Impact of a Lung Cancer Screening Information Film on Informed Decision-making: A Randomized Trial

Digital Interventions to Support Lung Cancer Screening: A Systematic Review

INTRODUCTION

Lung cancer remains a leading cause of cancer-related deaths globally. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce lung cancer mortality, but its adoption in the U.S. has been limited. Digital interventions have the potential to improve uptake of LCS. This systematic review aims to summarize the evidence for the effectiveness of digital interventions in promoting LCS.

METHODS

A systematic search of three electronic databases (PubMed, Embase, and Medline) was conducted to identify studies published between January 2014 and May 2023. Studies were reviewed and abstracted between February 2023 and July 2023. Outcomes related to knowledge, decision-making and screening were measured. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools.

RESULTS

Of 1,979 screened articles, 30 studies were included in this review. Digital interventions evaluated included decision aids (n=20), electronic health record (EHR)-based interventions (n=7), social media campaigns and mobile applications (n=3). Decision aids were the most commonly studied digital interventions, with most studies showing improved knowledge (13/13) and reduced decisional conflict (7/9) but most did not show a substantial change in screening use. Fewer studies tested clinician-facing or multi-level interventions.

DISCUSSION

Digital interventions, particularly decision aids, have shown promise in improving knowledge and the quality of decision-making around LCS. However, few interventions have been shown to substantially alter screening behavior and few clinician-facing or multi-level interventions have been rigorously tested. Further research is needed to develop effective tools for engaging patients in LCS, to compare the efficacy of different interventions, and evaluate implementation strategies in diverse healthcare settings.

Promoting Lung Cancer Screen Decision-Making and Early Detection Behaviors: A Systematic Review and Meta-analysis

BACKGROUND

Promoting lung cancer screening (LCS) is complex. Previous studies have overlooked that LCS behaviors are stage based and thus did not identify the characteristics of LCS interventions at different screening stages.

OBJECTIVE

The aims of this study were to explore the characteristics and efficacy of interventions in promoting LCS decision making and behaviors and to evaluate these interventions.

METHODS

We conducted a study search from the inception of each bibliographic database to April 8, 2023. The precaution adoption process model was used to synthesize and classify the evidence. The RE-AIM framework was used to evaluate the effectiveness of LCS programs. Heterogeneity tests and meta-analysis were performed using RevMan 5.4 software.

RESULTS

We included 31 studies that covered 4 LCS topics: knowledge of lung cancer, knowledge of LCS, value clarification exercises, and LCS supportive resources. Patient decision aids outperformed educational materials in improving knowledge and decision outcomes with a significant reduction in decision conflict (standardized mean difference, 0.81; 95% confidence interval, -1.15 to -0.47; P < .001). Completion rates of LCS ranged from 3.6% to 98.8%. Interventions that included screening resources outperformed interventions that used patient decision aids alone in improving LCS completion. The proportions of reported RE-AIM indicators were highest for reach (69.59%), followed by adoption (43.87%), effectiveness (36.13%), implementation (33.33%), and maintenance (9.68%).

CONCLUSION

Evidence from 31 studies identified intervention characteristics and effectiveness of LCS interventions based on different stages of decision making.

IMPLICATIONS FOR PRACTICE

It is crucial to develop targeted and systematic interventions based on the characteristics of each stage of LCS to maximize intervention effectiveness and reduce the burden of lung cancer.

Inadequate Uptake of USPSTF-Recommended Low Dose CT Lung Cancer Screening

In 2023, Journal of Primary Care and Community Health published the results of 4 outstanding studies in which investigators aimed to explore and improve clinician and eligible individuals' knowledge of the rationale for lung cancer screening (LCS). Their results highlighted the underutilization of LCS, particularly for certain high risk populations, and the continued disparities in screening seen between groups of eligible individuals. Here, key findings from those 2023 Journal of Primary Care and Community Health reports, along with salient findings of other recent LCS reports, are discussed. The bases for the United States Preventive Task Force (USPSTF) LCS recommendations, barriers primary care providers face, the perspective of eligible individuals, importance of shared decision-making (SDM) and disparities between groups in LCS are reviewed along with potential strategies to ensure that more eligible individuals are offered LCS.

