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Clinical Investigations: LUNG CANCER |

Do Australian Family Physicians Screen Smokers for Lung Cancer?* FREE TO VIEW

Michael J. Sladden, MB ChB, MAE; Jeanette E. Ward, MB BS, MHPEd, PhD
Author and Funding Information

*From the Division of Community and Rural Health (Dr. Sladden), University of Tasmania, Hobart, Australia; and the Needs Assessment and Health Outcomes Unit (Dr. Ward), Central Sydney Area Health Service, Sydney, Australia.



Chest. 1999;115(3):725-728. doi:10.1378/chest.115.3.725
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Published online

Study objectives: To determine family physicians’ perceptions of the effectiveness of chest radiographs (CXRs) in reducing premature mortality from lung cancer and their self-reported levels of screening asymptomatic heavy smokers.

Design: National postal survey of 1,271 family physicians, obtaining 855 completed questionnaires (67% response rate).

Setting and participants: Random sample of Australian family physicians.

Measurements and results: One in five (n = 169, 20%) indicated that an annual CXR was an effective screening test. Older physicians were significantly more likely to hold this view (p < 0.0001). Nearly 25% (n = 190, 22.5%) reported that they recommend an annual CXR as a screening test for asymptomatic heavy smokers. Three variables independently predicted such a practice: increasing physician age (p = 0.0085), being in solo practice (p = 0.0068), and the aforementioned belief in its effectiveness (p < 0.0001).

Conclusions: A substantial minority of family physicians recommends an annual CXR as a screening test despite contradictory evidence from randomized controlled trials. These significant variations in the absence of epidemiologic evidence invite further research to develop effective, efficient, and affordable preventive care in family practice.

Abbreviations:ACS = American Cancer Society; AMA = Australian Medical Association; CI = confidence interval; CXR = chest radiograph; df = degrees of freedom; RACGP = Royal Australian College of General Practitioners

The screening of asymptomatic individuals for lung cancer using chest radiographs (CXRs) is not recommended because evidence from randomized controlled trials indicates that early detection does not improve patient outcome.1,,2,,3,,4 However, recent studies by Strauss and colleagues5,,6 have suggested that annual CXRs should be performed, for example, on individuals at high risk for lung cancer and on asymptomatic heavy smokers. The argument posed by these authors in support of screening is that periodic CXRs lead to “clinically meaningful improvements in stage distribution, resectability, and survival in lung cancer”6 and “could result in a dramatic reduction in lung cancer mortality.”5However, they comment that “mortality reductions have not been demonstrated.”6

Little is known about the beliefs of family physicians concerning screening for lung cancer. In a survey conducted by the American Cancer Society (ACS) in 1984, 44% of family physicians recommended screening CXRs for asymptomatic patients.7An identical survey performed by the ACS in 19898 indicated that this proportion had remained constant at 44%. No national studies have been performed in Australia. Therefore, we conducted this study to assess family physicians’ perceptions of the effectiveness of CXRs in reducing premature mortality from lung cancer and, given recent international interest, their self-reported levels of screening asymptomatic heavy smokers.

Family Physician Sample and Survey Administration

In May 1996, a cover letter, questionnaire, and reply-paid envelope were mailed to a national random sample of 1,271 family physicians, as described fully elsewhere.9 Standardized response-aiding strategies were used to follow up nonresponders.

Questionnaire Content

Respondents were asked whether screening with an annual CXR was effective in reducing premature deaths from lung cancer. They also were asked whether they recommended annual CXRs as a screening test for asymptomatic heavy smokers.

Next, respondents rated the usefulness of the Royal Australian College of General Practitioners (RACGP) Guidelines for Preventive Activities in General Practice,10 which were available at the time of the survey. These guidelines recommend against screening for lung cancer by CXR. The final section of the questionnaire included eight sociodemographic questions.

Data Analysis

Data were entered, and descriptive, cross-tabulation, and logistic regression analyses were performed with computer software (SPSS for Windows 7.1; SPSS, Inc; Chicago, IL). We performed a logistic regression using 13 variables (respondent’s gender, age, State, practice location [metropolitan or rural], practice type[ group or solo], hours worked [full or part time], membership of a Division of General Practice [family medicine], RACGP affiliation, Australian Medical Association [AMA] membership, awareness of the RACGP guidelines, personal history of cancer, family history of cancer, and personal history of smoking) to identify independent predictors of screening effectiveness. A further variable (belief that CXR is an effective screening test) was included in a second regression analysis to identify predictors of self-reported screening.

We obtained a 67% response rate, resulting in 855 usable questionnaires (529 were men and 326 were women). The response rate for women (75%) was significantly higher than that for men (63%) (χ2 = 15.4, 1 degree of freedom [df], p < 0.001) but was not influenced by any other variable.9

Overall, 169 respondents (20.0%; 95% confidence interval [CI], 17 to 23) indicated that an annual CXR was an effective screening test and 382 (45.3%; 95% CI, 42 to 49) indicated that it was ineffective, whereas 293 (34.7%; 95% CI, 31 to 38) were unsure. The only significant independent predictor of believing that CXR was effective was increasing age (Wald χ2 = 75.7, df = 1, p < 0.0001), with older family physicians of either gender more likely to believe incorrectly that mortality from lung cancer can be reduced by CXR.

