BOSTON — Clinician judgment, not patient characteristics, often is the deciding factor in which VA patients are screened for lung cancer, according to a new study.
That led the authors of a study in The American Journal of Respiratory and Critical Care Medicine to suggest, “Achieving the net benefit of lung cancer screening (LCS) depends on optimizing patient selection.”1
The study team led by the VA Boston and Bedford Healthcare Systems sought to identify factors associated with clinician assessments that a patient was unlikely to benefit from lung cancer screening (“LCS-inappropriate”) because of comorbidities or limited life expectancy. Researchers from the VA Portland, OR, Health Care System, the Veterans Health Administration in Washington, DC, and the VA Ann Arbor, MI, Healthcare System also participated.
A retrospective analysis of patients assessed for LCS at 30 VHA facilities was conducted from Jan. 1, 2015, to Feb. 1, 2021. The focus was on clinicians’ designations of LCS inappropriateness—defined as the primary outcome—and the three-year predicted probability (i.e., competing risk) of non-lung cancer death.
Of the 38,487 LCS-eligible patients, 1,671 (4.3%) were deemed LCS-inappropriate by clinicians, while 4,383 (11.4%) had an estimated three-year competing risk of non-lung cancer death greater than 20%.
“Patients with higher competing risks of non-lung cancer death were more likely to be deemed LCS-inappropriate (odds ratio [OR], 2.66; 95% confidence interval [CI], 2.32-3.05),” the authors explained. “Older patients (ages 75-80; OR, 1.45; 95% CI, 1.18-1.78) and those with interstitial lung disease (OR, 1.98; 95% CI, 1.51-2.59) were more likely to be deemed LCS-inappropriate than would be explained by competing risk of non-lung cancer death, whereas patients currently smoking (OR, 0.65; 95% CI, 0.58-0.73) were less likely to be deemed LCS-inappropriate, suggesting that clinicians over- or underweighted these factors.”
The study pointed out that the probability of being deemed LCS-inappropriate varied from 0.4% to 74%, depending on the clinician making the assessment (median OR, 3.07; 95% CI, 2.89-3.25).
“Concerningly, the likelihood that a patient is deemed LCS-inappropriate is more strongly associated with the clinician making the assessment than with patient characteristics,” the researchers concluded. “Patient selection may be optimized by providing decision support to help clinicians assess net LCS benefit.”
- Núñez ER, Zhang S, Glickman ME, Qian SX, et. Al. What Goes into Patient Selection for Lung Cancer Screening? Factors Associated with Clinician Judgments of Suitability for Screening. Am J Respir Crit Care Med. 2024 Jan 15;209(2):197-205. doi: 10.1164/rccm.202301-0155OC. PMID: 37819144.