Barriers to Lung Cancer Screening Access from the Perspective of the Patient and Current Interventions

In the context of the Conceptual Model for Lung Cancer Screening Participation, this article describes patient barriers to lung cancer screening highlighting current interventions. Patient barriers include cognitive factors (lack of awareness, limited information/misinformation, and low perceived risk), factors related to access (logistical issues, no provider recommendation, cost, and other financial/social factors), and psychological factors (fear, fatalism, lung cancer worry, and stigma). Current interventions include the use of educational materials/presentations to address cognitive barriers, use of direct outreach and structural change to address factors related to access, and use of educational material focused on psychological barriers to address psychological barriers.

Lung Cancer Screening Decision Aid Designed for a Primary Care Setting: A Randomized Clinical Trial

Importance

Guidelines recommend shared decision-making prior to initiating lung cancer screening (LCS). However, evidence is lacking on how to best implement shared decision-making in clinical practice.

Objective

To evaluate the impact of an LCS Decision Tool (LCSDecTool) on the quality of decision-making and LCS uptake.

Design, Setting, and Participants

This randomized clinical trial enrolled participants at Veteran Affairs Medical Centers in Philadelphia, Pennsylvania; Milwaukee, Wisconsin; and West Haven, Connecticut, from March 18, 2019, to September 29, 2021, with follow-up through July 18, 2022. Individuals aged 55 to 80 years with a smoking history of at least 30 pack-years who were current smokers or had quit within the past 15 years were eligible to participate. Individuals with LCS within 15 months were excluded. Of 1047 individuals who were sent a recruitment letter or had referred themselves, 140 were enrolled.

Intervention

A web-based patient- and clinician-facing LCS decision support tool vs an attention control intervention.

Main Outcome and Measures

The primary outcome was decisional conflict at 1 month. Secondary outcomes included decisional conflict immediately after intervention and 3 months after intervention, knowledge, decisional regret, and anxiety immediately after intervention and 1 and 3 months after intervention and LCS by 6 months.

Results

Of 140 enrolled participants (median age, 64.0 [IQR, 61.0-69.0] years), 129 (92.1%) were men and 11 (7.9%) were women. Of 137 participants with data available, 75 (53.6%) were African American or Black and 62 (44.3%) were White; 4 participants (2.9%) also reported Hispanic or Latino ethnicity. Mean decisional conflict score at 1 month did not differ between the LCSDecTool and control groups (25.7 [95% CI, 21.4-30.1] vs 29.9 [95% CI, 25.6-34.2], respectively; P = .18). Mean LCS knowledge score was greater in the LCSDecTool group immediately after intervention (7.0 [95% CI, 6.3-7.7] vs 4.9 [95% CI, 4.3-5.5]; P < .001) and remained higher at 1 month (6.3 [95% CI, 5.7-6.8] vs 5.2 [95% CI, 4.5-5.8]; P = .03) and 3 months (6.2 [95% CI, 5.6-6.8] vs 5.1 [95% CI, 4.4-5.8]; P = .01). Uptake of LCS was greater in the LCSDecTool group at 6 months (26 of 69 [37.7%] vs 15 of 71 [21.1%]; P = .04).

Conclusions and Relevance

In this randomized clinical trial of an LCSDecTool compared with attention control, no effect on decisional conflict occurred at 1 month. The LCSDecTool used in the primary care setting did not yield a significant difference in decisional conflict. The intervention led to greater knowledge and LCS uptake. These findings can inform future implementation strategies and research in LCS shared decision-making.

Trial Registration

ClinicalTrials.gov Identifier: NCT02899754.

