The role of screening expectations in modifying short–term psychological responses to low-dose computed tomography lung cancer screening among high-risk individuals
Introduction
Lung cancer is the most commonly diagnosed cancer in the world [1] and the third most common in the UK [2]. It is the most common cause of cancer death in the UK [2] and is a significant economic burden. The average 10-year survival is 5% [3], significantly lower than other cancers, and partly attributable to late diagnosis [4]. Lung cancer screening may provide a way to improve lung cancer outcomes.
Screening has been shown to reduce mortality and morbidity for other cancers [5], [6] and although a routine lung screening programme is not yet available, there is evidence that a single low-dose computerised tomography (LDCT) scan can detect tumours at early stages [7]. It is more sensitive than chest x-ray and enables detection of small, asymptomatic lung tumours [8], [9]. A number of screening trials for early detection of lung cancer have been or are being conducted [10]. The UKLS pilot trial used LDCT screening in a high-risk sample and showed that it is possible to detect cancer at an early stage and deliver potentially curative treatment to a large proportion of identified cases [11]. The US-based National Lung Cancer Screening Trial (NLST) showed a 20% reduction in lung cancer-related mortality in those at high risk when comparing LDCT screening with chest radiography [12]. The Dutch-Belgian lung cancer screening trial (NELSON) started in 2003 and the final results are yet to be published [13].
Studies of cancer screening in both general and high-risk populations have highlighted adverse psychological effects, in particular for abnormal, false positive or inconclusive results [14], [15]. Some short-term psychological effects may be expected because major diagnoses can be made, but the process of screening itself may have negative psychological effects [16]. Identifying patients at a greater risk of adverse psychological effects following LDCT for lung cancer screening is important so that screening communication strategies can be developed and implemented to prepare and support individuals. Within the UKLS pilot trial, levels of distress, anxiety and depression were within the normal range at both short- and long-term follow-up [17]. However, those who were called back for a follow-up scan showed higher levels of lung cancer distress than those who received a normal result, and those who were positive for an MDT referral (multidisciplinary team meeting indicating a major lung abnormality) reported higher distress than each of the other result groups [17]. Levels of distress in those requiring an MDT referral were approaching clinical thresholds in the short-term [17]. These individuals should be identified for additional psychosocial support [18], however there may be further factors that could identify who may benefit from more support. Indeed, a number of sociodemographic factors (being female, younger, a smoker, from a lower socioeconomic group, having experience of lung cancer, recruited from the Liverpool area, or not being married/cohabiting) have been shown to be associated with higher lung cancer distress in the UKLS sample [17]. Expectation of what the screening result will be is an additional factor that has not yet been explored within this sample that may identify those who could benefit from support interventions.
The Cue Adaptive Reasoning Account (CARA) suggests that individuals’ responses to screening tests depend partly on the congruence between anticipated and actual results [19]. The model proposes that those who receive unexpected or abnormal results will perceive the test result to be less accurate and more threatening than those who receive expected normal results [19]. Either unexpected or unfavourable information are thought to trigger more elaborate stimulus analysis than expected information, and the CARA model assumes that either negative or unexpected feedback that conflicts with pre-existing risk perceptions will serve as a cue to draw attentional resources for more elaborate stimulus processing [19]. It is not known whether, in the context of the UKLS pilot trial, congruence between expected and actual results affects perceived threat (indexed by concern) about or perceived accuracy of the result.
The present study aimed to examine the role of screening expectations in modifying psychological responses to screening results among high-risk individuals receiving LDCT lung cancer screening. Two main hypotheses were tested. Firstly, based on the CARA model, participants with expected negative (normal) results would perceive the result to be less concerning and more accurate than participants with other results. Secondly, based upon a potential additive effect, those with an unexpected abnormal scan result would perceive the result to be more concerning and less accurate than participants with other results.
Section snippets
Procedures
UKLS is a multicentre randomised controlled pilot trial to compare LDCT screening versus usual care, for the early detection of lung cancer, in high-risk individuals [11], [20], [21], [22].
A random sample of 247,354 50–75 year olds from six primary care trusts (PCTs; three from the Liverpool area and three from the Cambridge area) was invited to participate in the trial. Having completed a risk screening questionnaire [23] individuals identified as at high-risk of lung cancer were invited to
Sample
Fig. 1 shows study participation and response rate. Of a total of 4055 individuals randomised, 2028 were assigned to the intervention arm (LDCT scan) of which 1994 were scanned and included in the UKLS CT scan arm [22]. While 1994 participants in the intervention arm were scanned, 1653 completed questionnaires at both T0 and T1 and were included in the main psycho-social analysis [17], and after making further exclusions (details in Fig. 1), data from 1589 participants were in the final sample.
Discussion
In the UKLS pilot trial, individuals receiving an expected negative result perceived the test to be less concerning and more accurate than those receiving results that were unexpected or requiring follow-up, thus supporting the CARA model. A combined effect of both unexpected and abnormal results being more concerning and perceived as less accurate was not supported. There was however, a non-significant trend suggesting that those with unexpected abnormal results perceived them to be less
Conflict of interest
None.
Funding
National Institute for Health Research Health Technology Assessment programme, grant reference no. HTA 09/61/01. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of NIHR HTA, NHS or the Department of Health.
Contributions
CD: Data analysis, data interpretation and manuscript preparation.
AE: Data analysis, data interpretation and manuscript preparation.
BC: Trial statistician, data analysis, data interpretation and manuscript review.
JKF: Trial conception and design, data interpretation and manuscript review.
KB: Trial conception and design, data interpretation and manuscript review.
KJL: Data collection, data analysis, data interpretation, and manuscript preparation.
Informed consent
I can confirm all patient/personal identifiers have been removed or disguised so that the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
Acknowledgements
We would like to acknowledge the members of the UKLS Trial Management group whose contribution to the trial has been invaluable: David Baldwin, Anand Devaraj, Stephen Duffy, David Hansell and David Weller. We would also like to thank members of the UKLS trial team who assisted with data collection and administration of the trial: Fiona McRonald, Ghasem Yadegarfar and Bev Green. We also thank the trial participants who gave their time to take part.
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