Smokers’ Perceptions of Lung Cancer Risks

Smokers’ Perceptions of Lung Cancer Risks

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Does lung screening promote smoking cessation?

More than 220,000 new cases of lung cancer are diagnosed each year, usually at a late stage. Cigarette smoking is responsible for 87 percent of lung cancer deaths in men and 70 percent in women. The U.S. Preventive Services Task Force Guidelines recently recommended annual lung cancer screening for current and former heavy smokers in an effort to detect lung cancers at an earlier, more treatable stage. Many health experts believe it is also important to understand smokers’ attitudes regarding their smoking behavior and whether the screening changes their attitudes.

Researchers at Massachusetts General Hospital Cancer Center, led by psychologist Elyse R. Park, PhD, MPH, undertook a series of studies to examine the effect of lung screening on attitudes and smoking behavior in a subset of participants in the National Lung Screening Trial (NLST) that ran from 2002 to 2004. “An important question, given the high cost of screening, is whether screening motivates smoking cessation and reinforces quitting among former smokers,” says Dr. Park.

Lung Screening

The NLST enrolled 53,545 participants who were current and former heavy smokers 55 years and older with a 30-pack-year smoking history. The trial, which included a baseline screening and a follow-up screening each of the following two years, aimed to determine whether low-dose computed tomography may detect lung cancer earlier than the standard chest X-ray.

Health experts hypothesized that lung screening may provide an opportunity to change an individual’s perception of the risk involved in smoking, and thus motivate current smokers to quit and former smokers to avoid relapse. But not much was known about how current and former smokers perceive their risk, or how screening affects those perceptions.

Determining what smokers actually think and do

Prior to the first baseline screening, 630 NLST participants completed a risk perception questionnaire created by Dr. Park. Previous studies of risk perception had focused primarily on an individual’s perception of his/ her personal risk (based on objective knowledge of the dangers of smoking) and focused only on lung cancer. This study, published in the June 2009 Annals of Behavioral Medicine, also considered other smoking-related diseases (SRDs) and the perception of comparative risk (an individual’s risk compared to the average person, others of the same age and sex, and other former/current smokers).

The following year, 430 of those participants completed a follow-up questionnaire prior to their second screening to see whether their risk perceptions for lung cancer and SRDs had changed, and whether those changes had affected smoking behavior. The results were reported in the April 2013 issue of Cancer.

In a second follow-up qualitative study, reported in the Sept. 2, 2013 issue of Nicotine & Tobacco Research,3 the researchers conducted structured, in-depth phone interviews of 35 randomly selected participants from the 2009 study one to two years after the initial screening. This study sought to determine if screening was a cue for behavioral change; elucidate risk perceptions and underlying behavior change determinants for lung cancer and smoking-related diseases; and explore post-screening intentions and changes.

The results were consistent across the three studies. Despite the fact that many participants understood that continuing to smoke put them at high risk for lung cancer and other SRDs, and that many of them intended to quit smoking when they started the trial, most did not quit. The lung screening test did not appear to affect their risk perceptions and was not in and of itself a cue for changing their smoking behavior.

In ongoing work, Dr. Park and Inga Lennes, MD, medical oncology director of Mass General’s Lung Screening Clinic and director of quality at Mass General Cancer Center, are administering a modified questionnaire at the Lung Screening Clinic.

A Need for Intervention

“Lung screening may provide a teachable moment, but participants do not teach themselves,” concludes Dr. Park. Recently, she and her team examined the effects of physicians’ interventions with smokers following lung screening. The results were presented at the 2013 American Society of Clinical Oncology meeting.

If physicians simply ask these smokers about smoking and advise them to quit, they are not likely to do so. However, if physicians actually assist patients—by giving them a counseling referral, a stop-smoking medication prescription or by following up—this increases the likelihood that a patient will quit.

Drs. Park and Lennes plan to develop a computerized risk-based personalized intervention to guide clinicians. “Even a brief intervention,” says Dr. Park, “whether by a physician, nurse or counselor, promotes smoking cessation.”

A Call for Screening High-Risk Current and Former Smokers

The United States Preventive Services Task Force (USPSTF) recommends annual low-dose CT screening for current and former smokers at high risk for lung cancer. High risk is defined as:

• individuals age 55-80
• cumulative smoking history of at least 30 pack-years
• must have smoked within the last 15 years
• asymptomatic

All persons undergoing screening should also receive smoking cessation counseling, and they must not have already-diagnosed lung cancer.

The Mass General Cancer Center, in collaboration with Thoracic Imaging, Pulmonary Medicine and Thoracic Surgery, offer a multidisciplinary approach to the detection and treatment of lung cancer.

For Patients

If you think you may be eligible for lung screening, contact your primary care physician to discuss it. Screening CTs should be ordered by your primary physician.

For Providers

To schedule a low dose CT scan, access the Radiology Order Entry system at http:// mghroe (within the Partners network) or http://www.mghroe.org (outside the Partners network), or call 617-724-9729.

For pulmonary nodule management, patients can be referred to the Lung Screening and Pulmonary Nodule Clinic by sending an email to LungScreeningClinic@partners.org.