Barriers and facilitators for low-dose computed tomography lung cancer screening in rural populations in the United States: a scoping review protocol : JBI Evidence Synthesis

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Barriers and facilitators for low-dose computed tomography lung cancer screening in rural populations in the United States: a scoping review protocol

Palokas, Michelle1,2; Hinton, Elizabeth1,2; Duhe, Roy1,2; Christian, Robin1,2; Rogers, Deirdre1,2; Sharma, Manvi2,3; Stefanek, Michael1,2

Author Information
doi: 10.11124/JBIES-21-00337
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Lung cancer is the leading cause of cancer-related deaths worldwide, with annual deaths surpassing colon, stomach, liver, and breast cancer deaths combined.1 In 2019, over 75,000 men and 65,000 women died of lung cancer in the United States (US) alone. Nationally, lung cancer continues to be the leading cause of death from cancer, more than doubling the total number of deaths from any other type of cancer.2

While 8 million people in the US are eligible for low-dose computed tomography (LDCT) for lung cancer screening, fewer than 5% of eligible Americans have been screened.3 The landmark randomized controlled National Lung Cancer Screening Trial reported a 20% relative reduction in lung cancer mortality among heavy smokers randomized to receive annual LDCT compared with an annual chest x-ray.4 Key to the potential value of lung cancer screening is early detection. Clinical outcomes from lung cancer range from a 60% 5-year survival rate for localized disease to a 6% 5-year survival for distant disease.5 A recent meta-analysis concluded that LDCT screening significantly increased the detection of stage 1 lung cancer and reduced lung cancer mortality.6

The United States Preventive Services Task Force (USPSTF) has established guidelines for screening for lung cancer that include annual screening with LDCT in adults aged 50 to 80 years who have a 20-pack-year smoking history (ie, a pack a day for the last 20 years, or two packs a day for the last 10 years) and currently smoke or have quit within the past 15 years, or who develop a health problem that substantially limits life expectancy or the ability to have lung surgery.7 Thus, screening involves not only “uptake” (initial screening), but also “adherence” (annual screening). This is a revised recommendation from the USPSTF.7 In 2013, the established guidelines were for adults aged 55 to 80 years with a 30-pack-year history. Along with potentially increased benefits of screening, the revision in 2021 to include younger adults and those with a shorter smoking history may mean an increase in costs associated with screening, including psychological distress, false-positive (resulting in over diagnosis and intrusive medical follow-up) and false-negative findings.1,8,9 However, the use of LDCT requires significant investments in capital equipment and specialized medical personnel, and this raises logistical challenges for implementing LDCT lung cancer–screening programs in resource-restricted areas in the US and internationally.10-12

The focus on rural populations for this scoping review is an important one. Almost 20% of the US population lives in a rural area and 20% of the US population with cancer is from rural areas.13 Rural populations have higher rates of late-stage lung cancer incidence and mortality compared with urban populations, due in part to system-, provider-, and individual-level barriers to screening and related health-seeking behavior (eg, smoking cessation),14 and these disparities appear to be widening.13 This problem is not unique to the US, and other nations, such as China, have documented the disparate burden of lung cancer in rural areas.15 To improve lung cancer survival rates, it is clear that screening and early detection and treatment are critical, and there is some evidence that rural populations are not screened at a level equivalent to urban populations.16,17 Such urban-rural disparities might be explained by a number of facilitators and/or barriers, including the fact that rural populations often live greater distances from health care providers engaged in lung cancer screening, and transportation may be limited.

While the focus on rural populations is important, defining “rural” is a challenging task. The US federal government uses 2 major definitions of “rural” (as defined by the US Census Bureau and the Office of Management and Budget), and there are many other variants. In addition, there are measurement challenges with each of these definitions.18 Due to significant variances among national definitions of “urban” and “rural” areas, multinational organizations, such as the United Nations and the World Bank, have attempted to provide a more universal approach based on the Degree of Urbanisation, which can be used to categorize territories as either cities, towns and semi-dense areas, or rural areas.19 For this reason, and to be inclusive, this scoping review will include any studies that utilize the word “rural” in the title or abstract of the study.

A preliminary search of PROSPERO, Campbell Collaboration, MEDLINE (PubMed), the Cochrane Database of Systematic Reviews, CINAHL (EBSCO), and JBI Evidence Synthesis (Ovid) was conducted on February 24, 2022, using the following search string: (review[ti] OR meta analysis[ti]) AND (“lung cancer screening” OR “low dose computed tomography” OR LDCT).

Two systematic reviews were registered in PROSPERO and 5 systematic reviews20-24 on similar topics to this proposed review were identified. Of the two reviews located in PROSPERO, one proposed to only include controlled trials and observational studies while the other did not detail the type of lung cancer screening that would be included; additionally, both listed anticipated completion dates in 2021 and no evidence of those full reviews could be located. Of the 5 published reviews, 1 focused on multiple preventative services, including lung cancer screenings,20 and 2 focused on the effectiveness or impact of interventions to improve screening.20,21 Another review by Van Hal et al.22 focused on contacting and improving participation of “hard to reach” populations, but these populations were not defined. The final two reviews focused on predictors of non-adherence23 and gender and social differences across lung cancer screening programs.24 Our proposed review will focus on barriers and facilitators of LDCT screening uptake and adherence in rural populations in the US only, which differs from these published systematic reviews.

The objective of this review is to identify barriers and facilitators for LDCT lung cancer screening uptake and adherence among rural populations in the US. In order to design, implement, and evaluate interventions to improve screening uptake and adherence, there is a need to systematically review the existing literature on barriers and facilitators for screening uptake and adherence.