Mixed-Method Systematic Review and Meta-Analysis of Shared Decision-Making Tools for Cancer Screening

This review aimed to synthesize evidence on the effectiveness of shared decision-making (SDM) tools for cancer screening and explored the preferences of vulnerable people and clinicians regarding the specific characteristics of the SDM tools. A mixed-method convergent segregated approach was employed, which involved an independent synthesis of quantitative and qualitative data. Articles were systematically selected and screened, resulting in the inclusion and critical appraisal of 55 studies. Results from the meta-analysis revealed that SDM tools were more effective for improving knowledge, reducing decisional conflict, and increasing screening intentions among vulnerable populations compared to non-vulnerable populations. Subgroup analyses showed minimal heterogeneity for decisional conflict outcomes measured over a six-month period. Insights from the qualitative findings revealed the complexities of clinicians' and vulnerable populations' preferences for an SDM tool in cancer screening. Vulnerable populations highly preferred SDM tools with relevant information, culturally tailored content, and appropriate communication strategies. Clinicians, on the other hand, highly preferred tools that can be easily integrated into their medical systems for efficient use and can effectively guide their practice for cancer screening while considering patients' values. Considering the complexities of patients' and clinicians' preferences in SDM tool characteristics, fostering collaboration between patients and clinicians during the creation of an SDM tool for cancer screening is essential. This collaboration may ensure effective communication about the specific tool characteristics that best support the needs and preferences of both parties.

Interventions Designed to Increase the Uptake of Lung Cancer Screening: An Equity-Oriented Scoping Review

Introduction

Participation in lung cancer screening (LCS) is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of health care utilization (through structurally inaccessible care) leading to a widening of health inequities.

Methods

We conducted a scoping review using the Arksey and O'Malley methodological framework to inform equitable access to LCS by illuminating knowledge and implementation gaps in interventions designed to increase the uptake of LCS. We comprehensively searched for LCS interventions (Ovid Medline, Excerpta Medica database, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus from 2000 to June 22, 2021) and included peer-reviewed articles and gray literature published in the English language that describe an intervention designed to increase the uptake of LCS, charted data using our previously published tool and conduced a health equity analysis to determine the intended-unintended and positive-negative outcomes of the interventions for populations experiencing the greatest inequities.

Results

Our search yielded 3572 peer-reviewed articles and 54,292 pieces of gray literature. Ultimately, we included 35 peer-reviewed articles and one gray literature. The interventions occurred in the United States, United Kingdom, Japan, and Italy, focusing on shared decision-making, the use of electronic health records as reminders, patient navigation, community-based campaigns, and mobile computed tomography scanners. We developed an equity-oriented LCS framework and mapped the dimensions and outcomes of the interventions on access to LCS on the basis of approachability, acceptability, availability, affordability, and appropriateness of the intervention. No intervention was mapped across all five dimensions. Most notably, knowledge and implementation gaps were identified in dimensions of acceptability, availability, and affordability.

Conclusions

Interventions that were most effective in improving access to LCS targeted priority populations, raised community-level awareness, tailored materials for sociocultural acceptability, did not depend on prior patient engagement/registration with the health care system, proactively considered costs related to participation, and enhanced utilization through informed decision-making.

The natural growth history of persistent pulmonary subsolid nodules: Radiology, genetics, and clinical management

The high detection rate of pulmonary subsolid nodules (SSN) is an increasingly crucial clinical issue due to the increased number of screening tests and the growing popularity of low-dose computed tomography (LDCT). The persistence of SSN strongly suggests the possibility of malignancy. Guidelines have been published over the past few years and guide the optimal management of SSNs, but many remain controversial and confusing for clinicians. Therefore, in-depth research on the natural growth history of persistent pulmonary SSN can help provide evidence-based medical recommendations for nodule management. In this review, we briefly describe the differential diagnosis, growth patterns and rates, genetic characteristics, and factors that influence the growth of persistent SSN. With the advancement of radiomics and artificial intelligence (AI) technology, individualized evaluation of SSN becomes possible. These technologies together with liquid biopsy, will promote the transformation of current diagnosis and follow-up strategies and provide significant progress in the precise management of subsolid nodules in the early stage of lung cancer.

