Consequences of screening in lung cancer: development and dimensionality of a questionnaire

Pulmonary nodules and the psychological harm they can cause: A scoping review

More than 1.6 million pulmonary nodules are diagnosed in the United States each year. Although the majority of nodules are found to be benign, nodule detection and the process of ruling out malignancy can cause patients psychological harm to varying degrees. The present study undertakes a scoping review of the literature investigating pulmonary nodule-related psychological harm as a primary or secondary outcome. Online databases were systematically searched to identify papers published through June 30, 2023, from which 19 publications were reviewed. We examined prevalence by type, measurement, associated factors, and behavioral or clinical consequences. Of the 19 studies reviewed, 11 studies investigated distress, anxiety (n = 6), and anxiety and depression (n = 4). Prevalence of distress was 24.0 %-56.7 %; anxiety 9.9 %-42.1 %, and 14.6 %-27.0 % for depression. A wide range of demographic and social characteristics and clinical factors were associated with nodule-related psychological harm. Outcomes of nodule-related harms included experiencing conflict when deciding about treatment or surveillance, decreased adherence to surveillance, adoption of more aggressive treatment, and lower health-related quality of life. Our scoping review demonstrates that nodule-related psychological harm is common. Findings provide evidence that nodule-related psychological harm can influence clinical decisions and adherence to treatment recommendations. Future research should focus on discerning between nodule-related distress and anxiety; identifying patients at risk; ascertaining the extent of psychological harm on patient behavior and clinical decisions; and developing interventions to assist patients in managing psychological harm for better health-related quality of life and treatment outcomes.

Exploring experiences and coping strategies of the surveillance of indeterminate pulmonary nodules: a qualitative content analysis among participants in the SCAPIS trial

OBJECTIVE

To elucidate experiences and coping strategies among adults in the surveillance of indeterminate pulmonary nodules detected with CT in the population-based Swedish CardioPulmonary bioImage Study (SCAPIS).

DESIGN

A qualitative study of conventional content analysis.

SETTINGS

The study was conducted at a university hospital in a southern region of Sweden. The SCAPIS setting is similar to the first round of a population-based lung cancer screening programme.

PARTICIPANTS

Participants in SCAPIS who had experienced psychosocial consequences of the surveillance were eligible. Participants of both genders, current, former and non-smokers and of different follow-ups in the surveillance were included. Face-to-face semi-structured interviews with 19 participants were performed using an interview guide with open-ended questions. The participants were aged 56-68 years. Nine were women, 6 and 13 were non-smokers and smokers or former smokers, respectively, and all participants had undergone at least one follow-up of the lungs in the surveillance programme.

RESULTS

The results depicted an emotional and mental journey for the participants from being distressed when informed about the need of surveillance, and realising their risks of getting sick if they did not take care of their own health, to eventually gathering the strength to cope with the situation, so the surveillance was finally valued with trust and satisfaction. The experiences and coping strategies in the surveillance programme developed a revelation of the value of health consciousness among the participants.

CONCLUSION

The study results demonstrated that a surveillance programme of pulmonary nodules might develop health consciousness among people. Still, some individuals might experience psychosocial consequences of the surveillance of indeterminate nodules. Therefore, healthcare professionals should be facilitated to perform person-centred communication to support individuals under surveillance. Preventive care to engage individuals as partners in the management of their own health should receive more attention and needs to be explored.

Fictitious cases as a methodology to discuss sensitive health topics in focus groups

PURPOSE

It can be challenging to research aspects of people's health behaviour, attitudes, and emotions due to the sensitive nature of these topics. We aimed to develop a novel methodology for discussing sensitive health topics, and explore the effectiveness in focus groups using prostate cancer and screening as an example.

METHOD

We developed a fictitious case and employed it as a projective technique in focus groups on prostate cancer and screening. The participants were men and their partners who lived in Denmark.

RESULTS

The technique encouraged emotional and cognitive openness in focus group discussions about the risk of prostate cancer, the benefits and harms of screening, and decision-making about screening. It appeared that using the fictitious case allowed the participants to personally distance themselves from the topic, project emotions onto the case, and thereby openly talk about their emotions.

CONCLUSION

This article presents a methodological contribution to communication about sensitive topics in focus groups, using prostate cancer screening as an example. Further refinement of the methodology is needed to enable participants to transfer improvements in knowledge to their own decision about screening.

Long-term psychosocial consequences of false-positive screening mammography: a cohort study with follow-up of 12-14 years in Denmark

OBJECTIVE

To compare the long-term psychosocial consequences of mammography screening among women with breast cancer, normal results and false-positive results.

DESIGN

A matched cohort study with follow-up of 12-14 years.

SETTING

Denmark from 2004 to 2019.

PARTICIPANTS

1170 women who participated in the Danish mammography screening programme in 2004-2005.

INTERVENTION

Mammography screening for women aged 50-69 years.

OUTCOME MEASURES

We assessed the psychosocial consequences with the Consequences Of Screening-Breast Cancer, a condition-specific questionnaire that is psychometrically validated and encompasses 14 psychosocial dimensions.

RESULTS

Across all 14 psychosocial outcomes, women with false-positive results averagely reported higher psychosocial consequences compared with women with normal findings. Mean differences were statistically insignificant except for the existential values scale: 0.61 (95% CI (0.15 to 1.06), p=0.009). Additionally, women with false-positive results and women diagnosed with breast cancer were affected in a dose-response manner, where women diagnosed with breast cancer were more affected than women with false-positive results.

CONCLUSION

Our study suggests that a false-positive mammogram is associated with increased psychosocial consequences 12-14 years after the screening. This study adds to the harms of mammography screening. The findings should be used to inform decision-making among the invited women and political and governmental decisions about mammography screening programmes.

Methodological Quality of PROMs in Psychosocial Consequences of Colorectal Cancer Screening: A Systematic Review

Objective

This systematic review aimed to assess the adequacy of measurement properties in Patient-Reported Outcome Measures (PROMs) used to quantify psychosocial consequences of colorectal cancer screening among adults at average risk.

Methods

We searched four databases for eligible studies: MEDLINE, CINAHL, PsycINFO, and Embase. Our approach was inclusive and encompassed all empirical studies that quantified aspects of psychosocial consequences of colorectal cancer screening. We assessed the adequacy of PROM development and measurement properties for content validity using The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist.

Results

We included 33 studies that all together used 30 different outcome measures. Two PROMs (6.7%) were developed in a colorectal cancer screening context. COSMIN rating for PROM development was inadequate for 29 out of 30 PROMs (97%). PROMs lacked proper cognitive interviews and pilot studies and therefore had no proven content validity. According to the COSMIN checklist, 27 out of 30 PROMs (90%) had inadequate measurement properties for content validity.

Discussion

The majority of included PROMs had inadequate development and measurement properties. These findings shed light on the trustworthiness of the included studies' findings and call for reevaluation of existing evidence on the psychosocial consequences of colorectal cancer screening. To provide trustworthy evidence about the psychosocial consequences of colorectal cancer screening, editors could require that studies provide evidence of the methodological quality of the PROM. Alternatively, authors should transparently disclose their studies' methodological limitations in measuring psychosocial consequences of screening validly.

A Comprehensive Survey on the Progress, Process, and Challenges of Lung Cancer Detection and Classification

Lung cancer is the primary reason of cancer deaths worldwide, and the percentage of death rate is increasing step by step. There are chances of recovering from lung cancer by detecting it early. In any case, because the number of radiologists is limited and they have been working overtime, the increase in image data makes it hard for them to evaluate the images accurately. As a result, many researchers have come up with automated ways to predict the growth of cancer cells using medical imaging methods in a quick and accurate way. Previously, a lot of work was done on computer-aided detection (CADe) and computer-aided diagnosis (CADx) in computed tomography (CT) scan, magnetic resonance imaging (MRI), and X-ray with the goal of effective detection and segmentation of pulmonary nodule, as well as classifying nodules as malignant or benign. But still, no complete comprehensive review that includes all aspects of lung cancer has been done. In this paper, every aspect of lung cancer is discussed in detail, including datasets, image preprocessing, segmentation methods, optimal feature extraction and selection methods, evaluation measurement matrices, and classifiers. Finally, the study looks into several lung cancer-related issues with possible solutions.

Is it okay to choose to receive bad news by telephone? An observational study on psychosocial consequences of diagnostic workup for lung cancer suspicion

BACKGROUND

In-person meeting is considered the gold standard in current communication protocols regarding sensitive information, yet one size may not fit all, and patients increasingly demand or are offered disclosure of bad news by, e.g., telephone. It is unknown how patients' active preference for communication modality affect psychosocial consequences of receiving potentially bad news.

