Lung cancer screening: focus on some psychological aspects, preliminary results| Tabaccologia

Abstract

Introduction: Over the past decades, the global scientific community has worked to establish common protocols for lung cancer screening (LCS). Few studies have examined the psychological aspects relevant to adherence to LCS or smoking cessation programs.

Materials and methods: Participants in the two pilot studies on LCS conducted in the Florence area were asked to complete questionnaires to assess their perception of their risk of developing lung cancer, beliefs associated with LCS, time perspective, an indicator of an individual’s tendency to consider and/or value the present/future consequences of their actions, and motivation to change smoking behavior.

Results: The results indicate that most of the smokers enrolled in this study were considering quitting smoking, and about 60% expressed their interest in referral to a Smoking Cessation Center (SCC). Current smoking status did not appear to be a barrier to participation in the LCS. Smokers showed less fatalistic present orientation than the Italian population. Smokers who refused to be sent to the SCC showed a higher hedonistic present orientation, an indicator of pleasure-seeking tendencies. Finally, smokers who were sent to the SCC showed greater dissatisfaction between their current (smoker) and desired (ex-smoker) status.

Conclusion: To our knowledge, this is the first study to carry out a psychological assessment of LCS participants in the Italian context. The data collected will allow communication aimed at increasing LCS adherence and, by knowing the possible barriers to participation, it will be possible to provide the necessary tools to overcome these barriers. The high percentage of smokers who agreed to be sent to the SCC confirms that participation in the LCS can be a “learning moment” to talk about smoking cessation and provide professional support for the cessation pathway.

Introduction

In most Western countries, including those in Europe and the United States, approximately 50% of cancer deaths and 40% of new cases are potentially preventable through risk factor intervention [1]. In 2022, lung cancer was the second most commonly diagnosed cancer in Italy in men (15% of male cases) and the third in women (6% of female cases). Furthermore, the incidence of lung cancer was estimated to increase by 1.6 percent in men and 3.6 percent in women by 2020 [1].

These data are consistent with the trend in smoking habits, which is decreasing in men and increasing in women [2]. Over the past few decades, the global scientific community has worked to define common protocols for implementing lung cancer screening (LCS). In particular, pilot studies have focused on defining medical aspects such as the choice of the gold standard examination (chest X-ray vs. low-dose computed tomography), the time interval between examinations, and the identification of the target population. Few studies have examined in depth the psychological aspects relevant to LCS, although some psychological characteristics appear to influence all phases of screening, from adherence to the positive and negative consequences of participation. Some studies have examined the risks and benefits associated with the LCS [3,4]. The results show that the main barriers to participation are the desire not to know about a possible disease, as a diagnosis of lung cancer is perceived as a “death sentence” [4]. Furthermore, smokers, the target population for screening, experience social stigma, which triggers to a belief that they cannot intervene in their situation and the fear of being blamed for their addiction [5]. Additionally, practical barriers such as logistical issues or those related to the cost of screening have also been highlighted [4]. Other studies have focused on the psychological consequences of receiving screening results. During LCS, a variety of situations may occur (negative result, positive result, false-positive result, identification of incidental findings) that impact psychological health in different ways. A positive or false-positive result appears to lead to an increase in time-limited negative psychological outcomes (e.g., increased anxiety and depressive symptoms) [6]. Moreover, the receipt of a false-positive result appears to reduce adherence to screening programs among smokers and ex-smokers, probably because of the emotional impact of having engaged in behavior that could lead to a lung cancer diagnosis [7]. Finally, the effect of different possible screening outcomes on smoking behavior remains unclear. In the National Lung Screening Trial (NLST) study, screening results were found to be a significant predictor of subsequent smoking behavior, and the likelihood of continued smoking was inversely associated with the severity of the diagnosis received [8]. In contrast, in the NELSON study [9], there was no significant association between smoking cessation and screening test results [10]. Moreover, receiving a negative result seems to create an unrealistic sense of reassurance, known as the “health certificate effect”, which would lead to continued or even resumed smoking [10].

This study aims to investigate some psychological aspects that might contribute to adherence to screening or smoking cessation programs.

Materials and methods

The Institute for the Study, Prevention and Oncology Network (ISPRO) is currently coordinating two pilot studies on lung cancer screening (CCM and ITALUNG2). The protocol of the studies combines the screening program with smoking cessation programs.

A total of 1270 people (335 in Florence, 100 in Massa, 250 in Milan, 335 in Pisa, 250 in Turin), aged 55 to 75 years, heavy smokers or former heavy smokers (with at least 25 pack-years), who have quit smoking for less than 10 years are included. Participants will receive two low-dose CT scans one year apart, with possible further evaluation in case of a positive result (identification of lung nodules with a risk of malignancy greater than 1%) of the CT scan. Recruited smokers will be offered access to a smoking cessation program at a local smoking cessation center (SCC).

