Veterans' Lung Cancer Risk Conceptualizations versus Lung Cancer Screening Shared Decision-Making Conversations with Clinicians: A Qualitative Study

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.