Review questions

  • i) What are the barriers to LDCT lung cancer screening uptake and adherence among rural populations in the US?
  • ii) What are the facilitators for LDCT lung cancer screening uptake and adherence among rural populations in the US?

Inclusion criteria


This review will consider studies that include adults who are eligible for annual LDCT lung cancer screening based on 2013 (aged 55 to 80 years with a 30-pack-year smoking history) and/or 2021 USPSTF lung cancer screening guidelines (adults aged 55 to 80 years with a 20-pack-year smoking history who currently smoke or have quit within the past 15 years).7


Studies that report on barriers and facilitators for LDCT lung cancer screening uptake and adherence will be included in this review. Only those studies utilizing LDCT scans as the screening measure will be included, given that evidence does not support the use of chest radiography or sputum cytology.7 For the purposes of this scoping review, barriers and facilitators will be categorized as either patient factors (ie, unawareness/awareness of screening programs, perceptions of a cancer diagnosis and perceived stigma, cost of screening, access to imaging sites) or provider factors (ie, unfamiliarity/familiarity with eligibility criteria and insurance coverage, difficulty/ease in identifying eligible patients, insufficient/sufficient time or knowledge to conduct shared decision-making, need/no need for guidance with management of lung cancer screening results, and skepticism/non-skepticism about the benefits of screening).


This scoping review will specifically focus on rural populations in the US. Any studies that include the word “rural” in the title or abstract of the study will be considered for inclusion.

Types of sources

This scoping review will consider both experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before-and-after studies, and interrupted time-series studies. In addition, analytical observational studies, including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies, will be considered for inclusion. This review will also consider descriptive observational study designs, including case series, individual case reports, and descriptive cross-sectional studies for inclusion.

Qualitative studies, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research, will also be considered for inclusion. In addition, quantitative, qualitative, and mixed methods systematic reviews, and text and opinion papers will be considered for inclusion in this scoping review.


The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews.25 The review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.26

Search strategy

The search strategy will aim to locate published and unpublished primary studies, reviews, and opinion papers. Initial limited searches of MEDLINE (PubMed), CINAHL Complete (EBSCO), and Embase were undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles, were used to develop a full search strategy for MEDLINE (PubMed), which is detailed in Appendix I. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of articles selected for full-text review will be screened for additional papers.

The databases to be searched include MEDLINE (PubMed), CINAHL Complete (EBSCO), Embase, Web of Science Core Collection, and Cochrane Library. The trial registries to be searched include the Cochrane Central Register of Controlled Trials and Sources of unpublished studies and gray literature to be searched include ProQuest Dissertations and Theses Sciences and Engineering Collection (ProQuest), and the websites of the National Cancer Institute, the National Heart Lung and Blood Institute, and the American Cancer Society.

Since translation services are not available, only studies published in English will be included. Studies published from 2013 until the search date will be included. In 2013, the USPSTF completed its initial evidence review and gave a “B” recommendation to LDCT screening for a targeted lung cancer high-risk population aged 55 to 80 years.7 Under the Affordable Care Act, this meant that such screening had to be covered for those eligible without co-pays or deductibles by commercial insurers (with certain exceptions) for those under 65. Thus, studies and reports prior to this date are unlikely to be relevant for a significant segment of the rural population.

Study selection

Following the search, all identified records will be collated and uploaded into EndNote v.20 (Clarivate Analytics, PA, USA) and duplicates removed. Following a pilot test, titles and abstracts will be screened by 2 independent reviewers for assessment against inclusion criteria for the review. Potentially relevant papers will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).27 The full text of selected citations will then be assessed in detail against the inclusion criteria by 2 independent reviewers. Reasons for exclusion will be recorded and reported in the scoping review. Any disagreements that arise between reviewers at each stage of the selection process will be resolved through discussion with a third reviewer. The results of the search will be reported in full in the scoping review and presented in a PRISMA flow diagram.28

Data extraction

Data will be extracted from papers included in the scoping review by 2 independent reviewers using a data extraction tool developed by the reviewers (Appendix II). The draft extraction tool was created based on methodological guidance by JBI.25 The data extracted will include specific details about the population, concept, context, and results relevant to the review questions. The tool will be modified and revised as necessary during the process of extracting data from each included paper. Modifications will be detailed in the full scoping review. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data analysis and presentation

The data extracted will be presented in diagrammatic or tabular format. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the review's objectives and questions. Barriers and facilitators for lung cancer screening and uptake will be presented as 8 tabular or diagrammatic representations: i) provider-related facilitators for screening uptake, ii) provider-related barriers to screening uptake, iii) provider-related facilitators for screening adherence, iv) provider-related barriers to screening adherence, v) patient-related facilitators for screening uptake, vi) patient-related barriers to screening uptake, vii) patient-related facilitators for screening adherence, viii) patient-related barriers to screening adherence. Additional groupings may be reported depending on the findings of the scoping review.

Author contributions

MP supervised all aspects of the writing and editing process and acted as the methodological expert for the protocol. EH searched for similar systematic reviews and helped clarify the inclusion criteria based on current, published reviews. EH, RD, RC, DR, MS, and MS all contributed to writing and editing the manuscript.

Appendix I: Search strategy


Search conducted: February 24, 2022


Appendix II: Data extraction instrument



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access to health care; low-dose computed tomography; lung cancer screening; rural; screening adherence

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