The effectiveness of video animations as information tools for patients and the general public: A systematic review

Background and objectives

Video animations are used increasingly as patient information tools; however, we do not know their value compared to other formats of delivery, such as printed materials, verbal consultations or static images.

Methods

This review compares the effectiveness of video animations as information tools vs. other formats of delivery on patient knowledge, attitudes and cognitions, and behaviours. Included studies had the following features: controlled design with random or quasi-random allocation; patients being informed about any health condition or members of the public being informed about a public health topic; comparing video animation with another delivery format. Multiple digital databases were searched from 1996-June 2021. We also undertook citation searching. We used dual, independent decision-making for inclusion assessment, data extraction and quality appraisal. Included studies were appraised using the Cochrane ROB2 tool. Findings were reported using narrative synthesis.

Results

We included 38 trials, focussed on: explaining medical or surgical procedures (n = 17); management of long-term conditions (n = 11); public health, health-promotion or illness-prevention (n = 10). Studies evaluated cartoon animations (n = 29), 3D animations (n = 6), or 2D animations, "white-board" animations or avatars (n = 1 each). Knowledge was assessed in 30 studies, showing greater knowledge from animations in 19 studies, compared to a range of comparators. Attitudes and cognitions were assessed in 21 studies, and animations resulted in positive outcomes in six studies, null effects in 14 studies, and less positive outcomes than standard care in one study. Patient behaviours were assessed in nine studies, with animations resulting in positive outcomes in four and null effects in the remainder. Overall risk of bias was "high" (n = 18), "some concerns" (n = 16) or "low" (n = 4). Common reasons for increased risk of bias were randomisation processes, small sample size or lack of sample size calculation, missing outcome data, and lack of protocol publication.

Discussion

The overall evidence base is highly variable, with mostly small trials. Video animations show promise as patient information tools, particularly for effects on knowledge, but further evaluation is needed in higher quality studies.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?, identifier: CRD42021236296.

Evaluation of a Web-Based Culturally Sensitive Educational Video to Facilitate Informed Cervical Cancer Screening Decisions Among Turkish- and Moroccan-Dutch Women Aged 30 to 60 Years: Randomized Intervention Study

Background

In the Netherlands, since 1996, a national cervical cancer (CC) screening program has been implemented for women aged 30 to 60 years. Regional screening organizations send an invitation letter and information brochure in Dutch to the home addresses of targeted women every 5 years. Although this screening is free of charge, Turkish- and Moroccan-Dutch women, especially, show low screening participation and limited informed decision-making (IDM). As Turkish- and Moroccan-Dutch women indicated their need for information on the practical, emotional, cultural, and religious aspects of CC screening, we developed a culturally sensitive educational video (CSEV) as an addition to the current information brochure.

Objective

In this study, we aimed to evaluate the added effect of the CSEV on IDM regarding CC screening participation among Turkish and Moroccan women aged 30 to 60 years in the Netherlands through a randomized intervention study.

Methods

Initial respondents were recruited via several social media platforms and invited to complete a web-based questionnaire. Following respondent-driven sampling, respondents were asked to recruit a number of peers from their social networks to complete the same questionnaire. Respondents were randomly assigned to the control (current information brochure) or intervention condition (brochure and CSEV). We measured respondents’ knowledge and attitude regarding CC screening and their intention to participate in the next CC screening round before and after the control or intervention condition. We evaluated the added effect of the CSEV (above the brochure) on their knowledge, attitude, intention, and IDM using intention-to-treat analyses.

