymous, online survey about lung cancer screening, offering a $50 incentive for completion. We stratified respondents into “screeners” (those who would offer screening to an NLST-eligible patient) and “nonscreeners” and compared proportions with chi-square tests. We also performed subgroup analyses restricted to respondents from the United States and those from academic centers. Data were analyzed using Stata 10.1 (College Station, TX). The Boston University Institutional Review Board approved this study. Results Sample characteristics Of 5,872 ATS members with a valid email address, 1,444 opened the email and 428 responded (response rate, 7% of all emailed, 30% of opened invitations). Respondents represented a variety of clinical experience and settings (Table 1). Table 1. Respondent Characteristics Most respondents reported familiarity with the NLST (52% extremely and 39% somewhat familiar) and LDCT screening guidelines (44% extremely and 45% somewhat familiar). A third of respondents (34%) reported their clinical site already had a screening program in place, and another 30% indicated their site was planning to start one. General perceptions of screening and evidence and guidelines for LDCT screening Although most believed that screening tests are an important public health tool (87%), many recognized that screening can cause harm (76%). Most perceived the evidence for LDCT screening to be strong (17% very strong, 57% strong). Most believed that LDCT screening is more effective than prostate-specific antigen screening (56%) but less effective than smoking cessation (80%) at reducing cancer death. When asked about the ideal population for LDCT screening, 48% selected the NLST inclusion criteria, which form the basis for the American College of Chest Physicians guidelines (age 55–74 yr, with ≥30 pack-years tobacco use, and smoking within the last 15 yr), 24% the U.S. Preventive Services Task Force criteria (same as NLST except age range 55–80 yr), 11.3% the more liberal National Comprehensive Cancer Network criteria, and 11.0% selected targeted screening (7) for individuals with a 5-year risk of lung cancer death higher than 0.85%. A small minority (4%) believed LDCT screening should not be offered at all. LDCT screening practices Most respondents were guideline-concordant in their self-reported screening behavior (Tables 2 and ​and3):3): 90% (“screeners”) would offer screening to a NLST-eligible patient, and 69% would not offer screening to an NLST-ineligible patient with a remote smoking history. Screeners were more familiar with and more heavily influenced by the NLST and guidelines. Screeners were more greatly influenced by the perceived benefits of screening and the availability of resources for managing screen-detected nodules. In contrast, nonscreeners were more likely to be influenced by the potential harms of screening. Table 2. Low-Dose CT Screening Practices Table 3. Low-Dose CT Influences on Decision Making and Perceived Barriers to Implementation Nonscreeners were significantly more likely to perceive major barriers to implementation of LDCT screening programs (Tables 2 and ​and3).3). Overall, clinicians were more likely to perceive insufficient resources as major barriers compared with lack of buy-in from relevant parties. When asked about a marginal candidate (NLST-eligible but with severe chronic obstructive pulmonary disease), 64% would offer LDCT screening. Clinicians who would not screen this patient were more likely to report that candidacy for surgical treatment was a major influence on decision making (75% vs. 50%; P < 0.001). Subgroup analyses U.S. clinicians were more familiar than non-U.S. clinicians with the NLST results (59% vs. 34% extremely familiar; P < 0.001), more likely to perceive the evidence for LDCT screening to be very strong (20% vs. 7%; P < 0.001), and more likely to offer screening to a NLST-eligible patient (95% vs. 74%; P < 0.001). There were no important differences in attitudes or screening behaviors between clinicians at academic versus nonacademic sites. Discussion In this first international survey, we found that responding clinician members of ATS support LDCT screening of the NLST-eligible population, believe the evidence for screening is strong, and also recognize potential harms. The most important concerns for clinicians who did not recommend screening were the potential harms and insufficient resources to run screening programs. This study has limitations. First, our response rate was low, which is unfortunately consistent with the trend of decreasing response rates to physician surveys and email surveys in particular (8). Thus, we cannot be certain that respondents represent the views of all clinicians, or even all ATS clinician members. Individuals who perceive LDCT screening more favorably may have been more likely to participate than those apathetic to this issue, resulting in overestimates of enthusiasm for LDCT screening. However, the enthusiasm our respondents expressed for lung cancer screening is similar to that observed in prior primary care provider and patient surveys (9, 10). Second, responses to hypothetical vignettes may not reflect actual screening behavior. Third, our results capture our respondents’ attitudes about LDCT screening in spring 2014; however, clinician perceptions of the new intervention of LDCT screening may evolve over time. On the eve of the anticipated widespread implementation of LDCT screening, it is encouraging that most clinicians who responded to our survey appeared to be driven by the evidence and guidelines in deciding which patients should be offered screening; namely, the NLST population. Most were cognizant of both the benefits and harms of LDCT screening and appeared to balance those considerations when deciding whether to offer screening, an ideal scenario for the shared decision making required for Medicare coverage. As screening is widely implemented, education will be important to ensure providers are fully aware of the trial evidence and can discriminate which patients are appropriate for screening.