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Abstract

Introduction

Lung cancer is the leading cause of cancer-related death. Screening for lung cancer using low dose computed tomography (LDCT) significantly reduces lung cancer mortality. However, their implementations must be cost-effective while also prioritizing inclusivity and equity. In this context, telemedicine has emerged as a strategy to reduce costs and enhance access to specialized healthcare. This study aims to describe a Brazilian experience with teleconsultation for delivering LDCT reports, its impact on smoking cessation counseling, and the factors influencing participants’ enrollment in the Barretos Cancer Hospital Lung Cancer Screening Program (BCH-LCSP).

Methods

This cross-sectional analysis was conducted within the BCH-LCSP cohort and describes the teleconsultation process implemented as part of the program. Differences in sociodemographic characteristics between participants who received LDCT results through in-person consultations vs teleconsultations were examined using t-test or chi-square test.

Results

Of 793 enrolled participants, 747 (94.2%) received reports via teleconsultation and 46 (5.8%) in person. Teleconsultations were more likely to be used by females (53%). Of the 793 participants, 559 were current smokers. Among those 559, 152 participated in the smoking cessation intervention for at least 1 year, and 26 (17.1%) of them successfully quit smoking. Participants’ motivations to enroll in the LCS included prevention, smoking-related concerns, as well as general health concerns, and desire to quit smoking.

Conclusion

Teleconsultation shows potential as a practical approach for LDCT delivery and smoking cessation counseling in Brazil, providing a scalable model that could improve access and equity in lung cancer screening programs in low and middle-income countries and globally.

Keywords

lung cancer screening telemedicine smoking prevention Latin America

Introduction

Lung cancer is the leading cause of cancer-related mortality worldwide and in Brazil, accounting for an estimated 1.8 million deaths (18%).¹ Yet, the 5-year survival rate for lung cancer patients is below 20%.² Obtaining a diagnosis at an earlier stage of lung cancer is key strategy to reduce mortality, improve prognosis, and enhance the quality of life.³ In this context, randomized controlled trials have shown that lung cancer screening through LDCT for high-risk individuals (eg, smokers with ≥30 pack-years and age ≥55 years) significantly reduces lung cancer mortality by at least 20%.^4-6

However, lung cancer screening implementation is still in an early phase worldwide compared to other cancer screening programs.⁷ To date, there are 7 national LCS (Lung Cancer Screening) programs worldwide⁸: 1 in North America (USA),⁸ 3 in Europe (Czech Republic, Poland, Croatia), and 3 in Asia (China, Taiwan, South Korea). Canada has provincially managed LCS programs, and the UK has a targeted lung health check program implemented in some parts of the country. Participants’ engagement and adherence to lung cancer screening are among the most significant challenges.⁸ One factor determining the success of screening programs is accessibility for the risk groups.⁹ Therefore, improving the availability of screening by reducing individual and social barriers to participation has become a crucial aspect of planning the screening programs, and ensuring that participation in cancer screening is as effortless as possible is essential. Reaching out to high risk groups would be both beneficial for the individuals and cost-effective.¹⁰ Other barriers include the availability and expertise of healthcare professionals, as well as service capacity.⁸

To enhance accessibility, interest in using mobile LDCT units for lung cancer screening has grown, particularly in areas with limited access to hospital-based screening programs due to geographic and socioeconomic factors.¹¹ In this context, the Barretos Cancer Hospital (BCH) (recently renamed Hospital de Amor), a non-profit institution that serves 100% of its patients through the Brazilian national public health system, (Sistema Único de Saúde [SUS] in Portuguese), has implemented a program targeting high-risk populations within its Health District V (RHD-V), which includes 18 cities.¹²

The COVID-19 pandemic accelerated the adoption of telemedicine, which has also emerged as a strategy not only to reduce the costs of implementing an LCS programs worldwide, but also to promote inclusivity, equity, and accessibility for underserved populations within the healthcare system.^13-15 Telemedicine provides patients with health-care services such as diagnosis, consultation, diagnosis and treatment, and employs communication technologies to exchange any information, including text, images, audio, or video between the health-care professionals and patients.¹⁶

Several systematic reviews have shown the clinical effectiveness of telemedicine in healthcare delivery, identifying it as a feasible option to improve access to care and patient outcomes in remote areas^16-18,19,20. Interestingly, a large Chinese initiative showed the feasibility of deploying telemedicine-enabled health care service to increase access to radiology and diagnostic services in resource-limited settings.²¹

However, barriers to telemedicine uptake persist, especially in low- and middle-income countries. These include limited internet or satellite coverage, lack of access to smartphones or compatible devices, digital illiteracy, and financial constraints. In Brazil, while urban centers often have reliable telecommunications infrastructure, rural and remote regions still face substantial challenges in accessing stable internet or mobile connectivity, which may limit the reach of telehealth services.^22,23

There is no data on integrating telemedicine into lung cancer screening programs in Brazil. The present study aims to describe a Brazilian single-center experience with teleconsultation for delivering LDCT reports, its impact on smoking cessation, and the factors influencing participants’ enrollment in the BCH lung cancer screening program (BCH-LCSP).