AIM

To explore psychosocial consequences in patients, who themselves chose to have results of lung cancer workup delivered either in-person or by telephone compared with patients randomly assigned to either delivery in a recently published randomised controlled trial (RCT).

METHODS

An observational study prospectively including patients referred for invasive workup for suspected lung cancer stratified in those declining (Patient's Own Choice, POC group) and those participating in the RCT. On the day of invasive workup and five weeks later, patients completed a validated, nine-dimension, condition-specific questionnaire, Consequences of Screening in Lung Cancer (COS-LC). Primary outcome: difference in change in COS-LC dimensions between POC and RCT groups.

RESULTS

In total, 151 patients were included in the POC group versus 255 in the RCT. Most (70%) in the POC group chose to have results by telephone. Baseline characteristics and diagnostic outcomes were comparable between POC and RCT groups, and in telephone and in-person subgroups too. We observed no statistically significant between-groups differences in any COS-LC score between POC and RCT groups, or between telephone and in-person subgroups in the POC group.

CONCLUSION

Continually informed patients' choice between in-person or telephone disclosure of results of lung cancer workup is not associated with differences in psychosocial outcomes. The present article supports further use of a simple model for how to prepare the patient for potential bad news.

Impact of low-dose computed tomography (LDCT) screening on lung cancer-related mortality

BACKGROUND

Lung cancer is the most common cause of cancer-related death in the world, however lung cancer screening has not been implemented in most countries at a population level. A previous Cochrane Review found limited evidence for the effectiveness of lung cancer screening with chest radiography (CXR) or sputum cytology in reducing lung cancer-related mortality, however there has been increasing evidence supporting screening with low-dose computed tomography (LDCT).  OBJECTIVES: To determine whether screening for lung cancer using LDCT of the chest reduces lung cancer-related mortality and to evaluate the possible harms of LDCT screening.

SEARCH METHODS

We performed the search in collaboration with the Information Specialist of the Cochrane Lung Cancer Group and included the Cochrane Lung Cancer Group Trial Register, Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library, current issue), MEDLINE (accessed via PubMed) and Embase in our search. We also searched the clinical trial registries to identify unpublished and ongoing trials. We did not impose any restriction on language of publication. The search was performed up to 31 July 2021.  SELECTION CRITERIA: Randomised controlled trials (RCTs) of lung cancer screening using LDCT and reporting mortality or harm outcomes.  DATA COLLECTION AND ANALYSIS: Two review authors were involved in independently assessing trials for eligibility, extraction of trial data and characteristics, and assessing risk of bias of the included trials using the Cochrane RoB 1 tool. We assessed the certainty of evidence using GRADE. Primary outcomes were lung cancer-related mortality and harms of screening. We performed a meta-analysis, where appropriate, for all outcomes using a random-effects model. We only included trials in the analysis of mortality outcomes if they had at least 5 years of follow-up. We reported risk ratios (RRs) and hazard ratios (HRs), with 95% confidence intervals (CIs) and used the I2 statistic to investigate heterogeneity.  MAIN RESULTS: We included 11 trials in this review with a total of 94,445 participants. Trials were conducted in Europe and the USA in people aged 40 years or older, with most trials having an entry requirement of ≥ 20 pack-year smoking history (e.g. 1 pack of cigarettes/day for 20 years or 2 packs/day for 10 years etc.). One trial included male participants only. Eight trials were phase three RCTs, with two feasibility RCTs and one pilot RCT. Seven of the included trials had no screening as a comparison, and four trials had CXR screening as a comparator. Screening frequency included annual, biennial and incrementing intervals. The duration of screening ranged from 1 year to 10 years. Mortality follow-up was from 5 years to approximately 12 years.  None of the included trials were at low risk of bias across all domains. The certainty of evidence was moderate to low across different outcomes, as assessed by GRADE. In the meta-analysis of trials assessing lung cancer-related mortality, we included eight trials (91,122 participants), and there was a reduction in mortality of 21% with LDCT screening compared to control groups of no screening or CXR screening (RR 0.79, 95% CI 0.72 to 0.87; 8 trials, 91,122 participants; moderate-certainty evidence). There were probably no differences in subgroups for analyses by control type, sex, geographical region, and nodule management algorithm. Females appeared to have a larger lung cancer-related mortality benefit compared to males with LDCT screening. There was also a reduction in all-cause mortality (including lung cancer-related) of 5% (RR 0.95, 95% CI 0.91 to 0.99; 8 trials, 91,107 participants; moderate-certainty evidence).  Invasive tests occurred more frequently in the LDCT group (RR 2.60, 95% CI 2.41 to 2.80; 3 trials, 60,003 participants; moderate-certainty evidence). However, analysis of 60-day postoperative mortality was not significant between groups (RR 0.68, 95% CI 0.24 to 1.94; 2 trials, 409 participants; moderate-certainty evidence).  False-positive results and recall rates were higher with LDCT screening compared to screening with CXR, however there was low-certainty evidence in the meta-analyses due to heterogeneity and risk of bias concerns. Estimated overdiagnosis with LDCT screening was 18%, however the 95% CI was 0 to 36% (risk difference (RD) 0.18, 95% CI -0.00 to 0.36; 5 trials, 28,656 participants; low-certainty evidence). Four trials compared different aspects of health-related quality of life (HRQoL) using various measures. Anxiety was pooled from three trials, with participants in LDCT screening reporting lower anxiety scores than in the control group (standardised mean difference (SMD) -0.43, 95% CI -0.59 to -0.27; 3 trials, 8153 participants; low-certainty evidence). There were insufficient data to comment on the impact of LDCT screening on smoking behaviour.  AUTHORS' CONCLUSIONS: The current evidence supports a reduction in lung cancer-related mortality with the use of LDCT for lung cancer screening in high-risk populations (those over the age of 40 with a significant smoking exposure). However, there are limited data on harms and further trials are required to determine participant selection and optimal frequency and duration of screening, with potential for significant overdiagnosis of lung cancer. Trials are ongoing for lung cancer screening in non-smokers.

Eudragit, a Nifty Polymer for Anticancer Preparations: A Patent Review

BACKGROUND

Polymers are the backbone of modern pharmaceutical formulations and drug delivery technologies. Polymers that may be natural, synthetic, or semisynthetic are used to control the release of drugs in a pre-programmed fashion. The drug delivery systems are mainly prepared to enhance the bioavailability, site-specific release, sustained release, controlled release, i.e., to modify the release of drug from dosage form may be a tablet, capsule, etc. Objective: The objective of the present study is to overview the recent patents concerning the application of eudragit in the prevention of cancer and other ailments. Eudragit polymers are polymethacrylates and may be anionic, cationic, or non-ionic polymers of methacrylic acid, dimethyl-aminoethyl methacrylates, and methacrylic acid esters in varying ratios. Eudragit is available in various grades with solubilities at different pH, thus helping the formulators design the preparation to have a well-defined release pattern.

METHOD

In this review, patent applications of eudragit in various drug delivery systems employed to cure mainly cancer are covered.

RESULTS

Eudragit has proved its potential as a polymer to control the release of drugs as coating polymer and formation of the matrix in various delivery systems. It can increase the bioavailability of the drug by site-specific drug delivery and can reduce the side effects/toxicity associated with anticancer drugs.

CONCLUSION

The potential of eudragit to carry the drug may unclutter novel ways for therapeutic intercessions in various tumors.

Surveillance of indeterminate pulmonary nodules detected with CT in a Swedish population-based study (SCAPIS): psychosocial consequences and impact on health-related quality of life-a multicentre prospective cross-sectional study

OBJECTIVES

To investigate whether surveillance of pulmonary nodules detected with low-dose CT (LDCT) impacted health-related quality of life and psychosocial consequences in the Swedish population-based study, Swedish CArdioPulmonary bioImage Study (SCAPIS).

DESIGN

A prospective cross-sectional study.

SETTINGS AND PARTICIPANTS

This multicentre (five sites) observational study, which included a cohort from SCAPIS, consisted of 632 participants with indeterminate pulmonary nodules detected with LDCT. These participants continued surveillance for up to 36 months, during which lung cancer was not detected (surveillance group). Additionally, 972 participants with a negative pulmonary LDCT scan were included as a control group. Matching criteria were LDCT date (±2 weeks), gender and site.

OUTCOME MEASURES

All participants completed a health-related quality of life questionnaire (RAND-36) and the Consequences of Screening (COS) questionnaire, an average of 3 years after LDCT was conducted at entry into SCAPIS.

