The reporting of pulmonary nodule results by letter in a lung cancer screening setting

Objectives: Pulmonary nodules are commonly found in Lung Cancer Screening (LCS), with results typically communicated by face-to-face or telephone consultation. Providing LCS on a population basis requires resource efficient and scalabe communication methods. Written communication provides one such method. Here, we assess participant satisfaction with this approach in a LCS setting and investigate characteristics associated with dissatisfaction. Materials and methods: The SUMMIT Study is a prospective observational cohort study which aims to assess the implementation of Low-Dose Computed Tomography (LDCT) scanning for LCS in a high-risk population and validate


Introduction
In UK Lung Cancer Screening (LCS) trials, 13-24% of participants are reported to have indeterminate pulmonary nodules on baseline Low-Dose Computed Tomography (LDCT) scans, requiring three-month follow-up imaging [1][2][3][4].The SUMMIT Study is a prospective observational cohort study which aims to assess the implementation of LDCT scanning for LCS in a high-risk population in North Central and East London and validate a multi-cancer early detection blood test (NCT03934866).Participants in the study with solid nodules ≥ 80 mm 3 , <300 mm 3 ; ≥6mm, <8mm; larger nodules with a Brock score of < 10%, and part-solid nodules [5] underwent a three-month interval LDCT scan.
Pulmonary nodule surveillance can cause clinically significant shortterm distress for a significant minority of patients [6] when experienced as a 'near-cancer' diagnosis.Quality of communication is therefore integral to patient-centred outcomes [7].
Here, we assess participant satisfaction with, and preferences for, a written method of communication and investigate characteristics associated with dissatisfaction.

Materials and methods
SUMMIT Study participants requiring a three-month interval LDCT were informed of their result by a postal letter containing information about the findings, need for a repeat scan in three-months' time (by scheduled appointment), and study team contact details for further discussion by telephone if needed.Participants undergoing an interval scan had a face-to-face appointment with a study practitioner immediately prior to the scan where they had the opportunity to ask questions.
At the face-to-face appointment, participants were verbally asked how satisfied they were with receiving their results by letter, how they felt about the amount of information in the letter, and if able to choose how to receive their result, which method they would have preferred.For each question, participants were provided with a range of options for response (shown in Tables 2 and 3).Participants were also asked if they had any questions about their results letter and if they had discussed their results with their GP or a member of the study team by telephone prior to attending their face-to-face appointment.
Participants with incidental pulmonary nodules detected at baseline LDCT scan who attended for a three-month interval Lung Health Check (LHC) appointment and LDCT between 18th July 2019 and 25th June 2021 were included.
The primary outcome measure was the proportion of individuals satisfied with pulmonary nodule results communication by letter.Secondary outcome measures included participant perception of the amount of information included in the letter, their preferred method of results communication, the type of questions asked during their appointment, and the proportion who contacted the study team or their General Practitioner (GP) to discuss the results further.
Descriptive frequencies were calculated for all outcome measures with logistic regression analyses used to explore demographic and smoking characteristics associated with responses.

Results
Data were analysed for the first 1,900 SUMMIT Study participants who attended for a three-month interval LHC.59.2% (n = 1,124) were male, with a mean age of 66.5 years (SD 6.0).Most (84.9%, n = 1,613) were of white ethnicity, nearly two thirds were from the two most deprived quintiles nationally (61.3%, n = 1,165) and half (49.4%, n = 939) were current smokers (Table 1).
82.8% (n = 1,573) of participants were satisfied with receiving their results by letter with 2.9% (n = 55) reporting dissatisfaction (Table 2).Most participants (86.3%, n = 1,640) reported the method used (letter from doctor) was their preferred choice of communication, with 5.4% (n = 103) preferring a telephone call from a doctor and 3.3% (n = 63) a nurse.
Few participants took the opportunity to discuss their results by

Table 1
The demographic and smoking characteristics of the participants attending for a three-month interval appointment.telephone with the study team (5.9%, n = 112) and GP (13.7%, n = 261) prior to the LHC.Of those who discussed with their GP, 83.9% (n = 219) were satisfied with receiving results by letter, with the same proportion preferring this method of communication.While not statistically significant, there was a trend for females (21.3%) to more frequently request discussion with the study team or GP, compared to males (18.5%).Older participants and those from less deprived socioeconomic quintiles were more likely to have discussed their results with their GP.

Discussion
There was high satisfaction with the communication of pulmonary nodule results by letter and the amount of information the letter provided.<3% of participants reported dissatisfaction, with the majority (86.3%) reporting they would have chosen this method over a telephone call or appointment.
Notably, all participants with pulmonary nodules were given a faceto-face appointment immediately before their interval scan, providing the opportunity to ask questions.A significant proportion (43.3%) did so, underscoring the importance of the opportunity for discussion or providing information about commonly asked questions in advance.
A significant minority (13.7%) discussed the results with their GP prior to their interval LHC appointment.Females, older participants and those from lower levels of socioeconomic deprivation were more likely to do so.Data were not available on the proportion who sought a GP consultation primarily to discuss these results, as opposed to opportunistically discussing during an unrelated consultation.Further assessment could examine this more closely and identify ways to reduce this proportion alongside considering how behaviours may differ outside of a trial setting.However, in absolute terms, the number of participants per practice who discuss results with their GP is expected to be small.Furthermore, the majority (83.9%) of those that did so were ultimately satisfied with receiving results by letter and reported that this was their preferred method.
Qualitative data from LCS in the United States suggests participants can be left dissatisfied by results communication by letter [8].However, our results provide real-world reassurance of the acceptability of this form of communication in a UK population.Future endeavours to understand the reasons for differences in rates of satisfaction across geographical and healthcare system boundaries should be welcomed to improve LCS communication.
In conclusion, we demonstrate high participant satisfaction with the communication of a pulmonary nodule diagnosis during LCS by postal letter, providing a feasible route forward for large-scale screening programmes in the future.

Table 2
Participant reported satisfaction of pulmonary nodule results being reported by letter.
*From primary care record, †Age at time of appointment, ‡From baseline (Y0) LHC.

Table 3
Participant reported perception of how much information was included in the pulmonary nodule results letter and preferred method of contact for pulmonary nodule results.