INTRODUCTION

Close to 30% of all cancer deaths are due to lung cancer¹. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality^2,3. The National Comprehensive Cancer Network (NCCN) and US Preventive Services Task Force (USPSTF) guidelines recommend LCS in high-risk patients, as do a number of other professional organizations^4,5. The USPSTF recommends screening current and former smokers aged 55–80 years who have smoked ≥30 pack-years, and who quit within 15 years if a former smoker. Although there is limited information on the proportion of high-risk people who undergo LCS, Pinsky and Berg6 estimated, using National Lung Screening Trial (NLST) criteria, that 6.2% of adults over the age of 40 years would be eligible for screening⁶. Yet, the number of patients screened at most LCS centers is anecdotally very low. We recently reported that only 8% of primary care physicians reported referring most or all high-risk patients to an LCS center during the prior 12 months⁷. A number of barriers to utilization of LCS in high-risk patients exist.

We recently conducted a survey of primary care physicians (PCPs) and identified that concerns regarding the effectiveness of LDCT to prevent death from lung cancer, potential risks of LDCT, and costs of LDCT were of greatest concern to PCPs⁷. We also identified that few PCPs have a mechanism to identify patients eligible for screening in an automated fashion because of the way that tobacco exposure is documented in the electronic medical record (EMR). We reported that capturing a detailed tobacco exposure history in the EMR improved utilization of LCS and tobacco cessation services⁸. Novel systems approaches are needed to overcome barriers and improve utilization of LCS.

In addition to the life-saving potential of early detection of lung cancer, LCS offers additional value by serving as a point-of-entry into tobacco cessation counseling for current smokers. Integration of tobacco cessation into LCS programs is mandated by the Centers for Medicare Services (CMS). Although a recent small interview study reported that a large proportion of current smokers expressed that LCS might lower their motivation for tobacco cessation⁹, data from the National Lung Screening Trial and from the International Early Lung Action Program have shown that LCS stimulates tobacco cessation and that cessation rates are highest among patients with abnormal screening test results^10-12.

A far larger number of current smokers seek out tobacco cessation services, such as telephone quitlines, tobacco cessation groups, or individual counseling, compared with the number of smokers screened with LDCT. For example, Davis et al.¹³ reported that 363656 calls were made to state quitlines over a 12-week period in 2012. Yet, most tobacco cessation services offer no education on LDCT. Moreover, the vast majority of smokers who are eligible for LCS and seek out tobacco cessation services do not know about the potential benefits of LDCT¹⁴. Education by tobacco cessation counselors on the benefits of LDCT and where to be screened, may be an important way to improve adherence to LCS guidelines. Questions regarding the effectiveness of this approach warrant investigation. These include the feasibility of LCS education in a variety of tobacco cessation counseling settings (one-on-one counseling, group counseling, telephone quitlines, and online courses) and the type of education that is most effective, but still within the scope of practice of the counselor.

In this study, we explored the feasibility of training tobacco cessation counselors in a large health system to educate smokers, attending group tobacco cessation classes, on lung cancer screening within a large health system.

METHODS

Current smokers who attended at least one tobacco cessation group session, part of a four-session course entitled ‘Freedom from Tobacco,’ at one of two participating Kaiser Permanente medical centers in Southern California, were eligible to participate during May 2019. A total of 25 volunteer participants completed surveys at the end of the class after distribution of the survey by tobacco cessation counselors. No class participant declined to complete a survey. Anonymous surveys were completed on paper forms and completed surveys were collected and mailed to City of Hope for analysis by study staff. Participants were not compensated for survey completion. This study was reviewed and approved by the Kaiser Permanente Institutional Review Board. A waiver of informed consent was obtained as protected health information was not collected as part of the survey.

RESULTS

We included 25 smokers in the analysis. Their sociodemographics are summarized in Table 2. Most participants (72%) were aged 55–80 years, the age range for LCS eligibility. The median pack-year history of smoking was 40, and 64% of participants had a smoking history of 30 pack-years or greater. The population was racially/ethnically diverse. Participants had varied educational backgrounds, with 32% of participants completing some or all of high school as their highest level of education. Four participants (16%) reported that they had previously undergone lung cancer screening.

Overall, the intervention was well received. The median score for the understanding of all components of the intervention was 5 (‘completely understand’). Most participants (92%) felt that the information provided about LCS was the right amount, while the remaining few participants felt that there was too little information. In addition, most participants (88%) were satisfied with the answers that the cessation counselors provided to questions asked during the session. No survey responder provided any specific comments about their experience or suggestions for improvement on the survey in response to the open-ended questions asked about the educational intervention.

We re-analyzed the study data after restricting our analysis to 21 participants who responded that they had never undergone lung cancer screening. Results were similar to the over group with regards to median score for understanding of the components of the intervention (5), the amount of information provided during the intervention (90% reported the right amount of information provided), and satisfaction with answers to questions asked (86% very or somewhat satisfied).

DISCUSSION

The study suggests that it is feasible to train tobacco cessation counselors to educate smokers, attending group tobacco cessation counseling classes, about LCS. Education provided in this study was both understood and well received by the large majority of smokers surveyed. This is the first study to our knowledge investigating the feasibility of training tobacco cessation counselors to educate smokers about LCS. There is considerable effort to incorporate tobacco cessation into lung cancer screening programs^12,15. In the United States, tobacco cessation services are required for sites in order for reimbursement to be given by the Center for Medicare and Medicaid Services (CMS). A number of studies have been published evaluating different modalities of tobacco cessation counseling for patients undergoing LCS^16-20.

While use of LCS as a teachable moment for tobacco cessation is important, far less has been known about use of tobacco cessation as a teachable moment for LCS. A far larger number of smokers seek out tobacco cessation services than LCS^7,13. While educating smokers on LCS, which is recommended by the U.S. Preventive Services Task Force and the American Cancer Society, may be well-intentioned, there are several issues that should be clarified. Again, our study shows that it is feasible for tobacco cessation counselors to administer education regarding lung cancer screening. While the U.S. Public Health Service recommends tobacco cessation counseling training for all healthcare professionals, the educational and training background of cessation counselors providing most cessation services can vary²¹. There are other important issues that need additional investigation, including what kind of LCS education and how much information should be administered. LCS education can be given in person, by telephone, or through video or online content. The format of education and length of the educational intervention may also depend on the type of cessation counseling that is administered, i.e. one-on-one, group counseling, phone counseling, or online counseling. Most importantly, the effect of the educational intervention on utilization of LCS has not been determined. It is also unclear whether such educational intervention has an effect on abstinence from tobacco. Several studies have shown that participating in LCS does not lead to increased smoking rates, and may lead to increased smoking cessation rates^11,22, but it is not known whether LCS education affects tobacco cessation rates in those seeking tobacco cessation services.

CONCLUSIONS

We found that it is feasible to train tobacco cessation counselors to deliver an educational intervention, and tobacco cessation counseling may be an opportune time to educate smokers about the benefits of LCS.