RESULTS

Participants were 51-70 years old at study commencement. Overall, the two groups did not differ in demographic or psychosocial variables, smoking habits or pulmonary medical history. Individuals from countries other than Sweden and those with low socioeconomic status were less likely to participate (p<0.001). No effects on health-related quality of life were observed via RAND-36. In COS, the surveillance group demonstrated a higher OR for anxiety about lung cancer (OR 3.96, 95% CI 2.35 to 6.66, p<0.001), experiencing a sense of dejection (OR 1.35, 95% CI 1.06 to 1.72, p=0.015) and thoughts about existential values (OR 1.30, 95% CI 1.04 to 1.60, p=0.018).

CONCLUSIONS

Lung surveillance with LDCT contributed to significant experiences of sense of dejection, anxiety about lung cancer and development of thoughts about existential values among participants in the surveillance group compared with the controls. The risk of side effects should be communicated for informed decision-making about (non-)attendance in lung cancer screening.

Surveillance life and the shaping of 'genetically at risk' chronicities in Denmark

Today, in the field of hereditary colorectal cancer in Denmark, more than 40,000 identified healthy individuals with an increased risk of cancer are enrolled in a surveillance program aimed at preventing cancer from developing, with numbers still growing. What this group of healthy individuals has in common is lifelong regular interaction with a healthcare system that has traditionally been geared towards treating the acutely and chronically ill. In this article, we explore how people living with an inherited elevated risk of colorectal cancer orient themselves towards their families' and their own predispositions as well as the lifelong surveillance trajectories that they have embarked upon - what we call surveillance life. Unlike prior critiques of predictive genetic testing as generative of 'pre-patients' or 'pre-symptomatically ill', we suggest that for those enrolled in lifelong surveillance programmes in welfare state Denmark, the relevance of risk fluctuates according to certain moments in life, e.g. at family reunions, when a close relative falls ill, in the time leading up to a surveillance colonoscopy or when enduring the procedures themselves. As such, rather than characterising surveillance life in terms of 'living with chronic risk' we show how 'genetically at risk' chronicities take shape as persons come to terms with a disease that possibly awaits them leading them to recalibrate familial bonds and responsibilities while leading lives punctuated by regular medical check-ups.

Breaking potentially bad news of cancer workup to well-informed patients by telephone versus in-person: A randomised controlled trial on psychosocial consequences

BACKGROUND

The use of telephone in delivering cancer care increases, but not in cancer workup. Current protocols for breaking bad news assume a single in-person meeting. Cancer workup involves multiple opportunities for patient information. We investigated the psychosocial consequences in gradually informed patients of receiving lung cancer workup results by telephone versus in-person.

METHODS

A randomised, controlled, open-label, assessor-blinded, single-centre trial including patients referred for invasive workup for suspected malignancy (clinical trials no. NCT04315207). Patients were informed on probable cancer at referral, after imaging, and on the day of invasive workup (Baseline visit). Primary endpoint: change (Δ) from baseline to follow-up (4 weeks after receiving workup results) in scores of a validated, sensitive, condition-specific questionnaire (COS-LC) assessing consequences on anxiety, behaviour, dejection and sleep.

RESULTS

Of 492 eligible patients, we randomised 255 patients (mean age: 68 years; female: 38%; malignancy diagnosed: 68%) to the telephone (n = 129) or in-person (n = 126) group. Groups were comparable at baseline and follow-up, and no between-groups difference in ΔCOS-LC was observed in the intention-to-treat population, or in subgroups diagnosed with or without malignancy.

CONCLUSION

Breaking final result of cancer workup by telephone is not associated with adverse psychosocial consequences compared to in-person conversation in well-informed patients.

The person behind the nodule: a narrative review of the psychological impact of lung cancer screening

Lung cancer is the leading cause of cancer mortality globally, responsible for an estimated 1.76 million deaths worldwide in 2018 alone. Screening adults at high risk of lung cancer using low-dose computed tomography (LDCT) significantly reduces lung cancer mortality by finding the disease at an early, treatable stage. Many countries are actively considering whether to implement screening for their high-risk populations in light of the recently published Dutch-Belgian trial 'NELSON'. In deciding whether to implement a national screening programme, policymakers must weigh up the evidence for the relative risks posed to the entire screened population, including the potential psychological burden. This narrative review aimed to critically summarise the evidence for both negative and positive psychological responses experienced throughout the LDCT screening pathway, to describe their magnitude, duration and clinical relevance, and to draw out different aspects of measurement design crucial to their interpretation. A further aim was to discuss the available evidence for individual differences in psychological response, as well as interventions designed to promote psychological well-being. In summary, there was no evidence that the LDCT screening process caused adverse psychological outcomes overall, although those receiving indeterminate and suspicious LDCT results did report clinically raised anxiety and lung cancer-specific distress in the short-term. There was early evidence that demographic factors, smoking status and screening-ineligibility could be associated with individual differences in propensity to experience distress. Qualitative data suggested health beliefs could be modifiable mediators of these individual differences, but their aetiology requires quantitative and prospective research. There was also some evidence of positive psychological responses that could be capitalised on, and of the potential for person-centred communication interventions to achieve this. Further research needs to be embedded in real-world LDCT lung cancer screening services and use condition-specific measures to monitor outcomes and test evidence-based communication interventions in promoting psychological well-being.

Psychosocial consequences of a three-month follow-up after receiving an abnormal lung cancer CT-screening result: A longitudinal survey

BACKGROUND

Participation in lung cancer CT-screening can be associated with a need for follow-up procedures. The screening and waiting for test results introduce the risk of experiencing psychosocial consequences. Therefore, the aims of this study were: 1) To investigate if the psychosocial consequences changed from before an annual screening round to before a three-month follow-up CT-scan in participants with a positive screening result. 2) To investigate potential differences in psychosocial consequences between false positives (FP) and true positives (TP). FP were defined as those where cancer was not confirmed in the follow-up CT-scan and TP where it was.

MATERIALS AND METHODS

This longitudinal study was based on data from the Danish Lung Cancer Screening Trial (DLCST). The Consequences of Screening - Lung cancer (COS-LC) questionnaire was used to measure psychosocial consequences among 130 participants who all received an abnormal CT-screening result at their annual screening round. Eligible participants completed the COS-LC before their annual CT-screening and before the three-month follow-up.

RESULTS

We found a statistically significant increase in negative psychosocial consequences between the annual lung cancer CT-screening and the three-month follow-up CT-scan in four of nine psychosocial scales; Sense of dejection, Self-blame, Focus on airway symptoms and Harm of smoking. Furthermore, an increase, however not statistically significant, was identified in all remaining scales, except for the scale Stigmatisation which was slightly decreased. We found no evidence of an association between psychosocial consequences and diagnostic groups, FP and TP.

CONCLUSIONS

An increase in negative psychosocial consequences was observed between the annual lung cancer CT-screening and the three-month follow-up CT-scan. Since we found no statistically significant difference between the diagnostic groups, the increase in negative psychosocial consequences is interpreted as a nocebo effect of living three months in uncertainty not knowing if one's positive CT-screening result was true or false.

Psychosocial consequences of invitation to colorectal cancer screening: a matched cohort study

Background

Psychosocial consequences of colorectal cancer (CRC) screening can arise anywhere in the screening cascade. Previous studies have investigated the consequences of participating in CRC screening; however, we have not identified any studies investigating the psychosocial consequences of receiving the invitation. Therefore, the objective of this study was to investigate psychosocial consequences of invitation to CRC screening.

Methods

The study was a longitudinal study performed in Region Zealand, Denmark. Participants included in this study were a random sample of 1000 CRC screening invitees and 1000 control persons, not invited to screening, matched in a 1:1 design on sex, age and municipality. We assessed psychosocial consequences before and after invitation in both study groups concurrently. The primary outcomes were psychosocial consequences measured with the condition-specific questionnaire Consequences of Screening in ColoRectal Cancer.

Results

Preinvitation response rates were 575 (57.5%) and 610 (61.0%) for the invitation group and control group, respectively. Postinvitation response rates were 442 (44.2%) for the invitation group and 561 (56.1%) for the control group.

No differences in mean change in scale score were seen except for the scale ‘Change in body perception’. The invitation group had a 0.39 lower change (99% CI (−0.78 to −0.004), p=0.009) in mean score than the control group in the direction of a less negative body perception after invitation.

Conclusions

This study did not identify an association between invitation to CRC screening and negative psychosocial consequences.