In the Florence area, 299 people were recruited between October 2022 and August 2023. Of these, 271 (90.6%) were smokers (53.1% female; mean age: 63.3 years; 46.2 pack-years) and 28 (9.4%) were ex-smokers (32.1% female; mean age: 64.0 years; 50.8 pack-years). 147 (54.2%) smokers expressed interest in starting a smoking cessation program and were referred to a SCC.

Specifically, all participants in the Florence area were asked to complete the following questionnaires:

1. Lung Cancer Screening Health Belief Scales (LCSHBS [11]). A self-report questionnaire with 35 items divided into four subscales:
   1. perceived risk of developing lung cancer;
   2. benefits associated with participation in the LCS;
   3. perceived barriers to participation in the LCS, and
   4. self-efficacy defined as the ability to take action to participate in LCS.

For the first three scales, the response mode is a 4-point Likert scale ranging from “strongly disagree“ to “strongly agree“. For the self-efficacy subscale, a 4-point Likert scale ranging from “not at all confident” to “very confident”.

1. Stanford Time Perspective Inventory – Short Form: Italian translation (STPI-SF, [12]). A self-report questionnaire consisting of 22 items divided into three subscales that assess an individual’s tendency to consider and/or value the present/future consequences of one’s actions:
   1. hedonistic present;
   2. fatalistic present;
   3. future.

Previous studies have shown that people with a hedonistic present orientation tend to be self-indulgent and to fulfil their wishes while people with a fatalistic present orientation believe that their lives are dominated by external forces. Finally, future-oriented people show great concern about the consequences of their actions. The response mode is a 5-point Likert scale ranging from “strongly disagree” to “strongly agree”.

Eligible smokers were also asked to complete:

1. Mini MAC-T (revised from the MAC-T questionnaire [13] adapted from Bimbo and Marsili). A 7-item self-report questionnaire. Tracks the smoker’s motivational profile by identifying the stage of change (precontemplation, contemplation, preparation and action) according to the transtheoretical model of behavior change developed by Prochaska and Di Clemente [14]. According to the model, those in the precontemplation stage have no intention of changing their behavior; in the contemplation stage, the pleasure of smoking is still very high, but worries are beginning to appear; the preparation stage includes those who have decided to quit smoking; and finally, those in the action stage have begun the journey of quitting cigarette smoking. In addition, the questionnaire assesses the level of internal fracture (between the perception of the current and desired state and the related worries) and self-efficacy, defined as the ability to take action to quit smoking.

All eligible subjects received the questionnaires when they were offered participation in the screening program. Those who chose to participate in the screening program and proceed with the psychological evaluation returned the completed questionnaires to the health care providers involved in the program.

Results

Psychological Questionnaire Response

One hundred sixty-five (55.2%) screening participants completed the psychological questionnaires.

There were no significant differences between the two groups with regard to gender, age, smoking status and pack-years. Questionnaire respondents had a higher level of education (diploma or higher) than non-respondents (p < .01; Table 1).

Of the smokers who responded to the questionnaires, 89 (60.5%) agreed to be referred to a SCC.

Lung Cancer Screening Health Belief Scales: Beliefs about Lung Cancer Screening in Italy

The respondents did not report any particular barriers to participation in screening. The possible reasons that could have led them to postpone the CT examination, which had the highest score, were the need to pay for the examination (26.1% of people), fear of the result of the examination (15.8% of people), and the current absence of lung disease or symptoms (10.3% of people). Current smoking was not considered a barrier to screening (3.6% of people). In contrast, the majority of respondents believed that participating in LCS would help detect lung cancer at an early stage (97.6% of people) and allow them to reduce the risk of dying from a lung cancer diagnosis (80.6% of people).

When comparing smokers who agreed (Smokers Yes_SCC) or refused (Smokers No_SCC) to be referred to the SCC, there were no significant differences in any of the subscales assessing beliefs about participating in LCS (Table 2).

Stanford Time Perspective Inventory: present or future orientation?

Compared to the Italian population, smokers tend to be less fatalistic (mean smokers’ score: 15.0; Italian population score range: 15.6-22.9). In contrast, the fatalistic present orientation of ex-smokers is average (mean smokers’ score: 15.9; Italian population score range: 15.6-22.9). Smokers’ future orientation and hedonistic present orientation (mean future orientation score: 31.8, Italian population range: 25.9-35.7; mean score hedonistic present orientation: 21.7; Italian population range: 14.5-22.7) and ex-smokers (mean future orientation score: 32.6, Italian population range: 25.9-35.7; mean score hedonistic present orientation: 21.4; Italian population range: 14.5-22.7) is in line with that of the general population. The results are shown in Table 3.

The comparison between Yes_SCC and No_SCC smokers shows no significant differences in the subscales related to fatalistic present and future orientation. In contrast, No_SCC smokers show significantly higher hedonistic present orientation (p=0.04; Table 2).