Results

The final sample (n=1564) included 686 (43.86%) Turkish and 878 (56.14%) Moroccan-Dutch women. Of this sample, 50.7% (793/1564) were randomized to the control group (350/793, 44.1% Turkish and 443/793, 55.9% Moroccan) and 49.3% (771/1564) to the intervention group (336/771, 43.6% Turkish and 435/771, 56.4% Moroccan). Among the Turkish-Dutch women, 33.1% (116/350) of the control respondents and 40.5% (136/336) of the intervention respondents consulted the brochure (not statistically significant). Among Moroccan-Dutch women, these percentages were 28.2% (125/443) and 37.9% (165/435), respectively (P=.003). Of all intervention respondents, 96.1% (323/336; Turkish) and 84.4% (367/435; Moroccan) consulted the CSEV. The CSEV resulted in more positive screening attitudes among Moroccan-Dutch women than the brochure (323/435, 74.3% vs 303/443, 68.4%; P=.07). Women, who had never participated in CC screening before, showed significantly more often a positive attitude toward CC screening compared with the control group (P=.01).

Conclusions

Our short and easily implementable CSEV resulted in more positive screening attitudes, especially in Moroccan-Dutch women. As the CSEV was also watched far more often than the current brochure was read, this intervention can contribute to better reach and more informed CC screening decisions among Turkish- and Moroccan-Dutch women.

Trial Registration

International Clinical Trial Registry Platform NL8453; https://tinyurl.com/2dvbjxvc

Decision Support Tools for Low-Dose CT Lung Cancer Screening: A Scoping Review of Information Content, Format, and Presentation Methods

Several countries mandate informed or shared decision-making for low-dose CT (LDCT) lung cancer screening, but knowledge is limited about the type of information and presentation techniques used to support decision-making in practice. This review aimed to characterize the content, format, mode, and presentation methods of decision support tools (DSTs) for LDCT lung cancer screening. DSTs reported within peer-reviewed articles (January 2000-April 2021) were identified systematically from PubMed, PsycInfo, EMBASE, and CINAHL Plus. Inclusion criteria revolved around the development or evaluation of a resource or tool intended to support individual or shared decision-making for LDCT lung cancer screening. The data-charting and extraction framework was based on the International Patient Decision Aids Standards instrument and Template for Intervention Description and Reporting. Extracted data were organized within two categories: (1) study characteristics and context, format, and mode of DST use and (2) DST content and presentation methods. This review identified 22 DSTs in paper, video, or electronic formats across 26 articles. Most DSTs (n = 13) focused on knowledge exchange, whereas seven used interactive techniques to support values clarification (eg, Likert scales) and nine DSTs guided deliberation (eg, suggested discussion topics). The DSTs addressed similar topics, but the detail, quantification of probability, and presentation methods varied considerably. None described all the potential screening harms and results. The heterogeneity in DST design may affect the quality of decision-making, particularly for participants with lower literacy and numeracy. Evidence-based consensus guidelines for DST content and presentation methods should be developed collaboratively with screening-eligible adults.

Clinical Decision Support with or without Shared Decision Making to Improve Preventive Cancer Care: A Cluster-Randomized Trial

BACKGROUND

Innovative interventions are needed to address gaps in preventive cancer care, especially in rural areas. This study evaluated the impact of clinical decision support (CDS) with and without shared decision making (SDM) on cancer-screening completion.

METHODS

In this 3-arm, parallel-group, cluster-randomized trial conducted at a predominantly rural medical group, 34 primary care clinics were randomized to clinical decision support (CDS), CDS plus shared decision making (CDS+SDM), or usual care (UC). The CDS applied web-based clinical algorithms identifying patients overdue for United States Preventive Services Task Force-recommended preventive cancer care and presented evidence-based recommendations to patients and providers on printouts and on the electronic health record interface. Patients in the CDS+SDM clinic also received shared decision-making tools (SDMTs). The primary outcome was a composite indicator of the proportion of patients overdue for breast, cervical, or colorectal cancer screening at index who were up to date on these 1 y later.

