Low education level raises risk for loss to follow-up in lung cancer screening program

Key takeaways:

• Educational attainment impacted an individual’s risk for loss to follow-up before lung cancer screening.
• The risk for loss to follow-up went up with inadequate vs. adequate health literacy.

Having an education level of high school or less heightened the risk for loss to follow-up among individuals eligible for lung cancer screening, according to a letter published in Annals of the American Thoracic Society.

“Programs can identify the individuals who are at higher risk for [loss to follow-up] by identifying those with low educational attainment and inadequate health literacy,” Everglad Mugutso, MBChB, MSc, graduate researcher at McGill University Health Centre, and colleagues wrote.

Using data from the McGill University Health Centre Lung Cancer screening pilot program, Mugutso and colleagues evaluated 168 individuals (36.3% aged 65-69 years; 57.7% men; 94% white) eligible for screening to determine if education is linked to loss to follow-up.

Individuals who did not get a scheduled CT scan and did not withdraw consent following a shared decision-making conversation were classified as lost to follow-up by researchers.

Of the total cohort, 81 individuals had a low education level of high school or less (38.3% aged 65-69 years; 61.7% men), whereas the remaining 87 individuals had a high education level (40.2% aged 60-64 years; 54% men).

More individuals in the low vs. high education group had COPD (49.4% vs. 36.8%), but fewer reported current smoking (53.1% vs. 62.1%).

Researchers found a higher proportion of screened individuals in the high education level group compared with the low level group (73.6% vs. 59.3%), meaning more individuals with low educational attainment were lost to follow-up (40.7% vs. 26.4%).

In an analysis adjusted for age, sex, smoking status, COPD and the Prostate, Lung, Colorectal and Ovarian Cancer Model 2012 score, the risk for loss to follow-up prior to CT screening was heightened in the low vs. high education level group (adjusted RR = 1.5; 95% CI, 0.97-2.32).

The risk for loss to follow-up also went up among older adults (> 65 years, RR = 1.75; 95% CI, 1.07-2.86).

To determine the impact of health literacy on the link between education and loss to follow-up, researchers asked 96 screened individuals, “How confident are you filling out medical forms by yourself?” on a 5-point Likert scale.

Nearly 23% of individuals had inadequate health literacy (score ≤ 3), and this was made up of more individuals with a low vs. high education level (39% vs. 10.9%).

Researchers reported second CT screening eligibility for 105 of 112 screened individuals, and 86 individuals (81.9%) carried out this screening.

The risk for loss to follow-up for the second screening did not significantly differ based on educational attainment.

However, inadequate health literacy did impact the risk for loss to follow-up at a second screening and contributed to an increased risk (aRR = 3.62; 95% CI, 1.34-9.73) in an analysis adjusted for education level and the previous covariates minus COPD.

“The relationship between low health literacy and [loss to follow-up] may be addressed by ensuring that the [lung cancer] screening process is less complex by improving the readability of health information, using nonwritten content (videos and interactive materials),” Mugutso and colleagues wrote.