Beyond the Scan: Understanding What Prevents Patients From Coming Back
An R&E Foundation grant helps researchers identify social factors influencing patient comfort, communication and long-term participation in lung cancer screening
Lung cancer remains the leading cause of cancer death in the U.S., despite the availability of an effective screening test that can detect the disease early and save lives. Adults aged 50 to 80 who meet eligibility criteria are recommended to undergo annual lung cancer screening (LCS) with low-dose computed tomography (LDCT). Yet adherence to recommended screening remains low, limiting the lifesaving potential of early detection. This challenged researchers to better understand the barriers that keep patients from returning for follow-up screening.
“The barriers to adherence are likely multifactorial with the screening test being unlikely to be the primary barrier for most patients,” said Jessica H. Porembka, MD, associate professor of radiology, Breast Imaging Division at UT Southwestern Medical Center, and vice chair of strategy and quality, and quality assurance medical director at Parkland Radiology, both in Dallas.
“The greatest challenges may be structural barriers tied to social determinants of health, such as insurance coverage, financial strain and access to care; and competing life priorities, particularly among patients facing socioeconomic instability,” Dr. Porembka continued. “However, it is possible that even small testing-related burdens, such as discomfort or anxiety, may contribute to non-adherence when layered on top of these broader challenges.”
Dr. Porembka and her team looked at the impact of testing-related health utilities and social determinants in her R&E Foundation Canon Medical System USA, Inc./RSNA Research Seed Grant.
Evaluating the Screening Experience
The purposes of the study were to assess testing-related morbidity for LDCT in LCS participants, including underserved and minoritized populations, and to assess the effects of LDCT service delivery location for an academic quaternary care health system compared with a county safety-net health system.
Dr. Porembka and colleagues used validated testing-related health surveys to learn more about the patient’s exam expectations, their social situation and their overall health. This included information on primary language spoken at home, marital status, transportation, housing stability, utilities, food security, employment, insurance and financial burden due to medical care.
The team also asked questions about the temporary effects of a test on quality of life and provided a validated assessment of physical, mental and social domains.
Patients underwent an LDCT exam and participated in a follow-up phone questionnaire within seven days.
Participants’ zip codes were used to match the area deprivation index (ADI) of their neighborhoods. ADI allows for rankings of neighborhoods by socioeconomic disadvantages at national and state levels. ADI includes factors for the theoretical domains of income, education, employment and housing quality.
Impact Factors on LCS Adherence and Patient Experience
In the analyses of patients following LDCT, there were surprising physical and emotional effects reported by patients overall.
“Participants generally reported minimal short-term burden associated with low-dose CT screening. Most individuals described little to no discomfort and only mild emotional effects, such as low levels of anxiety or concern,” Dr. Porembka said. “A meaningful minority of patients did report physical discomfort or pre-test anxiety, which aligns with what we and others have described as ‘scanxiety’.”
Dr. Porembka continued, “What was reassuring was just how well tolerated the exam was overall, even across a diverse population. At the same time, the persistence of measurable differences in experience across patient groups highlighted that testing-related burden is not evenly distributed.”
Among patients who completed screening, those screened at the county safety-net hospital reported different experiences related to pain, anxiety and overall screening compared with patients screened at the academic medical center.
“The most notable differences were that safety-net site participants reported experiencing significantly more pain or discomfort before and during the exam and more anxiety before the exam. These differences did not suggest that screening is poorly tolerated in either setting, but rather that patient experience varies based on healthcare context and underlying social factors,” Dr. Porembka said. “There was also a significant difference in knowledge of results, with fewer safety-net patients aware of their results at the time of survey, which may reflect structural differences in communication and access.”
The findings reflect the experiences of patients who completed screening and participated in follow-up surveys. Differences in patient experience appeared to be linked more strongly to broader social determinants of health than to race or ethnicity alone.
Surprisingly, while race and ethnicity were associated with differences in overall mental and physical health scores, the strongest predictors of testing-related burden were other social determinants of health including marital status, employment and insurance status.
“Participants who were uninsured or underinsured, unemployed or experiencing greater socioeconomic disadvantage reported higher testing-related burden and/or lower physical and mental health scores,” Dr. Porembka noted. “These findings reinforce that social context—more than any single demographic factor—plays a central role in how patients experience screening.”
These findings can help shift the focus of lung cancer screening programs toward a more patient-centered and equity-focused approach, according to Dr. Porembka.
“From a clinical and operational perspective, this could include targeted interventions to reduce anxiety and improve comfort during the exam; improved communication strategies, particularly around results and follow-up; and enhanced support systems in safety-net settings, including navigation and outreach,” Dr. Porembka noted. “Ultimately, improving adherence requires more than simply recommending screening. It requires making the screening experience accessible, acceptable and supportive for all patients.”
R&E Foundation Support Enables Understanding
The RSNA R&E Foundation grant was instrumental in enabling the team’s work, particularly in supporting the prospective, patient-reported outcomes design of the study.
“The funding allowed us to conduct detailed patient surveys, recruit participants across both university and safety-net healthcare systems and capture data on social determinants of health to provide a more nuanced understanding of disparities,” Dr. Porembka said. “This support made it possible to generate patient-centered evidence that would not typically be captured in routine clinical care. This evidence has laid the foundation for future work focused on improving screening adherence and reducing disparities.”
For More Information
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