RESULTS

From August 1, 2018, to March 15, 2019, 69,405 patients aged 21 to 74 y had visits at study clinics and 25,198 were overdue for 1 or more cancer screening tests at an index visit. At 12-mo follow-up, 9,543 of these (37.9%) were up to date on the composite endpoint. The adjusted, model-derived percentage of patients up to date was 36.5% (95% confidence interval [CI]: 34.0-39.1) in the UC group, 38.1% (95% CI: 35.5-40.9) in the CDS group, and 34.4% (95% CI: 31.8-37.2) in the CDS+SDM group. For all comparisons, the screening rates were higher than UC in the CDS group and lower than UC in the CDS+SDM group, although these differences did not reach statistical significance.

CONCLUSION

The CDS did not significantly increase cancer-screening rates. Exploratory analyses suggest a deeper understanding of how SDM and CDS interact to affect cancer prevention decisions is needed. Trial registration: ClinicalTrials.gov ID: NCT02986230, December 6, 2016.

Lung cancer screening implementation: Complexities and priorities

Lung cancer is the number one cause of cancer death worldwide. The benefits of lung cancer screening to reduce mortality and detect early-stage disease are no longer in any doubt based on the results of two landmark trials using LDCT. Lung cancer screening has been implemented in the US and South Korea and is under consideration by other communities. Successful translation of demonstrated research outcomes into the routine clinical setting requires careful implementation and co-ordinated input from multiple stakeholders. Implementation aspects may be specific to different healthcare settings. Important knowledge gaps remain, which must be addressed in order to optimize screening benefits and minimize screening harms. Lung cancer screening differs from all other cancer screening programmes as lung cancer risk is driven by smoking, a highly stigmatized behaviour. Stigma, along with other factors, can impact smokers' engagement with screening, meaning that smokers are generally 'hard to reach'. This review considers critical points along the patient journey. The first steps include selecting a risk threshold at which to screen, successfully engaging the target population and maximizing screening uptake. We review barriers to smoker engagement in lung and other cancer screening programmes. Recruitment strategies used in trials and real-world (clinical) programmes and associated screening uptake are reviewed. To aid cross-study comparisons, we propose a standardized nomenclature for recording and calculating recruitment outcomes. Once participants have engaged with the screening programme, we discuss programme components that are critical to maximize net benefit. A whole-of-programme approach is required including a standardized and multidisciplinary approach to pulmonary nodule management, incorporating probabilistic nodule risk assessment and longitudinal volumetric analysis, to reduce unnecessary downstream investigations and surgery; the integration of smoking cessation; and identification and intervention for other tobacco related diseases, such as coronary artery calcification and chronic obstructive pulmonary disease. National support, integrated with tobacco control programmes, and with appropriate funding, accreditation, data collection, quality assurance and reporting mechanisms will enhance lung cancer screening programme success and reduce the risks associated with opportunistic, ad hoc screening. Finally, implementation research must play a greater role in informing policy change about targeted LDCT screening programmes.

A Comparison of Web-Based Cancer Risk Calculators That Inform Shared Decision-making for Lung Cancer Screening

INTRODUCTION

To align patient preferences and understanding with harm-benefit perception, the Centers for Medicare & Medicaid Services (CMS) mandates that providers engage patients in a collaborative shared decision-making (SDM) visit before LDCT. Nonetheless, patients and providers often turn instead to the web for help making decisions. Several web-based lung cancer risk calculators (LCRCs) provide risk predictions and screening recommendations; however, the accuracy, consistency, and subsequent user interpretation of these predictions between LCRCs is ambiguous. We conducted a systematic review to assess this variability.