Psychometric properties of a condition-specific PROM for the psychosocial consequences of Labelling hypertension by using Rasch analysis

Background

A previous qualitative assessment of the psychosocial consequences of labelling hypertension describes the diagnosis of hypertension as a labelling event with potential unintended negative long-term psychosocial consequences (labelling effects). Until now, the benefits of diagnosing hypertension have been far more reported than the harms. To obtain the net result of the preventive interventions for cardiovascular disease, such as diagnosing and treating mild hypertension, assessing benefits and harms in the most comprehensive way possible is necessary, including the psychosocial consequences of labelling. When measuring psychosocial consequences of labelling hypertension, a questionnaire with high content validity and adequate psychometric properties is needed.

Objectives

The aim of this study was to describe the psychometric parameters of face and content-validated pool of items. Other objectives were also to screen the item pool by using Rasch model analysis and confirmatory factor analysis (CFA) for identifying such items with sufficient fit to the hypothesised models.

Methods

We surveyed the pool of items as a draft questionnaire to Brazilians recruited via social networks, sending e-mails, WhatsApp® messages and posting on Facebook®. The inclusion criteria were to be older than 18 years old, to be healthy and to have only hypertension.

We used Rasch model analysis to screen the item pool, discarding items that did not fit the hypothesised domain. We searched for local dependence and differential item functioning. We used CFA to confirm the derived measurement models and complementarily assessed reliability using Cronbach’s coefficient alpha.

Results

The validation sample consisted of 798 respondents. All 798 respondents completed Part I, whereas 285 (35.7%)—those with hypertension—completed Part II. A condition-specific questionnaire with high content validity and adequate psychometric properties was developed for people labelled with hypertension. This measure is called ‘Consequences of Labelling Hypertension Questionnaire’ and covers the psychosocial consequences of labelling hypertension in two parts, encompassing a total of 71 items in 15 subscales and 11 single items.

Conclusion

We developed a tool that can be used in future research involving hypertension, especially in scenarios of screening, prevention, population strategies and in intervention studies. Future use and testing of the questionnaire may still be required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-021-00291-4.

Consequences of screening in colorectal cancer (COS-CRC): development and dimensionality of a questionnaire

BACKGROUND

Harms of colorectal cancer (CRC) screening include psychosocial consequences. We have not identified studies using a participant-relevant questionnaire with adequate measurement properties to investigate these harms. However, Brodersen et al. have previously developed a core questionnaire consequences of screening (COS) for use in screening for life-threatening diseases. Therefore, the objectives were: (1) To investigate content validity of COS in a CRC screening setting and in case of gaps in content coverage (2) generate new items and themes and (3) test the possibly extended version of COS for dimensionality and differential item functioning (DIF) using Rasch Models.

METHODS

We performed two-part-focus-groups with CRC screenees. Screenees were recruited by strategic sampling. In the first part 16 screenees with false-positive results (n = 7) and low-risk polyps (n = 9) were interviewed about their CRC screening experiences and in the second part COS was examined for content validity. When new information was developed in the focus groups, new items covering this topic were generated. Subsequently, new items were, together with COS, tested in the subsequent interviews. A random subsample (n = 410) from a longitudinal questionnaire study, not yet published, was used to form the data for this paper. We analysed multidimensionality and uniform DIF with Andersen's conditional likelihood ratio test. We assessed individual item fit to the model. We also analysed Local Dependence (LD) and DIF by partial gamma coefficients using Rasch Models.

RESULTS

COS was found relevant in a CRC screening setting. However, new information was discovered in the focus groups, covered by 18 new CRC screening-specific items. The Rasch analyses only revealed minor problems in the COS-scales. The 18 new items were distributed on four new CRC screening-specific dimensions and one single item.

CONCLUSION

An extended version of COS specifically for use in a CRC screening setting has been developed. The extended part encompasses four new scales and one new single item. The original COS with the CRC-screening specific extension is called consequences of screening in colorectal cancer (COS-CRC). COS-CRC possessed reliability, unidimensionality and invariant measurement.

Psychosocial consequences of potential overdiagnosis in prostate cancer a qualitative interview study

BACKGROUND

Prostate cancer is a frequently diagnosed cancer and made up 6% of male cancer deaths globally in 2008. Its incidence varies more than 25-fold worldwide, which is primarily attributed to the implementation of the prostate-specific antigen (PSA) test in developed countries. To reduce harm of overdiagnosis, most international guidelines recommend surveillance programmes. However, this approach can entail negative psychosocial consequences from being under surveillance for an (over)diagnosed prostate cancer.

AIM

To explore men's feelings and experiences in a surveillance programme.

DESIGN AND SETTING

Qualitative study with Danish men diagnosed with asymptomatic prostate cancer Gleason score ≤ 6, who are in a surveillance programme.

METHODS

12 semi-structured, individual interviews were conducted and analysed with systematic text condensation and selected theories.

RESULTS

Most informants reported that they were astonished at the time of diagnosis. They were aware of the small likelihood of dying from cancer, but in some cases, the uncertainty created ambivalence between knowing and not knowing. The men expressed their risk awareness in different ways: a realization that life does not last forever, uncertainty towards the future, a feeling of powerlessness, and a need for control.

CONCLUSIONS

The men in this study had substantial psychosocial consequences from being labelled with a cancer diagnosis. Bearing these men's high risk of overdiagnosis in mind, it is important to discuss whether the harms of this diagnosis outweigh the benefits. The psychosocial consequences of being in a prostate cancer surveillance programme should be explored further. KEY POINTS Current awareness: The number of men living with an asymptomatic prostate cancer has increased the last 20 years after the implementation of the PSA test. Main Statements: Men living with an asymptomatic, low-risk prostate cancer experience negative psychocosial consequences GPs should consider the possible negative psychosocial consequences in their decision-making of measuring the PSA level.

How to develop a condition-specific PROM

Developing new patient-reported outcome measures (PROMs) for application in clinical studies can be necessary if an adequate PROM does not exist. For adequate measurement, it is essential that the PROM has face validity (ie, is perceived to be relevant by clinicians and researchers) and has high content validity (ie, content relevance and content coverage for the targeted patient group). The steps needed to create PROMs that possess face and content validity for a specific condition are described in this paper. Face validity is achieved by item identification and generation through literature review. Content validity is confirmed through repetitive cognitive interviews of patients from the targeted patient group in order to generate a consensus-based pilot-version of the new PROM. This qualitative process ensures that items are appropriately worded, understandable, and minimizes doubts about how items should be answered. A practical example of this process is presented, which shows the development of the Knee Numeric-Entity Evaluation Score (KNEES-ACL), a condition-specific PROM for patients with deficiency of the anterior cruciate ligament (ACL).

Psychosocial consequences of false positives in the Danish Lung Cancer CT Screening Trial: a nested matched cohort study

OBJECTIVES

Lung cancer CT screening can reduce lung cancer mortality, but high false-positive rates may cause adverse psychosocial consequences. The aim was to analyse the psychosocial consequences of false-positive lung cancer CT screening using the lung cancer screening-specific questionnaire, Consequences of Screening in Lung Cancer (COS-LC).

DESIGN AND SETTING

This study was a matched cohort study, nested in the randomised Danish Lung Cancer Screening Trial (DLCST).

PARTICIPANTS

Our study included all 130 participants in the DLCST with positive CT results in screening rounds 2-5, who had completed the COS-LC questionnaire. Participants were split into a true-positive and a false-positive group and were then matched 1:2 with a control group (n=248) on sex, age (±3 years) and the time of screening for the positive CT groups or clinic visit for the control group. The true positives and false positives were also matched 1:2 with participants with negative CT screening results (n=252).

PRIMARY OUTCOMES

Primary outcomes were psychosocial consequences measured at five time points.

RESULTS

False positives experienced significantly more negative psychosocial consequences in seven outcomes at 1 week and in three outcomes at 1 month compared with the control group and the true-negative group (mean ∆ score >0 and p<0.001). True positives experienced significantly more negative psychosocial consequences in one outcome at 1 week (mean ∆ score 2.86 (95% CI 1.01 to 4.70), p=0.0024) and in five outcomes at 1 month (mean ∆ score >0 and p<0.004) compared with the true-negative group and the control group. No long-term psychosocial consequences were identified either in false positives or true positives.

CONCLUSIONS

Receiving a false-positive result in lung cancer screening was associated with negative short-term psychosocial consequences. These findings contribute to the evidence on harms of screening and should be taken into account when considering implementation of lung cancer screening programmes.

TRIAL REGISTRATION NUMBER

NCT00496977.

Mapping the spectrum of psychological and behavioural responses to low-dose CT lung cancer screening offered within a Lung Health Check

BACKGROUND

Research on the psychological impact of low-dose computed tomography (LDCT) lung cancer screening has typically been narrow in scope and restricted to the trial setting.

