How does safety netting for lung cancer symptoms help patients to reconsult appropriately? A qualitative study

The Role of Smoking Status in Making Risk-Informed Diagnostic Decisions in the Lung Cancer Pathway: A Qualitative Study of Health Care Professionals and Patients

BACKGROUND

Lung cancer clinical guidelines and risk tools often rely on smoking history as a significant risk factor. However, never-smokers make up 14% of the lung cancer population, and this proportion is rising. Consequently, they are often perceived as low-risk and may experience diagnostic delays. This study aimed to explore how clinicians make risk-informed diagnostic decisions for never-smokers.

METHODS

Qualitative interviews were conducted with 10 lung cancer diagnosticians, supported by data from interviews with 20 never-smoker lung cancer patients. The data were analyzed using a framework analysis based on the Model of Pathways to Treatment framework and data-driven interpretations.

RESULTS

Participants described 3 main strategies for making risk-informed decisions incorporating smoking status: guidelines, heuristics, and potential harms. Clinicians supplemented guidelines with their own heuristics for never-smokers, such as using higher thresholds for chest X-ray. Decisions were easier for patients with high-risk symptoms such as hemoptysis. Clinicians worried about overinvestigating never-smoker patients, particularly in terms of physical and psychological harms from invasive procedures or radiation. To minimize unnecessary anxiety about lung cancer risk, clinicians made efforts to downplay this. Conversely, some patients found that this caused process harms such as delays and miscommunications.

CONCLUSION

Improved guidance and methods of risk differentiation for never-smokers are needed to avoid diagnostic delays, overreassurance, and clinical pessimism. This requires an improved evidence base and initiatives to increase awareness among clinicians of the incidence of lung cancer in never-smokers. As the proportion of never-smoker patients increases, this issue will become more urgent.

HIGHLIGHTS

Smoking status is the most common risk factor used by clinicians to guide decision making, and guidelines often focus on this factor.Some clinicians also use their own heuristics for never-smokers, and this becomes particularly relevant for patients with lower risk symptoms.Clinicians are also concerned about the potential harms and risks associated with deploying resources on diagnostics for never-smokers.Some patients find it difficult to decide whether or not to go ahead with certain procedures due to efforts made by clinicians to downplay the risk of lung cancer.Overall, the study highlights the complex interplay between smoking history, clinical decision making, and patient anxiety in the context of lung cancer diagnosis and treatment.

Factors affecting patient decisions to undergo testing for cancer symptoms: an exploratory qualitative study in Australian general practice

BACKGROUND

Patients presenting to their GP are often concerned their symptoms may be due to cancer. However, there is a lack of evidence on the factors that influence patient decisions to undergo investigation for suspected cancer in the general practice setting.

AIM

To identify the factors influencing patient decisions to undertake investigations for suspected cancer in general practice.

DESIGN & SETTING

An exploratory qualitative, semi-structured interview study of patients attending rural and metropolitan general practices in Victoria, Australia.

METHOD

A purposive sample of 15 general practice patients aged ≥40 years participated. Thematic analysis of transcripts drew on interpretative description methodology and shared decision-making (SDM) theory.

RESULTS

Cancer-related concerns such as 'cancer worry' prompt patients to seek investigations from their GP. Participants prefer that their symptoms are investigated regardless of cancer risk. The perceived 'best test' provides the most reassurance. Trust and SDM enhance dialogue between patients and GPs about diagnostic testing strategies. Deterrents to testing included out-of-pocket costs, waiting time, travel time, and competing work and family demands.

CONCLUSION

There may be a mismatch between efforts to rationalise investigation use and patient preferences for investigation. SDM that incorporates patient concerns, facilitators, and barriers to testing may ensure appropriate and timely investigation of cancer symptoms.