Adherence to Surveillance in Lung Cancer Screening

 描述（由申请人提供）： 肺癌是退伍军人癌症相关死亡的主要原因，占VHA所有癌症的18.8%。如果早期发现，它是有可能治愈的，但肺部肿瘤进展迅速，大多数病例长期以来被诊断为太晚而无法治愈。根据国家肺筛查试验（NLST）的结果，随着低剂量CT扫描筛查的实施，情况可能会发生显著变化。卫生部副部长已下令在8个退伍军人管理局地点进行一个示范项目，作为退伍军人管理局肺癌筛查的试验，目前正在进行中。通过筛查改善退伍军人健康的潜力是巨大的，尽管肺癌筛查将带来相当大的挑战，需要立即关注。 坚持随访CT对有效的肺癌筛查至关重要。NLST通过确保对连续CT扫描的近乎完美的依从性证明了筛查的有效性。在VA筛查的有效性将取决于确保退伍军人的接受和继续遵守筛查协议。这将是一个挑战。高分辨率CT扫描可以发现许多可疑的肺结节，但很少会被证明是癌症。4 mm至8 mm之间的可疑结节需要通过每隔3-12个月重复CT扫描进行监测，持续2年，此后恢复年度筛查CT扫描。更频繁的监测、不确定结节的不确定意义以及假阳性结果的高发生率将使筛查进一步复杂化。然而，不遵守不确定结节的监测或年度CT扫描将损害筛查的有效性，并可能导致诊断和治疗的危险延误。 对退伍军人来说，坚持计划的随访，包括错过预约和患者退出，将是一个问题。由于肺癌筛查在VHA中广泛实施，并且在试验的对照环境之外，我们可以预期对这些筛查和监测方案的依从性低于筛查试验中的依从率，并且退伍军人将遇到继续依从的多重障碍。然而，数据，以指导努力，以确保高水平的坚持肺癌筛查的VHA是相当有限的。 迫切需要有关退伍军人对筛查的看法及其对这一过程的遵守情况的数据。然而，由于以前的研究集中在患者开始肺癌筛查的决定上， 当初步结果已知并且动机可能处于新的基础上时，人们对患者坚持和遵守持续监测的态度进行了评价。 我们提出了一个试点研究，以确定退伍军人在肺癌筛查中坚持随访筛查和监测的决定。我们将进行一项定性研究，包括对通过肺部CT进行肺癌筛查的退伍军人和参与其护理的临床工作人员进行访谈。本研究将实现以下2个目标：1）确定导致依从性和不依从性的因素。这将包括描述退伍军人对肺癌风险的看法和肺癌筛查的必要性，以及评估退伍军人关于肺癌筛查的决策和对随访和监测的坚持。 2)描述参与协调肺癌筛查和促进/确保参与已实施筛查的诊所的随访的临床工作人员的看法。 重点将是了解为保持退伍军人参与筛查和监测而采用的策略，以便为未来在VHA实施肺癌筛查提供信息。

 DESCRIPTION (provided by applicant): Lung cancer is the leading cause of cancer-related death in Veterans and accounts for 18.8% of all cancers in VHA. It is potentially curable if found early, but lung tumors progress rapidly and most cases have long been diagnosed too late for cure. The situation may change dramatically with the implementation of low- dose CT scan screening, pursuant to findings from the National Lung Screening Trial (NLST). The Undersecretary for Health has ordered a demonstration project at 8 VA sites as a trial of lung cancer screening in VA, which is currently ongoing. The potential to improve Veterans' health through screening is enormous, although lung cancer screening will come with considerable challenges that need immediate attention. Adherence to follow-up CT is essential to effective lung cancer screening. The NLST demonstrated the efficacy of screening by ensuring near perfect adherence to serial CT scans. The effectiveness of screening in the VA will depend on ensuring Veterans' acceptance and continued adherence to screening protocols. This will be challenging. High resolution CT scans will detect many suspicious lung nodules, but few will turn out to be cancer. Suspicious nodules between 4 mm and 8 mm call for surveillance through repeated CT scans at 3-12 month intervals for a period of 2 years, with resumption of annual screening CT scans thereafter. More frequent surveillance, the uncertain significance of indeterminate nodules, and the high incidence of false positive findings will further complicate screening. Yet, non-adherence to either the surveillance of indeterminate nodules or annual CT scans will compromise the effectiveness of screening and may result in dangerous delays in diagnosis and treatment. Adherence to planned follow-up, including missed appointments and patient drop-out, will be problematic for Veterans. As lung cancer screening is implemented on a wide scale in the VHA, and outside the controlled settings of trials, we can expect adherence to these screening and surveillance protocols to be lower than adherence rates in screening trials and that Veterans will encounter multiple barriers to continued adherence. However, data to guide efforts to ensure high levels of adherence to lung cancer screening in the VHA are quite limited. Data relating to Veterans' perceptions of screening and their adherence to the process are urgently needed. However, as previous research has focused on patients' decisions to initiate lung cancer screening, little attention has been given to patients' persistence and adherence to continued surveillance when initial results are known and motivations may be on a new footing. We propose a Pilot study to characterize the decisions veterans make regarding adhering to follow-up screening and surveillance in lung cancer screening. We will conduct a qualitative study involving interviews with veterans who have initiated lung cancer screening through lung CT and clinical staff who are involved in their care. This study will accomplish the following 2 objectives: 1) Identify factors that lead to adherence and non-adherence. This will include characterizing Veterans' perceptions of lung cancer risk and the need for lung cancer screening, and the evaluation of Veterans' decision-making regarding lung cancer screening and adherence to follow- up and surveillance. 2) Characterize perceptions of clinical staff who are involved in coordinating lung cancer screening and in promoting/ensuring engagement with follow-up in clinics that have implemented screening. The focus will be to gain an understanding of strategies that have been employed for keeping Veterans engaged with screening and surveillance in order to inform future implementation of lung cancer screening across VHA.