OBJECTIVE

To explore the range of psychological and behavioural responses to LDCT screening offered as part of a Lung Heath Check (LHC), including lung cancer risk assessment, spirometry testing, a carbon monoxide reading and smoking cessation advice.

METHODS

Semi-structured interviews were carried out with 28 current and former smokers (aged 60-75), who had undergone LDCT screening as part of a LHC appointment and mostly received an incidental or indeterminate result (n = 23). Framework analysis was used to map the spectrum of responses participants had across the LHC appointment and screening pathway, to their LDCT results and to surveillance.

RESULTS

Interviewees reported a diverse range of both positive and negative psychological responses, beginning at invitation and spanning the entire LHC appointment (including spirometry) and LDCT screening pathway. Similarly, positive behavioural responses extended beyond smoking cessation to include anticipated implications for other cancer prevention and early detection behaviours, such as symptom presentation. Individual differences in responses appeared to be influenced by smoking status and LDCT result, as well as modifiable factors including perceived risk and health status, social support, competing priorities, fatalism and perceived stigma.

CONCLUSIONS

The diverse ways in which participants responded to screening, both psychologically and behaviourally, should direct a broader research agenda to ensure all stages of screening delivery and communication are designed to promote well-being, motivate positive behaviour change and maximize patient benefit.

Did psychosocial status, sociodemographics and smoking status affect non-attendance in control participants in the Danish Lung Cancer Screening Trial? A nested observational study

OBJECTIVES

We investigated if psychosocial status, sociodemographics and smoking status affected non-attendance in the control group in the randomised Danish Lung Cancer Screening Trial (DLCST).

DESIGN AND SETTING

This study was an observational study nested in the DLCST. Due to large non-attendance in the control group in the second screening round we made an additional effort to collect questionnaire data from non-attenders in this group in the third screening round. We used a condition-specific questionnaire to assess psychosocial status. We analysed the differences in psychosocial status in the third and preceding rounds between non-attenders and attenders in the control group in multivariable linear regression models adjusted for sociodemographics and smoking status reported at baseline. Differences in sociodemographics and smoking status were analysed with χ2 tests (categorical variables) and t-tests (continuous variables).

PRIMARY OUTCOME MEASURE

Primary outcome was psychosocial status.

PARTICIPANTS

All control persons participating in the third screening round in the DLCST were included.

RESULTS

Non-attenders in the third round had significantly worse psychosocial status than attenders in the scales: 'behaviour' 0.77 (99% CI 0.18 to 1.36), 'self-blame' 0.59 (99% CI 0.14 to 1.04), 'focus on airway symptoms' 0.22 (99% CI 0.08 to 0.36), 'stigmatisation' 0.51 (99% CI 0.16 to 0.86), 'introvert' 0.56 (99% CI 0.23 to 0.89) and 'harms of smoking' 0.35 (99% CI 0.11 to 0.59). Moreover, non-attenders had worse scores than attendees in the preceding screening rounds. Non-attenders also reported worse sociodemographics at baseline.

CONCLUSIONS

Non-attenders had a significantly worse psychosocial status and worse sociodemographics compared with attenders. The results of our study contribute with evidence of non-response and attrition driven by psychosocial status, which in turn may be influenced by the screening intervention itself. This can be used to adjust cancer screening trial results for bias due to differential non-attendance.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov Protocol Registration System (NCT00496977).

ESR/ERS statement paper on lung cancer screening

In Europe, lung cancer ranks third among the most common cancers, remaining the biggest killer. Since the publication of the first European Society of Radiology and European Respiratory Society joint white paper on lung cancer screening (LCS) in 2015, many new findings have been published and discussions have increased considerably. Thus, this updated expert opinion represents a narrative, non-systematic review of the evidence from LCS trials and description of the current practice of LCS as well as aspects that have not received adequate attention until now. Reaching out to the potential participants (persons at high risk), optimal communication and shared decision-making will be key starting points. Furthermore, standards for infrastructure, pathways and quality assurance are pivotal, including promoting tobacco cessation, benefits and harms, overdiagnosis, quality, minimum radiation exposure, definition of management of positive screen results and incidental findings linked to respective actions as well as cost-effectiveness. This requires a multidisciplinary team with experts from pulmonology and radiology as well as thoracic oncologists, thoracic surgeons, pathologists, family doctors, patient representatives and others. The ESR and ERS agree that Europe's health systems need to adapt to allow citizens to benefit from organised pathways, rather than unsupervised initiatives, to allow early diagnosis of lung cancer and reduce the mortality rate. Now is the time to set up and conduct demonstration programmes focusing, among other points, on methodology, standardisation, tobacco cessation, education on healthy lifestyle, cost-effectiveness and a central registry.

ESR/ERS statement paper on lung cancer screening

In Europe, lung cancer ranks third among the most common cancers, remaining the biggest killer. Since the publication of the first European Society of Radiology and European Respiratory Society joint white paper on lung cancer screening (LCS) in 2015, many new findings have been published and discussions have increased considerably. Thus, this updated expert opinion represents a narrative, non-systematic review of the evidence from LCS trials and description of the current practice of LCS as well as aspects that have not received adequate attention until now. Reaching out to the potential participants (persons at high risk), optimal communication and shared decision-making will be key starting points. Furthermore, standards for infrastructure, pathways and quality assurance are pivotal, including promoting tobacco cessation, benefits and harms, overdiagnosis, quality, minimum radiation exposure, definition of management of positive screen results and incidental findings linked to respective actions as well as cost-effectiveness. This requires a multidisciplinary team with experts from pulmonology and radiology as well as thoracic oncologists, thoracic surgeons, pathologists, family doctors, patient representatives and others. The ESR and ERS agree that Europe's health systems need to adapt to allow citizens to benefit from organised pathways, rather than unsupervised initiatives, to allow early diagnosis of lung cancer and reduce the mortality rate. Now is the time to set up and conduct demonstration programmes focusing, among other points, on methodology, standardisation, tobacco cessation, education on healthy lifestyle, cost-effectiveness and a central registry.Key Points• Pulmonologists and radiologists both have key roles in the set up of multidisciplinary LCS teams with experts from many other fields.• Pulmonologists identify people eligible for LCS, reach out to family doctors, share the decision-making process and promote tobacco cessation.• Radiologists ensure appropriate image quality, minimum dose and a standardised reading/reporting algorithm, together with a clear definition of a "positive screen".• Strict algorithms define the exact management of screen-detected nodules and incidental findings.• For LCS to be (cost-)effective, it has to target a population defined by risk prediction models.

Development of an item pool for a questionnaire on the psychosocial consequences of hypertension labelling

Background

Hypertension is the most prevalent risk factor for cardiovascular disease globally. Roughly one-third of the adult population has hypertension. However, most people diagnosed with hypertension do not benefit from blood pressure control with pharmacologic interventions: they are overdiagnosed and overtreated and might experience negative psychosocial consequences of being labelled. These consequences are relevant outcomes that need to be assessed and validly measured to identify all benefits and harms related to interventions designed to prevent cardiovascular disease.

Objectives

To develop a pool of items with high content validity for a draft version of a condition-specific questionnaire to measure the psychosocial consequences of being labelled with mild hypertension.

Methods

We selected relevant items from existing Consequences of Screening (COS) questionnaires. These items belonged to two groups: COS core items and potential condition-specific items. All items were originally in Danish and were translated into Brazilian Portuguese using the dual-panel method. Individual and group interviews were conducted with people with mild hypertension and low risk for cardiovascular disease, and were designed to test the translated items for face and content validity and were also used to generate new relevant items. Structured individual interviews were conducted to categorise all the items into domains.

Results

The Brazilian Portuguese dual-panel translation of both groups of items was found to be relevant for adults diagnosed with hypertension. We generated 52 new items to achieve high content validity. The result was a set of 132 items divided into 22 domains in 2 parts. Part I was directed at the general population, whereas part II was directed only at people diagnosed with hypertension and it consisted of 38 items in 8 domains. Twelve items remained as single items. High content validity was achieved with the pool of 132 items divided into 22 domains in 2 parts.

Discussion

High content validity was achieved for a condition-specific questionnaire measuring the psychosocial consequences of being labelled with mild hypertension. This instrument encompassed 132 items divided into 22 domains in 2 parts. Thereby, a draft of the Consequneces of Hypertension questionnaire (COH) was developed. The psychometric properties of this questionnaire will be discussed in a diferent paper.

