Perspectives of family physicians towards access to lung cancer screening for individuals living with low income – a qualitative study

It is estimated that one in 15 Canadians will be diagnosed with lung cancer over their lifetime, making it one of the most frequently diagnosed cancers amongst Canadians [1]. Lung cancers are usually detected at an advanced stage (stage III or stage IV) when the chances for curative therapy are low. Consequently, lung cancer contributes to a quarter of all cancer -related deaths in Canada [1]. Lung cancers that are diagnosed at an early stage require less invasive therapy, are more amenable to treatment, and associated with lower mortality [2]. The National Lung Screening Trial (NLST) published in 2011 demonstrated that screening with low-dose CT (LDCT) versus x-ray led to detection of more lung cancers and fewer lung cancer deaths after seven years of follow-up. In 2020, The Dutch–Belgian lung-cancer screening trial (Nederlands–Leuvens Longkanker Screenings Onderzoek [NELSON]), demonstrated a reduction in lung cancer specific mortality for individuals who underwent lung cancer screening at eleven years of follow up [3]. In Canada, it is currently a health system priority to plan and implement lung cancer screening (LCS) for individuals at a high-risk of developing lung cancer, i.e. individuals between the ages of 55 and 74 years who have a 30 pack year smoking history (pack-year defined as the [average number of cigarette packs smoked daily] x [number of years smoking]) or quit smoking less than fifteen years ago [4]. In Ontario, this mandate is currently undergoing pilot testing by the provincial healthcare agency Ontario Health across four locations in the region.

Smoking remains the single largest risk factor for developing lung cancer. Importantly, smoking is more prevalent amongst individuals living with low income [5] who by extension are more likely to have lung cancer [6]. In Canada, evidence points to the unequal utilization of cancer screening programs by individuals living with low income [7]. Inequities in cancer screening arise due to a lack of awareness of cancer screening programs in socially disadvantaged population groups and resources required to access care such as, transportation and childcare [7]. Importantly, however, these differences reflect an unequal distribution of the social determinants of health (SDH) such as income, and the unfair distribution of resources that shape opportunities to access and utilize cancer care [8, 9]. Much like inequities in other cancer screening programs (breast, colon, cervical) [10] participation in LCS is influenced by conditions of social disadvantage, such that individuals living with low income are less likely to use the preventative test [11].

Referrals to all types of cancer screening are typically make by family physicians (FPs) who are situated between individuals at-need of receiving cancer screening on one hand, and access to cancer screening through the cancer care system on the other hand. FPs can both facilitate access to cancer screening or serve as a barrier [12], and evidence points to increase utilization of cancer screening based on a positive relationship with FPs, adequate time in the clinical encounter to make recommendations towards preventative care and the presence of automated reminders in the patients electronic medical record (EMR) [13‐15]. Given the disproportionate burden of lung cancer in populations living with social disadvantage, it is important to understand the perspectives of physicians on access to LCS for individuals living with low income. This knowledge can provide a window into the complexity of tailoring preventative care to populations experiencing both social and health inequities and therefore can inform the delivery of equitable cancer screening to high-risk populations.

Figure 2, shows a thematic map connecting our four main themes: Social disadvantage, the clinical encounter, equity-oriented health care, and improving health outcomes.

An overview of the themes is discussed below. The complete set of themes, subthemes and illustrative quotes that were derived from the transcripts is shown in Table 2.

Historically, individuals with lower levels of income are less likely to participate in preventative health checks such as cancer screening [10]. For LCS this is particularly problematic since the highest incidence of lung cancer is found in populations disadvantaged by a variety of SDH such as income and education. LCS therefore presents two very specific challenges: (i) the highest prevalence of disease among those with the greatest degree of social disadvantage; and (ii) the lowest uptake of screening in the highest risk target population.

Our work highlights barriers to screening from the physician’ perspective such as, the nature of acute care visits, multiple patient comorbidities, and a lack of reminders through EMRs. None of these findings are novel, and have been previously documented in studies which have described physician barriers and facilitators to screening for other cancers such as breast [13], cervix [14] and colon [15]. In our analysis however, we apply the synergies of oppression theoretical framework in orderto illuminate how the need and ability to access care is shaped by intersecting oppressions resulting in social disadvantage. We describe therefore the need for a reorientation of services and resource allocation in order to achieve health equity. This is one of the strengths of using a theoretical thematic analysis as it is able to produce evidence that is relevant to the development of policy by illuminating experiences and perspectives in the real-world setting of patients, providers and policy makers [23]. Our qualitative study which contextualizes the lived experiences of poverty and the choice to participate in LCS for individuals living with low income in Ontario is described elsewhere [24].

Although our research question was focused on understanding physicians’ perspectives towards LCS for patients living with low income, FPs described how other intersecting identities (such as, race and sexual orientation) and SDH (such as, education and housing) were often associated with low income and higher rates of smoking. The frequent presence of multiple comorbidities represented a further challenge to care, particularly in the context of a mismatch between time allocated to provide care, and the complex care needs of socially disadvantaged patients. FPs frequently emphasized the need for a more integrated approach to care that included a larger interprofessional team of nurses, social workers, and patient navigators as one way to improve screening rates. FPs also described the need for resources such as transportation and communication tools as ways to improve access to screening, and subsequently health outcomes. However, few FPs questioned the underlying structural processes such as, jurisdictional policies that influence the unequal distribution of income. These policies include affordable housing, a living wage and better support for individuals facing discrimination and societal exclusion. No FPs spoke of the role of the tobacco industry and contraband manufacturers and the structural violence of large companies that profit from addicting the population for profit [25].

There are several implications of our findings. First, socially disadvantaged populations cannot be accommodated by a one size fits all approach to health care delivery. Our findings suggest that interprofessional teams of health providers, such as is found in community health centres (CHCs) where providers work on a salaried basis rather than fee-for-service may be ideally positioned to provide wraparound health and social services. This integrated approach has been shown to improve cancer screening [26] by empowering patients to enhance their overall opportunities to attain good health. Whether this model will work to improve uptake of LCS has yet to be tested. Second, for populations facing multiple oppressions, EOHC is an important way to improve health equity at the point of care [22]. By understanding that health behaviour is shaped more by the unequal distribution of the SDH through policies that promote inequities and social discrimination, rather than personal choice and control over life chances, providers will be able to avoid perpetuating cycles of poverty and oppression. EOHC thus forms an important way of delivering culturally safe, and contextually tailored care, through a trauma-informed approach [22]. This has been shown to improve care experiences for socially disadvantaged groups towards a goal of health equity [22]. Finally, improving health outcomes through LCS will require a multiprong approach that will require a mix of interventions which improve access to care, as well as an emphasis on upstream policies which will enhance the quality and distribution of the SDH. This underscores the need to transform healthcare to include the lived experiences of those who are marginalized and often excluded from the design of health interventions in order to improve the offer of cancer screening and appropriate uptake as well as a reduction in cancer risk.

A team-based approach to clinical care that addresses the social determinants of health and facilitates overall health and wellbeing can form the basis of an equity-informed way to enhance access to LCS. All health care providers must recognise that the living and working conditions which predispose patients to ill-health and influence their ability to access care are shaped by jurisdictional policies, and therefore must be acknowledged in the clinical encounter and addressed at the political level.