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PURPOSE Lung cancer screening (LCS) has less benefit and greater potential for iatrogenic harm among people with multiple comorbidities and limited life expectancy. Yet, such individuals are more likely to undergo screening than healthier LCS-eligible people. We sought to understand how patients with marginal LCS benefit conceptualize their health and make decisions regarding LCS. METHODS We interviewed 40 people with multimorbidity and limited life expectancy, as determined by high Care Assessment Need scores, which predict 1-year risk of hospitalization or death. Patients were recruited from 6 Veterans Health Administration facilities after discussing LCS with their clinician. We conducted a thematic analysis using constant comparison to explore factors that influence LCS decision making. RESULTS Patients commonly held positive beliefs about screening and perceived LCS to be noninvasive. When posed with hypothetical scenarios of limited benefit, patients emphasized the nonlongevity benefits of LCS (eg, peace of mind, planning for the future) and generally did not consider their health status or life expectancy when making decisions regarding LCS. Most patients were unaware of possible additional evaluations or treatment of screen-detected findings, but when probed further, many expressed concerns about the potential need for multiple evaluations, referrals, or invasive procedures. CONCLUSIONS Patients in this study with multimorbidity and limited life expectancy were unaware of their greater risk of potential harm when accepting LCS. Given patient trust in clinician recommendations, it is important that clinicians engage patients with marginal LCS benefit in shared decision making, ensuring that their values of desiring more information about their health are weighed against potential harms from further evaluations. Key words: lung cancer; lung cancer screening; qualitative methods: key informant/depth interviewing; cancer: screening; chronic care: comorbidity/multimorbidity; primary care issues: patient-centered care, INTRODUCTION Achieving mortality reduction with lung cancer screening (LCS) (1,2) while minimizing iatrogenic harm requires optimizing patient selection: screening people likely to benefit from early detection and not screening those [...]

Background: The Veterans Health Administration (VA) recommends lung cancer screening (LCS), including shared decision making between clinicians and veteran patients. We sought to characterize 1) veteran conceptualization of lung cancer risk and 2) veteran and clinician accounts of shared decision-making discussions about LCS to assess whether they reflect veteran concerns. Methods: We conducted qualitative interviews at 6 VA sites, with 48 clinicians and 34 veterans offered LCS in the previous 6 mo. We thematically analyzed transcripts, focusing on lung cancer risk perceptions, LCS decision making, and patient-clinician conversations. Results: Three themes emerged. 1) Veterans' lung cancer risk conceptualizations incorporated smoking, occupational hazards, and family history, whereas clinicians focused on smoking as the primary risk factor. 2) Veterans' risk perceptions were influenced by symptoms, recency of exposures, and anecdotes about smoking, cancer, and lung disease, leading some veterans to believe other risk factors outweighed smoking in increasing lung cancer risk. 3) Both veterans and clinicians described LCS conversations centered on smoking, with little mention of other risks. Limitations: Our findings may not reflect non-VA settings; for example, veterans may be more concerned about airborne hazards. Conclusions: While airborne hazards strongly influenced veterans' lung cancer risk conceptualizations, clinicians seldom addressed this risk factor during LCS shared decision making, instead focusing on smoking. Implications: In 2022, the US Congress highlighted the link between military toxic exposures and lung cancer risk, requiring VA clinicians to discuss these exposures and conferring automatic VA benefits to exposed veterans with cancer. There is a time-sensitive need for tools to support VA clinicians in discussing military hazards as a lung cancer risk factor, which may result in more engaging, less stigmatizing LCS shared decision-making conversations. Highlights: Veterans' conceptualizations of their lung cancer risk were multifactorial and sometimes ranked exposure to occupational airborne hazards and family history above smoking in increasing lung cancer risk. However, patient-clinician lung cancer screening (LCS) conversations were typically brief and focused on smoking, which could stigmatize patients and failed to engage veterans in discussing what mattered most to them in thinking about their lung cancer risk. These findings are of heightened importance in light of the 2022 Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act, which requires VA clinicians to discuss toxic military exposures and their relationship to lung cancer and other health conditions. Tools that help clinicians assess and incorporate multiple risk factors into discussions about lung cancer may better address patients' concerns and beliefs and lead to more engaging, less stigmatizing shared decision-making conversations about LCS. [ABSTRACT FROM AUTHOR]

Rationale: Achieving the net benefit of lung cancer screening (LCS) depends on optimizing patient selection. Objective: To identify factors associated with clinician assessments that a patient was unlikely to benefit from LCS (“LCSinappropriate”) because of comorbidities or limited life expectancy. Methods: Retrospective analysis of patients assessed for LCS at 30 Veterans Health Administration facilities from January 1, 2015 to February 1, 2021. We conducted hierarchical mixed-effects logistic regression analyses to determine factors associated with clinicians’ designations of LCS inappropriateness (primary outcome), accounting for 3-year predicted probability (i.e., competing risk) of non–lung cancer death. Measurements and Main Results: Among 38,487 LCS-eligible patients, 1,671 (4.3%) were deemed LCS-inappropriate by clinicians, whereas 4,383 (11.4%) had an estimated 3-year competing risk of non–lung cancer death greater than 20%. Patients with higher competing risks of non–lung cancer death were more likely to be deemed LCS-inappropriate (odds ratio [OR], 2.66; 95% confidence interval [CI], 2.32–3.05). Older patients (ages 75–80; OR, 1.45; 95% CI, 1.18–1.78) and those with interstitial lung disease (OR, 1.98; 95% CI, 1.51–2.59) were more likely to be deemed LCSinappropriate than would be explained by competing risk of non–lung cancer death, whereas patients currently smoking (OR, 0.65; 95% CI, 0.58–0.73) were less likely to be deemed LCSinappropriate, suggesting that clinicians over- or underweighted these factors. The probability of being deemed LCS-inappropriate varied from 0.4% to 74%, depending on the clinician making the assessment (median OR, 3.07; 95% CI, 2.89–3.25). Conclusion: Concerningly, the likelihood that a patient is deemed LCS-inappropriate is more strongly associated with the clinician making the assessment than with patient characteristics. Patient selection may be optimized by providing decision support to help clinicians assess net LCS benefit. [ABSTRACT FROM AUTHOR]