Psychosocial consequences among women with false-positive results after mammography screening in Norway

BACKGROUND

Mammography screening may cause psychosocial harm for women experiencing a false-positive screening result. Previous studies suggest long-term consequences. The aim of the present study was to assess psychosocial consequences of false-positive findings on screening mammography within a six month follow-up.

METHODS

A prospective matched cohort survey study using the questionnaire 'Consequences of Screening for Breast Cancer' (COS-BC), which was translated from Danish to Norwegian. Psychometric analyses investigated the measurement properties of the Norwegian version. Two screening clinics in Norway distributed the survey to 299 women with an abnormal mammogram and 541 women with a normal screen. Women received the questionnaire when receiving the screening result, and one and six months after screening.

RESULTS

At six months, statistically significant differences appeared in two scales: existential values and breast examination. At six-month follow-up, women with false-positive results showed no statistically significant differences from women diagnosed with breast cancer in three outcomes: sense of dejection, anxiety, and keeping my mind off things.

CONCLUSION

Our results indicate that the psychosocial consequences from having false-positive screening mammography results diminish after six months. The results support previous research describing breast-specific outcomes. However, our results indicate that Norwegian women are less frightened than other Scandinavian mammography screening participants.

Consequences of screening in abdominal aortic aneurysm: development and dimensionality of a questionnaire

Background

In interview studies, men under surveillance for screening-detected abdominal aortic aneurysms have reported ambivalence towards this diagnosis: the knowledge was welcomed together with worries, feelings of anxiety and existential thoughts about life’s fragility and mortality due to the diagnosis. Previous surveys about health-related quality of life aspects among men under surveillance for screening-detected aneurysm have all used generic patient-reported outcomes. Therefore, the aim of this study was to extend the core-questionnaire Consequences of Screening for use in abdominal aortic aneurysm screening by testing for comprehension, content coverage, dimensionality, and reliability.

Methods

In interviews, the suitability, content coverage, and relevance of the core-questionnaire Consequences of Screening were tested on men under surveillance for a screeningdetected abdominal aortic aneurysm. The results were thematically analysed to identify the key consequences of abnormal screening results. Item Response Theory and Classical Test Theory were used to analyse data. Dimensionality, differential item functioning, local response dependency and reliability were established by item analysis, examining the fit between item responses and Rasch models.

Results

The core-questionnaire Consequences of Screening was found to be relevant for men offered regular follow-up of an asymptomatic screening-detected abdominal aortic aneurysm.

Fourteen themes especially relevant for men diagnosed with a screening-detected abdominal aortic aneurysm were extracted from the interviews: ‘Uncertainty about the result of the ultra sound examination’, ‘Change in body perception’, ‘Guilt’, ‘Fear and powerlessness’, ‘Negative experiences from the examination’, ‘Emotional reactions’, ‘Change in lifestyle’, ‘Better not knowing’, ‘Fear of rupture’, ‘Sexuality’, ‘Information’, ‘Stigmatised’, ‘Self-blame for smoking’, ‘Still regretful smoking’. Altogether, 55 new items were generated: 3 were single items and 13 were only relevant for former or current smokers. 51 of the 52 items belonging to a theme were confirmed to fit Rasch models measuring fourteen different constructs. No differential item functioning and only minor local dependency was revealed between some of the 51 items.

Conclusions

The reliability and the dimensionality of a condition-specific measure with high content validity for men under surveillance for a screening-detected abdominal aortic aneurysm have been demonstrated. This new questionnaire called COS-AAA covers in two parts the psychosocial experience in abdominal aortic aneurysm screening.

Consequences of screening in cervical cancer: development and dimensionality of a questionnaire

Background

Cervical cancer screening will inevitably lead to unintentional harmful effects e.g. detection of indolent pathological conditions defined as overdetection or overdiagnosis. Overdiagnosis often leads to overutilisation, overtreatment, labelling and thereby negative psychosocial consequences. There is a lack of adequate psychosocial measures when it comes to measurement of the harms of medical screening. However, the Consequences of Screening questionnaire (COS) has been found relevant and comprehensive with adequate psychometric properties in breast and lung cancer screening. Therefore, the aim of the present study was to extend the Consequences of Screening Questionnaire for use in cervical cancer screening by testing for content coverage, dimensionality, and reliability.

Methods

In interviews, the suitability, content coverage, and relevance of the COS were tested on participants in cervical screening. The results were thematically analysed to identify the key consequences of abnormal screening results. Item Response Theory and Classical Test Theory were used to analyse data. Dimensionality, invariance, and reliability were established by item analysis, examining the fit between item responses and Rasch models.

Results

All COS items were found relevant by the interviewees and the ten COS constructs were confirmed each to be unidimensional in the Rasch models. Ten new themes specifically relevant for participants having abnormal cervical screening result were extracted from the interviews: ‘Uncertainty about the screening result’, ‘Uncertainty about future pregnancy’, ‘Change in body perception’, ‘Change in perception of own age’, ‘Guilt’, ‘Fear and powerlessness’, ‘Negative experiences from the pelvic examination’, ‘Negative experiences from the examination’, ‘Emotional reactions’ and ‘Sexuality’ Altogether, 50 new items were generated: 10 were single items. Most of the remaining 40 items were confirmed to fit Rasch models measuring ten different constructs. However, the two items in the scale ‘Change in perception of own age’ both possessed differential item functioning in relation to time, which can bias longitudinal repeated measurement.

Conclusions

The reliability and the dimensionality of a condition-specific measure with high content validity for women having an abnormal cervical cancer screening results have been demonstrated. This new questionnaire called Consequences Of Screening in Cervical Cancer (COS-CC) covers in two parts the psychosocial experience in cervical cancer screening.

Pilot study of a video intervention to reduce anxiety and promote preparedness for lung cancer screening

BACKGROUND

Lung cancer screening (LCS) with low dose computed tomography (LDCT) is associated with a 20% reduction in lung cancer mortality. Psychological burden is a potential harm associated with LCS, and is a major barrier to utilization. We aimed to examine the feasibility and acceptability of a video intervention designed to reduce anxiety and promote psychological preparedness of LCS.

PATIENTS AND METHODS

This is a two group, sequential enrollment pilot study of a video intervention that integrates information on screen criteria, procedures, benefits and harms, and follow-up plan. Participants were enrolled 1-2 weeks prior to baseline LDCT, and the intervention was administered in one in-person session on the day of LDCT. Outcomes were assessed at baseline (pre-screen), immediately after LDCT, and at 1 week, 3 months, and 7 months post-screen. Outcome measures included the SF-12 (HRQOL), STAI (anxiety), psychosocial consequences of LCS (COS-LC), risk perceptions for lung cancer, and a satisfaction tool. The student's t-test was used for exploratory evaluations on change from baseline scores both within and between groups.

RESULTS

Sixteen participants (8 intervention, 8 controls) enrolled and completed the study (61.5% retention). Participants in the control group reported a significantly increased sense of dejection at 1-month and 7-months post-screen as measured by the COS-LC (p = 0.01). Participants were highly satisfied with the intervention.

CONCLUSION

A video intervention that promoted psychological preparedness for LCS was feasible to implement as part of an LCS program and highly accepted by participants.

How to conduct research on overdiagnosis. A keynote paper from the EGPRN May 2016, Tel Aviv

Overdiagnosis is a growing problem worldwide. Overdiagnosis is the diagnosis of deviations, abnormalities, risk factors, and pathologies that in themselves would never cause symptoms (this applies only to risk factors and pathology), would never lead to morbidity, and would never be the cause of death. Overdiagnosis is often misinterpreted as overutilization or overtreatment. Overutilization, overtreatment, and overdiagnosis are interrelated but three distinct topics. Overutilization (establishment of standard practice that does not provide net benefit) does not have to lead to overdiagnosis or overtreatment, but the risk exists. Treatment of overdiagnosed conditions is one category of overtreatment. Another is when the best available evidence shows that the treatment has no beneficial effect. Overdiagnosis can be caused by overutilization and is nearly always followed by overtreatment. Treating an overdiagnosed condition cannot improve the patient’s prognosis, and therefore can only be harmful. At the individual level, we can never be sure if the person is overdiagnosed. However, experiences and thoughts of individuals who are most likely overdiagnosed can be explored in qualitative interviews, e.g. men with a small screening detected abdominal aortic aneurism. In longitudinal surveys, the degree and length of psychosocial consequences associated with overdiagnosis can be estimated. In high-quality RCTs, the magnitude of overdiagnosis can be quantified, and in cohort studies, we can find indications of overdiagnosis. Finally, we can conduct research about the consequences of overdiagnosis in at least eight different areas: financial strain, hassles/inconveniences, medical costs, opportunity costs, physical harms, psychological harms, societal costs and work-related costs.

