Prevalence and Barriers to Lung Cancer Screening in Karachi, Pakistan: A Cross-Sectional Survey of Smokers and Physicians

Abstract

BackgroundEarly detection of lung cancer using low-dose computed tomography (LDCT) can potentially reduce morbidity and mortality. However, LDCT for lung cancer screening, especially in low income countries, has been underutilized. The objective of this study was to evaluate the prevalence and the potential personal, social, and economic barriers of lung cancer screening using LDCT.MethodsA total sample of 156 smokers and 200 general physicians was collected during December 2016-February 2017 from community settings in Karachi, Pakistan. Two separate questionnaires were constructed to characterize participants’ knowledge, attitudes, and practices regarding lung cancer screening. Screening-eligible smokers and physicians were asked to identify patient barriers to screening and were asked their opinion regarding most effective approach for increasing awareness of screening guidelines.ResultsThe majority of smokers' (n=91, 58.3%) and physicians' (n=131, 65.7%) beliefs about the US Preventive Services Task Force (USPSTF) eligibility criteria were inconsistent with the actual recommendations. Major barriers to screening included financial cost, lack of patient counseling and health anxiety related to screening. Over two-thirds (n=105, 67.3%) of smokers were receptive to further information about LDCT screening, and half (n=78, 50.0%) favored one-on-one counseling by their physician, compared to other media. Only one-third (n=65, 33.3%) of physicians reported use of LDCT screening, although 54.5% (n=108) felt that screening implementation would be very effective in their practice.ConclusionLDCT screening is currently an uncommon practice in Pakistan. Financial cost, inadequate doctor-patient communication, and lack of awareness of guidelines among both patients and physicians are the major barriers in the utilization of LDCT screening.

The challenges of implementing low-dose computed tomography for lung cancer screening in low- and middle-income countries

“…Hence, in addition to building infrastructure that equitably reaches the population in the long term, the employment of mobile CT scanners and one-stop 'lung health-checks' among community centers 60 , as well as the provision of complementary transportation within screening programs, are essential strategies to address such scenarios 61 . Moreover, physician unawareness of screening guidelines and lack of time for counseling represent challenges for the identification and adherence of eligible high-risk individuals in LMICs 62,63 . For instance, in Egypt, a national pilot survey demonstrated that physicians do not frequently perform LCS, notwithstanding expert group recommendations 64 .…”

“…For instance, in Egypt, a national pilot survey demonstrated that physicians do not frequently perform LCS, notwithstanding expert group recommendations 64 . In Pakistan, a sample survey of 200 primary care physicians revealed that even though 54.5% acknowledged the effectiveness of LCS, only 33.3% reported ordering the test 63 . Furthermore, counseling has a significant impact on screening adherence, as corroborated by a study among Korean men showing that physician discussions with patients regarding the harms and benefits of LDCT screening improved participation from 10.6% to 95.1% (ref.…”

“…Cultural barriers, including fear, stigmas and blame for patients with lung cancer, also affect screening adherence, as has been demonstrated in several communities 69 . In Pakistan, a survey among 186 smokers demonstrated that fear of positive results (52.6%) and skepticism regarding treatment effectiveness (47.4%) were significant reasons for lack of screening participation 63 . In India, 53% of 500 survey respondents believed that cancer patients were to blame for presenting with the disease 70 .…”

“…Therefore, smoking cessation interventions must be prioritized in LCS programs. Screening counseling should address potential false reassurance that negative results of LDCT screening might be an encouragement to continue smoking 63 and should serve as an additional 'teachable moment' for smoking cessation 130 . Successful results are endorsed by a subsequent analysis from the NLST, demonstrating that approximately 40% of individuals had quit smoking at the 7-year follow-up, compared with 5% in the general population 131 .…”

“…Furthermore, out-of-pocket costs paid by patients represent up to 50% of overall medical costs in LMICs, harming access to care and leading to catastrophic health expenditure estimated to push millions into poverty every year 147 . For instance, the price of a CT scan in Pakistan is estimated to be US$99-1,000, the lower end of which represents more than a month's salary for most citizens 63 . Thus, stakeholders in LMICs need to leverage 'high-value oncology' by designing and expanding UHC with pricing schemes and pay-per-performance incentives that can help push the premise that any intervention costs should be linked to its benefit, bringing the LDCT screening program price closer to the country-specific thresholds in LMICs 148 .…”