Material and Methods

This study presents a cross-sectional analysis of data collected within the prospective cohort of the Barretos Cancer Hospital Lung Cancer Screening Program (BCH-LCSP), and it was reported in accordance with the STROBE guidelines.²⁴

Selection for Lung Cancer Screening and Study Population (BCH-LCSP)

The Barretos Cancer Hospital (BCH), implemented in 2019 a regional lung cancer screening program targeting high-risk populations.¹² Lung cancer risk was assessed using an online tool (https://tcbd.hospitaldeamor.com.br/), that employs evidence-based criteria from the National Lung Screening Trial (NLST)⁴ and the PLCO_m2012²⁵ no-race risk prediction model at the time of implementation.

Individuals from the target population who met at least 1 of these criteria and were asymptomatic for lung cancer or other severe conditions were invited to participate and undergo LDCT screening. Thus, the selection was based on predefined eligibility criteria for lung cancer risk.

The LDCT scans were interpreted by experienced thoracic radiologist who evaluates the scans and issue two reports per examination: one with detailed, structured technical information, and another illustrated version with colloquial language, designed to enhance communication and foster adherence¹² (Supplementary material: Figure 1). The Lung CT Screening Reporting and Data System (Lung-RADS®)²⁶ versions 2019 and 2022 were used for radiographic reporting and follow-up recommendations. Participants classified as Lung-RADS 4b or 4x were referred for discussion in the multidisciplinary tumor board of the Thoracic Division at BCH.

Figure 1.

Workflow of Participants and Their Outcomes

Among 2985 individuals invited, 1495 met the NLST or PLCO criteria and underwent LDCT. Of the 47 participants classified as Lung-RADS 4b or 4x and referred to the multidisciplinary team, 5 cases (10.6%) were considered not to require biopsy. Among the 42 individuals referred to biopsy (89.4%), 40 (95.2%) underwent the procedure. Of those, 31 (77.5%) were diagnosed with lung cancer, 2 (5%) with other types of cancer, and 7 (17.5%) had benign lesions. One participant refused to undergo the biopsy, and one was still awaiting the procedure at the time of data cutoff (Figure 1).

Teleconsultation was offered to all participants who underwent LDCT screening. All participants included in this study were screened either using the mobile LDCT unit or at the Barretos Cancer Hospital, and individuals in the teleconsultation cohort were undergoing their initial LDCT screening or returning after 12 months.

Sociodemographic data such as age, sex, education level, smoking history, level of tobacco dependence, comorbidities, self-perceived health status, and information about attempts, plans, or desires to quit smoking were collected when the participant underwent an LDCT scan. Additionally, participants are asked about their motivation for enrolling in the lung cancer screening program. The study included individuals from both urban and rural regions, and participants were actively recruited through structured outreach efforts, including community campaigns and referrals from primary care units. This recruitment strategy ensured diversity in the sample and minimized selection bias related to digital access or health-seeking behavior.

Ethical Approval Statement

This study was approved by the Research Ethics Committee of Fundação Pio XII – Hospital de Amor, located in Barretos, São Paulo, Brazil. The protocol was registered under the CAAE number 96087018.3.0000.5437 and received approval through opinion number 2.907.024, dated September 20, 2018. This study was conducted in accordance with the World Medical Association Declaration of Helsinki. All patient details were fully de-identified to ensure that no individual could be identified in any way.

Teleconsultation/Telemedicine Service Delivery

Teleconsultation was the primary strategy for delivering BDCT reports to participants of the BCH-LSCP (Figure 2), as well as for providing smoking cessation counseling. All participants screened through the mobile or fixed LDCT units were offered a teleconsultation after the structured and illustrated reports were finalized. The teleconsultation program was conducted by a dedicated team of trained nurses and physicians using a secure, HIPAA-compliant video platform, and received a QMentum International Diamond accreditation in 2025. Participants were informed about the teleconsultation option during the pre-screening stage and received printed and verbal instructions on how the remote consultation would be conducted. Follow-up reminders via phone or text message were used to ensure attendance. The platform allows video and audio calls. When teleconsultation was not feasible (eg, due to lack of connectivity), participants were referred to for in-person consultations at the coordinating center. This structure ensured that results delivery and smoking cessation counseling were accessible regardless of digital barriers.

Figure 2.

Flowchart of the Teleconsultation Process for Ld-Ct Report Delivery

Smoking cessation interventions followed a standardized protocol that included behavioral counseling and counseling for participation in existing smoking cessation groups at primary health care centers, where pharmacotherapy (e.g., nicotine replacement therapy or bupropion) is available when clinically indicated.