Overdiagnosis: An Unrecognised and Growing Worldwide Problem in Healthcare

Overdiagnosis is the diagnosis of deviations, abnormalities, risk factors, and pathologies that in themselves would never cause symptoms (this applies only to risk factors and pathology), would never lead to morbidity, and would never be the cause of death. Therefore, treating an overdiagnosed condition (deviation, abnormality, risk factor, pathology) cannot, by definition, improve the patient's prognosis, and can therefore only be harmful. Overdiagnosis is an extremely harmful and big problem all over the world, and the problem is increasing. This is especially the case in high-income countries, where more sensitive tests, more testing, more screening and earlier diagnosis is in focus, and more of the same will be implemented in the future. Moreover, disease definitions have been and are still being widened, plus thresholds for treating, e.g. risk factors, have been and are still being lowered. Finally, disease mongering is growing, because it is cheaper and faster to invent new "diseases" than new pharmaceutical drugs. From the definition of overdiagnosis it can be reasoned that a patient who has been correctly diagnosed and a person who has been overdiagnosed can have the same kind of pathologies. Therefore, at the level of the individual person or patient it can never be verified whether he or she has in fact been correctly diagnosed or overdiagnosed. Therefore, the complexity, dilemmas and pitfalls in understanding what overdiagnosis really is so succinctly captured by this quote from the Danish philosopher S⊘ren Kirkegaard (1813-55): 'Life can only be understood backwards; but it must be lived forwards'.

Psychological Burden Associated With Lung Cancer Screening: A Systematic Review

Lung cancer screening (LCS) with low-dose radiation computed tomography (LDCT) reduces mortality and is recommended for high-risk current and former smokers. Several potential harms associated with LCS have been identified, including the potential for psychological burden. To summarize the current state of the scientific knowledge on psychological burden associated with LCS, we performed a systematic search of the contemporary quantitative and qualitative research literature. We included randomized controlled trials and cohort studies that evaluated the effect of LCS with LDCT on psychological burden and health-related quality of life assessed using validated and nonvalidated measures. PubMed, CINAHL, PsychINFO, and Scopus were searched for English language articles published between 2004 and January 2015. Data abstraction and quality assessment were conducted by 2 independent reviewers. Thirteen studies were included that met our inclusion criteria. Overall, results were variable with some studies reporting worse psychological burden for patients with indeterminate results at prescreening, after screening, and at short-term follow-up (<6 months after screen). These adverse effects diminished or resolved at long-term follow-up (> 6 months after screen). LCS might be associated with short-term adverse psychological burden, particularly after a false positive result. However, these adverse effects diminished over time. The amount of current evidence is small, with limitations in study design and use of outcome measures. More high-quality research is needed to determine the frequency, duration, and overall magnitude of LCS-related psychological burden in nonclinical trial settings.

The psychological harms of screening: the evidence we have versus the evidence we need

BACKGROUND

Systematic reviews for the US Preventive Services Task Force have found less high-quality evidence on psychological than physical harms of screening. To understand the extent of evidence on psychological harms, we developed an evidence map that quantifies the distribution of evidence on psychological harms for five adult screening services. We also note gaps in the literature and make recommendations for future research.

METHODS

We systematically searched PubMed, PsycInfo, and CINAHL from 2002 to 2012 for studies of any research design that assessed the burden or frequency of psychological harm associated with screening for: prostate and lung cancers, osteoporosis, abdominal aortic aneurysm (AAA) and carotid artery stenosis (CAS). We also searched for studies that estimated rates of overdiagnosis (a marker for unnecessary labeling). We included studies published in English and used dual independent review to determine study inclusion and to abstract information on design, types of measures, and outcomes assessed.

RESULTS

Sixty-eight studies assessing psychological harms met our criteria; 62 % concerned prostate cancer and 16 % concerned lung cancer. Evidence was scant for the other three screening services. Overall, only about one-third of the studies used both longitudinal designs and condition-specific measures (ranging from 0 % for AAA and CAS to 78 % for lung cancer), which can provide the best evidence on harms. An additional 20 studies that met our criteria estimated rates of overdiagnosis in lung or prostate cancer. No studies estimated overdiagnosis for the non-cancer screening services.

DISCUSSION

Evidence on psychological harms varied markedly across screening services in number and potential usefulness. We found important evidence gaps for all five screening services. The evidence that we have on psychological harms is inadequate in number of studies and in research design and measures. Future research should focus more clearly on the evidence that we need for decision making about screening.

Psychosocial consequences in the Danish randomised controlled lung cancer screening trial (DLCST)

OBJECTIVES

To measure the psychosocial consequences in the Danish lung cancer screening trial (DLCST) and compare those between the computed tomography (CT) group and the control group.

MATERIALS AND METHODS

This study was a single centre randomised controlled trial with five annual screening rounds. Healthy current or former heavy smokers aged 50-70 years (men and women) were randomised 1:1 to a CT group and a control group. Heavy smokers were defined by having smoked ≥20 pack years and former smokers by being abstinent ≤10 years. Both groups were invited annually to the screening clinic to complete the validated lung-cancer-specific questionnaire consequences of screening lung cancer (COS-LC). The CT group was also offered a low dose CT scan of the lungs. The COS-LC measures nine scales with psychosocial properties: Anxiety, Behaviour, Dejection, Negative impact on sleep, Self-blame, Focus on Airway Symptoms, Stigmatisation, Introvert, and Harm of Smoking.

RESULTS

4104 participants were randomised to the DLCST and the COS-LC completion rates for the CT group and the control group were 95.5% and 73.6%, respectively. There was a significant increase in negative psychosocial consequences from baseline through rounds 2-5 for both the CT group and the control group (mean increase >0, p<.0001 for 3 of 4 possible scales). During rounds 2-5 the control group experienced significantly more negative psychosocial consequences in seven of nine scales compared with the CT group (mean Δ score >0 and p<.033).

CONCLUSIONS

Lung cancer CT-screening trials induced more negative psychosocial reactions in both the CT group and the control group compared with the baseline psychosocial profile. The CT group experienced less negative psychosocial consequences compared with the control group, which might be explained by reassurance among those with normal screening results.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00496977.

Patient-centered outcomes among lung cancer screening recipients with computed tomography: a systematic review

INTRODUCTION

Lung cancer screening using low-dose computed tomography (LDCT) is now widely recommended for adults who are current or former heavy smokers. It is important to evaluate the impact of screening on patient-centered outcomes. Among current and former smokers eligible for lung cancer screening, we sought to determine the consequences of screening with LDCT, and subsequent results, on patient-centered outcomes such as quality of life, distress, and anxiety.

METHODS

We searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth Quarter 2012), MEDLINE (2000 to May 31, 2013), reference lists of articles, and Scopus for relevant English-language studies and systematic reviews. To evaluate the effect of LDCT screening on patient-centered outcomes, we included only randomized controlled trials (RCTs) involving asymptomatic adults. To evaluate the association of particular results and/or recommendations from a screening LDCT with patient-centered outcomes, we included results from RCTs as well as from cohort studies.

RESULTS

A total of 8215 abstracts were reviewed. Five publications from two European RCTs and one publication from a cohort study conducted in the United States met inclusion criteria. The process of LDCT lung cancer screening was associated with short-term psychologic discomfort in many people but did not affect distress, worry, or health-related quality of life. False-positive results were associated with short-term increases in distress that returned to levels that were similar to those among people with negative results. Negative results were associated with short-term decreases in distress.

CONCLUSIONS

As lung cancer screening is implemented in the general population, it will be important to evaluate its association with patient-centered outcomes. People considering lung cancer screening should be aware of the possibility of distress caused by false-positive results. Clinicians may want to consider tailoring communication strategies that can decrease the distress associated with these results.

Psychometric properties of a Swedish version of the Consequences of Screening--Breast Cancer questionnaire

AIM

To evaluate the psychometric properties of a questionnaire addressing psychosocial consequences of false-positive mammographic screening.

BACKGROUND

The Consequences of Screening--Breast Cancer and Lung Cancer questionnaires target psychosocial consequences of false-positive cancer screening. The Consequences of Screening--Breast Cancer questionnaire and ten items not considered lung cancer specific from the Lung Cancer questionnaire have been adapted for use in mammographic screening in Sweden, but remain psychometrically untested.

DESIGN

Instrument development paper with psychometric cross-sectional and test-retest design.

METHODS

Twelve scales of a Swedish questionnaire version were tested by the Rasch model and traditional psychometric methods. Women with false-positive (Group I, n = 640) and negative (Group II, n = 802) screening mammography responded to the study questionnaire and the Nottingham Health Profile during 2009-2011.

