What Goes into Patient Selection for Lung Cancer Screening? Factors Associated with Clinician Judgments of Suitability for Screening
Rationale: Achieving net benefit of lung cancer screening (LCS) depends on optimizing patient selection.
Objective: To identify factors associated with clinician assessments that a patient was unlikely to benefit from LCS ("LCS-inappropriate") due to comorbidities or limited life expectancy.
Methods: Retrospective analysis of patients assessed for LCS at 30 Veterans Health Administration facilities from 1/1/2015-2/1/2021. We conducted hierarchical mixed effects logistic regression analyses to determine factors associated with clinicians' designations of LCS-inappropriateness (primary outcome), accounting for 3-year predicted probability (i.e., competing risk) of non-lung cancer death.
Measurements and main results: Among 38,487 LCS-eligible patients, 1,671 (4.3%) were deemed LCS-inappropriate by clinicians, whereas 4,383 (11.4%) had an estimated 3-year competing risk of non-lung cancer death >20%. Patients with higher competing risks of non-lung cancer death were more likely to be deemed LCS-inappropriate (OR 2.66, 95% CI 2.32-3.05). Older patients (ages 75-80: OR 1.45 [95% CI 1.18-1.78]) and those with interstitial lung disease (OR 1.98 [1.51-2.59]) were more likely to be deemed LCS-inappropriate than would be explained by competing risk of non-lung cancer death, while patients currently smoking (OR 0.65 [0.58-0.73]) were less likely to be deemed LCS-inappropriate, suggesting clinicians over- or under-weight these factors. The probability of being deemed LCS-inappropriate varied from 0.4%-74% depending on the clinician making the assessment (median OR 3.07 [2.89-3.25]).
Conclusion: Concerningly, the likelihood that a patient is deemed LCS-inappropriate is more strongly associated with the clinician making the assessment than patient characteristics. Patient selection may be optimized by providing decision support to help clinicians assess net LCS benefit.
Keywords: clinician decision making; competing risk; limited life expectancy; lung cancer screening; veterans health administration.
Núñez ER, Zhang S, Glickman ME, Qian SX, Boudreau JH, Lindenauer PK, Slatore CG, Miller DR, Caverly TJ, Wiener RS. What Goes into Patient Selection for Lung Cancer Screening? Factors Associated with Clinician Judgments of Suitability for Screening. Am J Respir Crit Care Med. 2023 Oct 11. doi: 10.1164/rccm.202301-0155OC. Epub ahead of print.