DESIGN

Through a systematic Internet search, we identified 10 publicly available LCRCs and categorized their input variables: demographic factors, cancer history, smoking status, and personal/environmental factors. To assess variance in LCRC risk prediction outputs, we developed 16 hypothetical patients along a risk continuum, illustrated by randomly assigned input variables, and individually compared them to each LCRC against the empirically validated "gold-standard" PLCO risk model in order to evaluate the accuracy of the LCRCs within identical time-windows.

RESULTS

From the inclusion criteria, 11 calculators were initially identified. The analyzed calculators also vary in output characteristics and risk depiction for hypothetical patients. There were 13 total instances across ten hypothetical patients in which the sample standard error exceeded the mean risk percentage across all general samples and set standard calculations. The largest measured difference is 16.49% for patient 8, and the smallest difference is 0.01% for patient 2. The largest measured difference is 16.49% for patient 8, and the smallest difference is 0.01% for patient 2.

CONCLUSION

Substantial variability in the depiction of lung cancer risk for hypothetical patients exists across the web-based LCRCs due to their respective inputs and risk prediction models. To foster informed decision-making in the SDM-LDCT context, the input variables, risk prediction models, risk depiction, and screening recommendations must be standardized to best practice.

Lung cancer screening: targeting the hard to reach-a review

Lung cancer (LC) is the leading cause of cancer death in the USA for both men and women, and also worldwide, it is the commonest cause of cancer death. The five-year survival rate for LC depends on the stage at which it is diagnosed. It is over 50% for cases detected in a localized stage but when the disease has spread to other organs, the five-year survival rate is only 5%. Unfortunately, only 16% of LC cases are diagnosed at an early stage. In 2013, the US Preventive Services Task Force (USPSTF) recommended annual LC screening with low dose chest computed tomography (CT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years, based on the evidence from the National Lung Screening Trial (NLST) in the USA. When it comes to recruiting the target group for lung cancer screening (LCS), there are several barriers to overcome, such as whom exactly to include, where to find the target group, how to convince the target to participate or how to attract participants from all socioeconomic groups. The aim of this review is to find out what is already known about how the target group for LCS can be contacted and how participation can be improved, since uptake is a key issue in every (cancer) screening program. A review of the literature was conducted using ‘lung cancer screening and participation and uptake’ as search string. We searched in Web of Science and PubMed for reviews, systematic reviews and articles, published between 2015 and 2020. Compared to the target groups for screening in the long-running cancer screening programs of breast, cervical and colorectal cancer, there are several additional obstacles regarding defining, locating and recruiting of the target group for LCS. Shared decision-making is crucial when we want to reach the hard to reach for LCS and it should be improved, by educating primary care practitioners about LCS guidelines and providing them with the necessary tools, such as decision aids, to facilitate their job in this respect. Moreover, the information materials should be more tailored to specific groups who participate least.

Managing screening-detected subsolid nodules-the Asian perspective

The broad application of low-dose computed tomography (CT) screening has resulted in the detection of many small pulmonary nodules. In Asia, a large number of these detected nodules with a radiological ground glass pattern are reported as lung adenocarcinomas or premalignant lesions, especially among female non-smokers. In this review article, we discuss controversial issues and conditions involving these subsolid pulmonary nodules that we often face in Asia, including a lack or insufficiency of current guidelines; the roles of preoperative biopsy and imaging; the location of lesions; appropriate selection of localization techniques; the roles of dissection and sampling of frozen sections and lymph nodes; multifocal lesions; and the roles of non-surgical treatment modalities. For these complex issues, we have tried to present up-to-date evidence and our own opinions regarding the management of subsolid nodules. It is our hope that this article helps surgeons and physicians to manage the complex issues involving ground glass nodules (GGNs) in a balanced manner in their daily practice and provokes further discussion towards better guidelines and/or algorithms.