One hundred ninety respondents (22.5%; 95% CI, 20 to 25) reported that they recommend an annual CXR as a screening test for asymptomatic heavy smokers, whereas 653 (77.5%) did not. Three variables independently predicted such a practice: increasing physician age (χ2 = 11.7, df = 3, p = 0.0085), being in a solo practice (χ2 = 7.3, df = 1, p = 0.0068), and belief that an annual CXR is effective (χ2 = 137.8, df = 1, p < 0.0001) (Table 1 ).

The RACGP guidelines were rated as very or somewhat useful by 281 respondents (33%), but 446 respondents (52.2%) were unable to recall the guidelines. Logistic regression analysis demonstrated only one independent predictor of guidelines awareness, RACGP membership. RACGP members were three times more likely to be aware of the guidelines than nonmembers (adjusted odds ratio = 3.2; 95% CI, 2.3 to 4.3;χ 2 = 57.0; df = 1; p < 0.0001). Univariate analysis suggested that older physicians were likely to be less aware of RACGP guidelines (Waldχ 2 = 9.9, df = 3, p < 0.019), but this ceased to be significant after logistic regression analysis. Similarly, logistic regression analysis indicated that RACGP members were three times more likely to find the guidelines useful than nonmembers (adjusted odds ratio = 2.9; 95% CI, 2.2 to 3.9;χ 2 = 48.4; df = 1; p < 0.0001). The age of the physician was not associated with the belief that the guidelines were useful. Awareness of the guidelines did not independently predict knowledge or self-reported practices of lung cancer screening.

Our results show that a substantial minority of Australian family physicians (approximately one in five) incorrectly believes that an annual CXR is effective in reducing premature mortality from lung cancer, and almost 25% recommend annual CXR screening for asymptomatic heavy smokers. This is despite good evidence that better outcomes will not ensue.1,,2 Interestingly, this proportion is less than that demonstrated in two ACS surveys7,,8 in which 44% of family physicians indicated that they have performed screening CXRs.

Not surprisingly, the belief that screening is effective predicts the self-reported use of the test. Family physicians in solo practice were more likely to recommend screening, perhaps because the clinical isolation of their practice reduces educational opportunities and peer interaction. As already known for other aspects of clinical practice, physician age was a significant independent predictor of this belief.11 It is not known why older physicians are more likely to recommend screening. Possibly they are more reticent about incorporating evidence-based medicine into their clinical practice than are their younger colleagues, or they have less of an understanding of clinical epidemiology. Perhaps they do not yet trust the guidelines. We found only limited evidence from our study that older physicians were less aware of the RACGP guidelines.

Awareness of the RACGP guidelines did not predict physician beliefs or recommendations about CXR screening. These guidelines have been revised every 2 years since their conception in 1990,12 although the recommendation against lung cancer screening has not altered. RACGP members were more likely than nonmembers to be aware of the guidelines and to find them useful. The popularity and overall awareness of the guidelines was low, possibly because the guidelines are not distributed free of charge to all general practitioners but have to be purchased from the RACGP ($6.00 US). No other guidelines concerning lung cancer screening were available in Australia at the time of the study. It appears that the lack of evidence supporting the effectiveness of lung cancer screening has not yet been communicated adequately to physicians.

There are serious implications for lung cancer screening of smokers. It is possible that high-risk patients will perceive that early detection of lung cancer through annual CXR will result in a quick and easy cure, and this could result in postponing attempts at smoking cessation. Further, there is the potential for causing anguish and psychological harm to patients whose annual CXRs give false-positive or false-negative results. Our findings suggest that clinical time and resources are being diverted into screening for which there is insufficient evidence of effectiveness. The financial costs of this ineffective intervention to the health care system are likely to be high, and these resources could be better spent on issues of proven benefit. There is a widespread perception that family physicians work under considerable time pressure and that these time constraints detract from their capacity to provide optimal preventive care.13It is probable that time could be made available to perform effective interventions, such as smoking cessation advice, if ineffective interventions, such as annual screening CXRs, were abandoned.14

The absence of rigorously acquired evidence in support of the effectiveness of lung cancer screening in primary care does not appear to have been communicated adequately to Australian family physicians, despite a national commitment to evidence-based preventive care.15 These significant variations in the absence of epidemiologic evidence invite further research to understand and develop preventive care in family practice that is effective, efficient, and affordable, a common goal for many developed countries.

A substantial minority of Australian family physicians recommends annual CXR as a screening test despite a lack of compelling evidence that a better outcome will ensue. These significant variations in the absence of epidemiological evidence invite further research to develop effective, efficient, and affordable preventive care in family practice.

The authors have no financial involvement in any organization with a direct financial interest in the subject discussed in this manuscript.

Supported by funding from The Commonwealth Department of Human Services and Health, Australia.