Mini-MAC-T: Assessment of the stage of change in smokers

The results of the Mini-MAC-T questionnaire show that of the 147 smokers who responded, 7.5% were in the precontemplation stage, 35.4% were in the contemplation stage, 12.2% were in the preparation stage, and 2.0% were in the action stage. 6.1% of smokers were simultaneously in precontemplation and contemplation, while 6.1% were simultaneously in precontemplation and preparation.

A comparison of Yes_SCC and No_SCC smokers showed that twice as many No_SCC smokers were in precontemplation stage (5.6% vs. 10.3%), whereas there were significantly more smokers in a contemplation stage in the Yes_SCC group (40.4% vs. 27.6%; Table 4).

Furthermore, there were no significant differences between the two groups with regard to internal fracture (worry) and self-efficacy scores, while the Yes_SCC smokers showed significantly more internal fracture (importance) than the No_SCC smokers (p<0.01).

Discussion

To the best of our knowledge, this is the first study to have conducted a psychological assessment of lung cancer screening participants in the Italian context.

The results indicate that most of the smokers included in this study were considering changing their smoking status. Of these, approximately 60% felt that they needed professional support in their quit attempt. Furthermore, current smoking status did not appear to be a barrier to participation in lung cancer screening. On the contrary, respondents reported the need to cover the cost of the CT scan as the most important hypothetical barrier to participation in screening, although there was no cost to cover in this study. The smokers included in this study showed a lower fatalistic present orientation than the Italian population.

Furthermore, No_SCC smokers show a greater orientation towards the hedonistic present, an indicator of a greater pleasure-seeking tendency and a more indulgent attitude towards this behavior. Finally, Yes_SCC smokers showed greater dissatisfaction between their current (smoker) and desired (ex-smoker) status.

The data collected allows this information to be used for effective communication aimed at increasing adherence to the screening program. Although most participants did not identify any particular barriers that might cause them to avoid adherence to lung cancer screening, some possible themes emerge that should be considered when trying to increase adherence to this screening program.

Conducting the evaluation in the Italian context is necessary because some of the barriers highlighted in the US studies (e.g., health insurance issues) may not be present in the Italian context. Although our results do not indicate current smoking status as a possible barrier to screening participation, it is important to consider that the assessment of smokers’ motivation to change showed that more than 63% were considering changing their smoking status in the short term. In contrast, less than 10% of respondents were in the precontemplation stage. It would be necessary to investigate whether being in a precontemplation stage also affects participation in screening programs. Indeed, smokers in this stage of change may perceive higher levels of stigma and be pressured to avoid situations in which they might feel judged for their behavior [15].

The high percentage of smokers who agreed to be referred to a SCC confirms that participation in lung screening can be a “teachable moment” to discuss smoking cessation and to refer those who felt they needed professional support to SCCs. However, it is important not to send the message that supporting cessation is the only way forward; in fact, most smokers who succeed in quitting do so without the need for professional support or as a simple consequence of a serendipitous event [16]. Simply participating in a lung screening program or receiving a positive or false-positive CT scan result could be considered serendipitous events. Conversely, receiving a negative CT scan result could lead to a “health certificate effect” and induce smokers not to change their smoking behavior.

Previous studies have shown that the receipt of CT scan results has an impact on screening uptake and smoking behavior. Further studies are needed to determine whether the timing of test result delivery should be considered a “teachable moment” to be used to reiterate the brief advice to smokers to motivate them to implement a quit attempt.

The results regarding the assessment of participants’ time orientation confirm some data already reported in the literature. Indeed, there is a negative correlation between fatalistic attitudes and the adoption of healthy behaviors. The responding smokers were found to be less fatalistic than the general population, and in fact they were all people who decided to be screened for lung cancer and most were considering changing their smoking status.

It will be necessary to continue to follow the study participants to see how many of the referrals to the SCC had a positive outcome resulting in the initiation of a smoking cessation pathway and how many changed their smoking status.

Limits

The present study has some limitations that need to be considered when interpreting the results. As the target population of lung cancer screening consists of both smokers and ex-smokers, it would be necessary to increase the number of ex-smokers surveyed. In addition, it would be necessary to administer the questionnaires also to those who voluntarily decided not to participate in the screening program after receiving an invitation in order to achieve effective communication aimed at the entire target population of lung cancer screening. Finally, the results should be considered preliminary because there are no data on the actual initiation of a smoking cessation program at SCCs or on the monitoring of smoking behavior after receipt of the CT scan result or 6 months after enrollment in the study.

Conclusions

The data collected from this first study on the psychological evaluation of LCS participants in the Italian context will allow for more effective communication aimed at increasing motivation and consequently adherence to the LCS. The knowledge of the psychological evaluation can be useful in identifying possible barriers to participation, thus providing the necessary tools to overcome such barriers. Finally, participation in the LCS with the offer of assistance from the Anti-Smoking Center can be a “learning moment” to talk about smoking cessation and provide professional support for the cessation process.

Figures and tables

References

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