Promoting lung cancer awareness, help-seeking and early detection: a systematic review of interventions

Lung cancer (LC) is the leading cause of cancer death. Barriers to the early presentation for LC include lack of symptom awareness, symptom misappraisal, poor relationship with doctors and lack of access to healthcare services. Addressing such barriers can help detect LC early. This systematic review describes the effect of recent interventions to improve LC awareness, help-seeking and early detection. This review was guided by the Cochrane Handbook for Systematic Reviews of Interventions. Electronic databases MEDLINE, CINAHL, ERIC, APA PsycARTICLES, APA PsycInfo and Psychology and Behavioral Sciences Collection were searched. Sixteen studies were included. Knowledge of LC was successfully promoted in most studies using educational sessions and campaigns. LC screening uptake varied with most studies successfully reducing decision conflicts using decision aids. Large campaigns, including UK-based campaign 'Be Clear on Cancer', were instrumental in enhancing LC awareness, promoting help-seeking and yielding an increase in chest X-rays and a decrease in the number of individuals diagnosed with advanced LC. Multimodal public health interventions, such as educational campaigns are best suited to raise awareness, reduce barriers to help-seeking and help detect LC early. Future interventions ought to incorporate targeted information using educational resources, face-to-face counselling and video- and web-based decision aids.

Cancer Screening Among Older Adults: a Geriatrician's Perspective on Breast, Cervical, Colon, Prostate, and Lung Cancer Screening

PURPOSE OF REVIEW

We summarize the evidence of benefits, harms, and tools to assist in individualized decisions among older adults in screening for breast, prostate, colon, lung, and cervical cancer.

RECENT FINDINGS

The benefits of cancer screening in older adults remain unclear due to minimal inclusion of adults > 75 years old in most randomized controlled trials. Indirect evidence suggests that the benefits of screening seen in younger adults (< 70 years old) can be extrapolated to older adults when they have an estimated life expectancy of at least 10 years. However, older adults, especially those with limited life expectancy, may be at increased risk for experiencing harms of screening, including overdiagnosis of clinically unimportant diseases, complications from diagnostic procedures, and distress after false positive test results. We provide a framework to integrate key factors such as health status, risks and benefits of specific tests, and patient preferences to guide clinicians in cancer screening decisions in older adults.

Tools to Promote Shared Decision-Making in Lung Cancer Screening Using Low-Dose CT Scanning: A Systematic Review

BACKGROUND

Decisions about lung cancer screening are inherently complex and create a need for methods to convey the risks and benefits of screening to patients.

RESEARCH QUESTION

What kind of decision aids or tools are available to support shared decision-making for lung cancer screening? What is the current evidence for the effectiveness, acceptability, and feasibility of those tools?

STUDY DESIGN AND METHODS

We conducted a systematic review of studies and searched PubMed, MEDLINE, EMBASE, Cochrane Clinical Trials Register, and ClinicalTrials.gov from inception to December 2019 for studies that evaluated the effectiveness and acceptability of tools to promote shared decision-making for patients who are considering lung cancer screening.

RESULTS

After screening 2,427 records, we included one randomized control trial, two observational studies, 11 before/after studies of a decision aid or an educational tool. Fifteen distinct tools in various formats were evaluated in 14 studies. Most studies were of fair quality. Studies reported improvement in patients' knowledge of lung cancer screening (n = 9 studies), but improvements in specific areas of knowledge were inconsistent. Decisional conflict was low or reduced after the administration of the tools (n = 7 studies). The acceptability of tools was rated as "high" by patients (n = 7 studies) and physicians (n = 1 study). Low dose CT scan completion rates varied among studies (n = 6 studies).

INTERPRETATION

Evidence from 14 studies suggests that some elements of existing tools for lung cancer screening may help to prepare patients for decision-making by improving knowledge and reducing decisional conflict. Such tools generally are acceptable to patients and providers. Further studies that use consistent measures and reporting methods and assess relevant decisional and clinical outcomes are needed to determine the comparative effectiveness and feasibility of implementation of these tools.

CLINICAL TRIAL REGISTRATION

PROSPERO 2018 CRD4201874814.