Lung Cancer Screening and Tobacco Cessation: Barriers, Facilitators and the Role of Tobacco Counselors, Patient Navigators, and Clinician Education in Addressing Social Determinants of Health
Introduction
Lung cancer is the leading cause of cancer-related mortality in the U.S. and the number one risk factor for lung cancer is cigarette smoking. Although tobacco use has declined over the past two decades, disparities exist based on race/ethnicity, education, household income, and geographic area. Compared to urban areas, individuals living in rural communities are more likely to smoke (19.2% versus 14.4%) and have lower smoking cessation rates. The U.S. Preventive Services Task Force (USPSTF) recommends annual screening for adults ages 50 to 80 years who have a 20 pack-year smoking history, currently smoke, or have quit within the past 15 years. Early-detection screening using a low-dose computed tomography (LDCT) scan is an effective method for early detection of lung cancer. This qualitative study assesses barriers and facilitators for lung cancer screening using key informant interviews.
Methods
Key informant interviews were conducted with 45 representatives from participating healthcare centers to assess overall impressions of lung cancer screening practices. A semi-structured interview guide was used to elicit responses relating to clinic-specific successes, barriers, and lessons learned. Video-interviews were conducted by staff with qualitative research experience and knowledge of lung cancer screening program implementation. The study was approved by the Baylor College of Medicine Institutional Review Board. We used convenience sampling and aimed to include a balanced representation of each of the 19 clinics. NVivo software was used for qualitative data management and for analysis of interviews. Thematic analysis was used to identify, analyze, and report themes in the data by two researchers with training in qualitative research. Nearly all interviews were conducted one-on-one, with one group interview consisting of three participants.
Results
Qualitative data from semi-structured interviews (n = 45) across 19 community health centers were analyzed. The length of the interviews ranged from 30-60 minutes. Three major themes were identified: (1) impact of social determinants of health on individual treatment seeking behaviors, (2) practice/clinician level barriers, and (3) difficulty with the process of ordering LDCT. Individual barriers included: insurance eligibility and coverage, cost, transportation and distance to screening or follow-up appointments. Practice-level barriers included: lack of tobacco counselors, misconceptions and lack of understanding regarding LDCT, and lack of education/training. There were inconsistent reports regarding the perceived difficulty of screening, identifying, and referring patients for LCDT. Nearly two-thirds of the participants did not have a system in place in their electronic health record to facilitate the ordering process, particularly as compared to other preventive services (e.g., mammography). Clinicians working in rural clinics cited barriers across all three domains, with distance to imaging centers, access to pulmonary specialty care, and limited patient resources being the most reported.
Conclusion
Clinicians working in rural clinics face similar barriers encountered in the urban safety net healthcare system. However, unique barriers such as distance to imaging facilities and limited access to resources compounded the challenges in implementing effective screening programs. The study emphasizes the importance of having tobacco counselors and patient navigators in a successful Lung Cancer Screening program. The findings highlight the necessity for educating all primary care clinicians about effective implementation strategies to improve lung cancer screening and encourage patient participation in tobacco cessation services. The research underscores the significance of comprehensive efforts to enhance lung cancer screening and tobacco cessation services through better clinician education and addressing social determinants of health.