Correspondence to: Dr. Michael J Sladden, Div of Community and Rural Health, PO Box 252-33, University of Tasmania, Hobart, Tasmania 7001, Australia; e-mail: M.Sladden@utas.edu.au

Table Graphic Jump Location
Table 1. Independent Predictors of Family Physicians Recommending Annual CXR Screening for Lung Cancer

We thank the family physicians who participated in our study with no financial incentive, Phoebe Holt for contributing to the design of the questionnaire, and Tracey Bruce for diligent survey administration. The Royal Prince Alfred Hospital Ethics Committee approved this study.

Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical preventive care. Ottawa, Canada: Canada Communication Group 1994; 780–786.
 
US Preventive Services Task Force.. Guide to clinical preventive services 2nd ed.1996,135-139 Williams and Wilkins. Baltimore, MD:
 
American Cancer Society.. Report on the cancer-related health checkup: cancer of the lung.CA Cancer J Clin1980;30,199-207. [CrossRef]
 
American Cancer Society... Guidelines for the cancer-related health checkup: an update. 1993; American Cancer Society. Atlanta, GA:.
 
Strauss, GM Measuring effectiveness of lung cancer screening: from consensus to controversy and back.Chest1997;112,216S-228S. [PubMed]
 
Strauss, GM, Gleason, RE, Sugarbaker, DJ Screening for lung cancer: another look; a different view.Chest1997;111,754-768. [PubMed]
 
American Cancer Society.. Survey of physicians’ attitudes and practices in early cancer detection.CA Cancer J Clin1985;35,197-213. [PubMed]
 
American Cancer Society.. 1989 survey of physicians’ attitudes and practices in early cancer detection.CA Cancer J Clin1990;40,77-101. [PubMed]
 
Ward, J, Bruce, T, D’Este, C, et al Labour-saving strategies to increase response rates in general practice surveys.Aust N Z J Public Health1998;22,394-396. [PubMed]
 
Guidelines for Preventive Activities in General Practice. 3rd ed. Sydney: Royal Australian College of General Practitioners, 1994.
 
Ward, J, Young, J, Sladden, M Australian general practitioners’ views and use of tests to detect early prostate cancer.Aust N Z J Public Health1998;22,374-380. [PubMed]
 
Guidelines for Preventive Activities in General Practice. 1st ed. Sydney, Australia: Royal Australian College of General Practitioners, 1990.
 
Ward, J, Gordon, J, Sanson-Fisher, R Strategies to improve preventive care in general practice.Med J Aust1991;154,523-530. [PubMed]
 
Ward, J Concluding commentary: challenges and choices in health promotion in general practice.Behav Change1994;11,186-188
 
National Health, and Medical Research Council. Preventive interventions in primary health care–cardiovascular disease and cancer. Canberra, Australia: Australian Government Publishing Service, 1997.
 

Figures

Tables

Table Graphic Jump Location
Table 1. Independent Predictors of Family Physicians Recommending Annual CXR Screening for Lung Cancer

References

Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical preventive care. Ottawa, Canada: Canada Communication Group 1994; 780–786.
 
US Preventive Services Task Force.. Guide to clinical preventive services 2nd ed.1996,135-139 Williams and Wilkins. Baltimore, MD:
 
American Cancer Society.. Report on the cancer-related health checkup: cancer of the lung.CA Cancer J Clin1980;30,199-207. [CrossRef]
 
American Cancer Society... Guidelines for the cancer-related health checkup: an update. 1993; American Cancer Society. Atlanta, GA:.
 
Strauss, GM Measuring effectiveness of lung cancer screening: from consensus to controversy and back.Chest1997;112,216S-228S. [PubMed]
 
Strauss, GM, Gleason, RE, Sugarbaker, DJ Screening for lung cancer: another look; a different view.Chest1997;111,754-768. [PubMed]
 
American Cancer Society.. Survey of physicians’ attitudes and practices in early cancer detection.CA Cancer J Clin1985;35,197-213. [PubMed]
 
American Cancer Society.. 1989 survey of physicians’ attitudes and practices in early cancer detection.CA Cancer J Clin1990;40,77-101. [PubMed]
 
Ward, J, Bruce, T, D’Este, C, et al Labour-saving strategies to increase response rates in general practice surveys.Aust N Z J Public Health1998;22,394-396. [PubMed]
 
Guidelines for Preventive Activities in General Practice. 3rd ed. Sydney: Royal Australian College of General Practitioners, 1994.
 
Ward, J, Young, J, Sladden, M Australian general practitioners’ views and use of tests to detect early prostate cancer.Aust N Z J Public Health1998;22,374-380. [PubMed]
 
Guidelines for Preventive Activities in General Practice. 1st ed. Sydney, Australia: Royal Australian College of General Practitioners, 1990.
 
Ward, J, Gordon, J, Sanson-Fisher, R Strategies to improve preventive care in general practice.Med J Aust1991;154,523-530. [PubMed]
 
Ward, J Concluding commentary: challenges and choices in health promotion in general practice.Behav Change1994;11,186-188
 
National Health, and Medical Research Council. Preventive interventions in primary health care–cardiovascular disease and cancer. Canberra, Australia: Australian Government Publishing Service, 1997.
 
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