Chest
Volume 143, Issue 3, March 2013, Pages 672-677
Journal home page for Chest

Original Research
Lung Cancer
What Do You Mean, a Spot?: A Qualitative Analysis of Patients' Reactions to Discussions With Their Physicians About Pulmonary Nodules

https://doi.org/10.1378/chest.12-1095Get rights and content

Background

More than 150,000 Americans each year are found to have a pulmonary nodule. Even more will be affected following the publication of the National Lung Screening Trial. Patient-doctor communication about pulmonary nodules can be challenging. Although most nodules are benign, it may take 2 to 3 years to rule out cancer. We sought to characterize patients' perceptions of communication with their providers about pulmonary nodules.

Methods

We conducted four focus groups at two sites with 22 adults with an indeterminate pulmonary nodule. Transcripts were analyzed using principles of grounded theory.

Results

Patients described conversations with 53 different providers about the pulmonary nodule. Almost all patients immediately assumed that they had cancer when first told about the nodule. Some whose providers did not discuss the actual cancer risk or explain the evaluation plan experienced confusion and distress that sometimes lasted for months. Patients were frustrated when their providers did not address their concerns about cancer or potential adverse effects of surveillance (eg, prolonged uncertainty, radiation exposure), which in some cases led to poor adherence to evaluation plans. Patients found it helpful when physicians used lay terms, showed the CT image, and quantified cancer risk. By contrast, patients resented medical jargon and dismissive language.

Conclusions

Patients commonly assume that a pulmonary nodule means cancer. What providers tell (or do not tell) patients about their cancer risk and the evaluation plan can strongly influence patients' perceptions of the nodule and related distress. We describe simple communication strategies that may help patients to come to terms with an indeterminate pulmonary nodule.

Section snippets

Materials and Methods

We recruited participants from Boston Medical Center (which serves a racially diverse, economically disadvantaged urban population) and Dartmouth-Hitchcock Medical Center (a referral center for a rural population of mixed socioeconomic status). We identified English-speaking adults with an indeterminate pulmonary nodule by soliciting names from pulmonary and primary-care providers, reviewing referrals to pulmonary clinics, and searching problem lists and CT imaging reports (e-Table 1). Eligible

Results

Patients described conversations about their nodule with 53 providers from academic and community practices, including primary-care providers, pulmonologists, and thoracic surgeons. The involvement of multiple clinicians most often stemmed from referral by the provider first faced with an incidental nodule (eg, ED physician) to the primary-care provider, often followed by a second referral to a pulmonologist. Table 1 shows the characteristics of the study patients.

Discussion

This study is the first to our knowledge to provide data on provider-patient communication about pulmonary nodules, offering insight into patients' experiences through their own words. Study patients described both satisfying and frustrating conversations. From their accounts, we identified patient-important communication elements; formulated them into seven questions that providers might consider in framing discussions about a nodule; and identified specific, patient-endorsed strategies that

Acknowledgments

Author contributions: Dr Wiener had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Wiener: contributed to the conception, hypotheses delineation, and design of the study; data acquisition, analysis, and interpretation; and writing and revision of the article prior to submission.

Dr Gould: contributed to the conception, hypotheses delineation, and design of the study; data acquisition, analysis, and

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    Funding/Support: This study is funded by a career development award from the National Cancer Institute [K07 CA138772]. Dr Gould is supported by the National Cancer Institute. Drs Wiener, Woloshin, Schwartz, and Clark receive salary support from the Department of Veterans Affairs.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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