RESULTS

Iterative analyses resulted in nine scales demonstrating Rasch model fit, but all scales exhibited poor targeting with relatively large floor effects. Corrected item-total correlations exceeded the recommended criterion. Score differences between Groups I and II and correlations with Nottingham Health Profile sections followed an expected pattern. Cronbach's α and test-retest reliability was acceptable for group-level assessments for ten and seven scales, respectively.

CONCLUSIONS

Five scales (Sense of dejection, Anxiety, Behavioural, Sleep and Existential values) of the Swedish questionnaire version demonstrated the best psychometric properties. Other scales should be used more cautiously. Although filling an important gap, causes of concern were identified across scales. The questionnaire should therefore be considered for group-level assessments rather than for measurement of individual degrees of psychosocial consequences.

The development and validation of a multidimensional sum-scaling questionnaire to measure patient-reported outcomes in acute respiratory tract infections in primary care: the acute respiratory tract infection questionnaire

OBJECTIVE

Patient-reported outcomes are seldom validated measures in clinical trials of acute respiratory tract infections (ARTIs) in primary care. We developed and validated a patient-reported outcome sum-scaling measure to assess the severity and functional impacts of ARTIs.

METHODS

Qualitative interviews and field testing among adults with an ARTI were conducted to ascertain a high degree of face and content validity of the questionnaire. Subsequently, a draft version of the Acute Respiratory Tract Infection Questionnaire (ARTIQ) was statistically validated by using the partial credit Rasch model to test dimensionality, objectivity, and reliability of items. Test of known groups' validity was conducted by comparing participants with and without an ARTI.

RESULTS

The final version of the ARTIQ consisted of 38 items covering five dimensions (Physical-upper, Physical-lower, Psychological, Sleep, and Medicine) and five single items. All final dimensions were confirmed to fit the Rasch model, thus enabling sum-scaling of responses. The ARTIQ scores in participants with an ARTI were significantly higher than in those without ARTI (known groups' validity).

CONCLUSION

A self-administered, multidimensional, sum-scaling questionnaire with high face and content validity and adequate psychometric properties for assessing severity and functional impacts from ARTIs in adults is available to clinical trials and audits in primary care.

Long-term psychosocial consequences of false-positive screening mammography

PURPOSE

Cancer screening programs have the potential of intended beneficial effects, but they also inevitably have unintended harmful effects. In the case of screening mammography, the most frequent harm is a false-positive result. Prior efforts to measure their psychosocial consequences have been limited by short-term follow-up, the use of generic survey instruments, and the lack of a relevant benchmark-women with breast cancer.

METHODS

In this cohort study with a 3-year follow-up, we recruited 454 women with abnormal findings in screening mammography over a 1-year period. For each woman with an abnormal finding on a screening mammogram (false and true positives), we recruited another 2 women with normal screening results who were screened the same day at the same clinic. These participants were asked to complete the Consequences of Screening in Breast Cancer-a validated questionnaire encompassing 12 psychosocial outcomes-at baseline, 1, 6, 18, and 36 months.

RESULTS

Six months after final diagnosis, women with false-positive findings reported changes in existential values and inner calmness as great as those reported by women with a diagnosis of breast cancer (Δ = 1.15; P = .015; and Δ = 0.13; P = .423, respectively). Three years after being declared free of cancer, women with false-positive results consistently reported greater negative psychosocial consequences compared with women who had normal findings in all 12 psychosocial outcomes (Δ >0 for 12 of 12 outcomes; P <.01 for 4 of 12 outcomes).

CONCLUSION

False-positive findings on screening mammography causes long-term psychosocial harm: 3 years after a false-positive finding, women experience psychosocial consequences that range between those experienced by women with a normal mammogram and those with a diagnosis of breast cancer.

Psychometric evaluation of the Taiwan Chinese version of the EORTC QLQ-PR25 for HRQOL assessment in prostate cancer patients

Objective

To evaluate the psychometric properties of the Taiwan Chinese Version of the EORTC QLQ-PR25 health-related quality of life (HRQOL) questionnaire for patients with prostate cancer.

Methods

135 prostate cancer patients were recruited in the urology outpatient clinic of a university teaching hospital. Each patient completed the EORTC QLQ-PR25 at every clinic visit between 2004 and 2008, totaling 633 assessments. Confirmatory factor analysis and Rasch analysis were used to evaluate the domain- and item-level psychometric properties.

Results

The results supported the unidimensionality of each of the four EORTC QLQ-PR25 domains (urinary, bowel, and hormonal-treatment-related symptoms, and sexual functioning). Item calibrations for each domain were found invariant across the three assessment time periods. The item-person maps showed 71.3% of item coverage for the urinary symptoms domain and 13–42.7% for the other three domains.

Conclusions

The Taiwan Chinese Version of the EORTC QLQ-PR25 questionnaire is reliable and can be used to measure HRQOL over time. Adding new items to each domain may improve its clinical content coverage and measurement precision.

Psychosocial consequences of allocation to lung cancer screening: a randomised controlled trial

OBJECTIVE

To examine the psychosocial consequences of being allocated to the control group as compared with the screen group in a randomised lung cancer screening trial.

METHOD

The Danish Lung Cancer Screening Trial, a randomised controlled trial, ran from 2004 to 2010 with the purpose of investigating the benefits and harms of lung cancer screening. The participants in Danish Lung Cancer Screening Trial were randomised to either the control group or the screen group and were asked to complete the questionnaires Consequences Of Screening and Consequences Of Screening in Lung Cancer (COS-LC). The Consequences Of Screening and the COS-LC were used to examine the psychosocial consequences of participating in the study, by comparing the control and the screen groups' responses at the prevalence and at the incidence round.

RESULTS

There was no statistically significant difference in socio-demographic characteristics or smoking habits between the two groups. Responses to the COS-LC collected before the incidence round were statistically significantly different on the scales 'anxiety', 'behaviour', 'dejection', 'self-blame', 'focus on airway symptoms' and 'introvert', with the control group reporting higher negative psychosocial consequences. Furthermore, the participants in both the control and the screen groups exhibited a mean increase in negative psychosocial consequences when their responses from the prevalence round were compared with their responses from the first incidence round.

CONCLUSIONS

Participation in a randomised controlled trial on lung cancer screening has negative psychosocial consequences for the apparently healthy participants-both the participants in the screen group and the control group. This negative impact was greatest for the control group.

Can we rely on the Dermatology Life Quality Index as a measure of the impact of psoriasis or atopic dermatitis?

The Dermatology Life Quality Index (DLQI) is a widely used health-related quality of life measure. However, little research has been conducted on its dimensionality. The objectives of the current study were to apply Rasch analysis to DLQI data to determine whether the scale is unidimensional, to assess its measurement properties, test the response format, and determine whether the measure exhibits differential item functioning (DIF) by disease (atopic dermatitis versus psoriasis), gender, or age group. The results show that there were several problems with the scale, including misfitting items, DIF by disease, age, and gender, disordered response thresholds, and inadequate measurement of patients with mild illness. As the DLQI did not benefit from the application of Rasch analysis in its development, it is argued that a new measure of disability related to dermatological disease is required. Such a measure should use a coherent measurement model and ensure that items are relevant to all potential respondents. The current use of the DLQI as a guide to treatment selection is of concern, given its inadequate measurement properties.

Participation bias in a randomised trial of screening for lung cancer

INTRODUCTION

Participation bias might affect the results and the representability of randomised controlled trials. We investigated the degree of socio-demographic and psychosocial participation bias in the Danish Lung Cancer Screening Trial (DLCST).

METHODS

In DLCST the questionnaire COS-LC (Consequences of Screening in Lung Cancer) was used to measure the psychosocial aspects of screening. To investigate a difference with a comparable representative sample from the Danish population, we sent out an inclusion questionnaire to 3999 Danes in the age from 50 to 70 years randomly selected from the Central National Register. Those who completed the inclusion questionnaire and met the inclusion criteria from DLCST received the COS-LC. Those who completed the COS-LC-and thus formed a population sample comparable to DLCST - were compared to the DLCST participants on socio-demographics and psychosocial measures.

RESULTS

Participation rates were high among the comparable population sample: 75.3% completed the inclusion questionnaire and 77.4% of those who were eligible completed the COS-LC. The analyses revealed differences between the DLCST participants and the comparable population sample in the following socio-demographic aspects: social group, living alone, gender, age and geographical area. DLCST participants reported less negative psychosocial aspects than the comparable population sample.

CONCLUSION

The present study has shown substantial socio-demographic and psychosocial participation bias in DLCST.