To assess the effectiveness of teleconsultation for smoking cessation counseling, we included participants who had at least 1 follow-up visit after a minimum interval of 1 year from their enrollment in the BCH-LSCP Tobacco Control Program. Participants were classified as quitters if they had maintained smoking abstinence for at least 1 year at the time of follow-up. Smoking cessation was self-reported; no biochemical tests (e.g., cotinine testing) were performed.

Statistical Analysis

Pearson’s Chi-squared test or Wilcoxon rank sum test were used, as appropriate, to compare sociodemographic and clinical characteristics between the telemedicine and in-person consultation groups. Associations with variables such as age, gender, skin color, education level, and tobacco status were explored using these univariate methods. Statistical significance was defined as P ≤ 0.05.

Results

Of the 2985 individuals initially invited, 1495 met the NLST or PLCO eligibility criteria and underwent LDCT. To further assess the applicability of the eligibility criteria for lung cancer screening, we analyzed the overlap between participants who met the NLST and PLCOm2012 risk models. Among the 31 participants diagnosed with lung cancer, 74.2% met both NLST and PLCOm2012 criteria, 9.7% met only NLST, and 16% only PLCOm2012. Among the 1464 participants without lung cancer, 73.3% met both criteria, 12.7% met only NLST, and 14.1% only PLCOm2012. These findings support the use of both models as complementary tools for risk-based selection in the BCH-LCSP.

Seven hundred ninety-three participants attended at least 1 medical appointment, with 747 (94.2%) receiving LDCT reports via telemedicine, representing a high uptake rate of this modality, and 46 (5.8%) in person. These individuals were predominantly older adults with lower educational attainment (Figure 3). Additionally, 705 appointments (88.9%) were scheduled for the first contact attempt. For the remaining 88 participants (11.1%), 2 or more contact attempts were necessary to schedule the appointment. Importantly, all 88 individuals were successfully reached and included in the teleconsultation process, with none excluded due to contact failure.

Figure 3.

Characterization of Teleconsultation or In-Person Consultation, Gender, and the Number of Attempts to Schedule

We characterized and compared participants who received LDCT reports through in-person consultations vs teleconsultations to understand the differences between sociodemographic characteristics. In summary, individuals who attended in-person consultations were predominantly older (P = 0.003), males (P = 0.031), and residents of Barretos (P = 0.001) (Table 1).

Table 1.

Sociodemographic Characterization of Participants Who Received LDCT Reports via Telemedicine or In-Person Consultation

Sociodemographic variables	In-person 46 (5.8%)¹	Telemedicine 747 (94.2%)^a	P-value^b
Age	69.0 (60.5, 72.0)	64.0 (60.0, 68.0)	0.003
Sex			0.031
Male	29 (63%)	349 (47%)
Female	17 (37%)	398 (53%)
Tobacco status
Person who smokes	34 (76%)	525 (71%)	0.5
Quitters	11 (24%)	218 (29%)
Unknown	1	4
Education			0.041
<8 years of schooling	29 (64%)	363 (49%)
≥8 years of schooling	16 (36%)	382 (51%)
Unknown	1	2
Ethnicity			0.6
White	25 (54%)	435 (58%)
No white	21 (46%)	309 (42%)
Unknown	0	3
Marital status			0.5
Single	20 (49%)	301 (43%)
Married	21 (51%)	395 (57%)
Unknown	5	51
Monthly family income			0.4
Below 1 minimum wage	8 (25%)	171 (29%)
Between 2 and 5 minimum wages	20 (63%)	309 (52%)
≥5 minimum wages	4 (13%)	119 (20%)
Unknown	14	148
City of residence			0.001
Other	5 (11%)	254 (34%)
Barretos	40 (89%)	489 (66%)
Unknown	1	4
Eligibility criteria
NLST	12 (26%)	192 (24%)	0.8
PLCO	8 (17%)	83 (10%)
NLST and PLCO	26 (57%)	472 (60%)

^an (%); Median (IQR).

^bPearson’s Chi-squared test; Wilcoxon rank sum test.

The main reasons for teleconsultations not being held included inability to connect to the internet (57.64%), the participant not having a contact telephone number (18.30%), requesting rescheduling the teleconsultation (11.28%), limited internet access (9.78%), and requesting an in-person appointment (3.01%) (Table 2).

Table 2.

Reasons for Teleconsultation Non-completion

Reasons for not completing teleconsultations	%
Unable to connect to the internet	57.64
No contact phone number	18.30
Requested rescheduling of teleconsultation	11.28
Limited internet access	9.78
Requested in-person appointment	3.01

Regarding the smoking cessation intervention, 152 participants met the inclusion criteria, which required at least 1 follow-up visit after a minimum interval of 1 year from enrollment in the tobacco control program. All 152 participants completed the follow-up, with no losses recorded due to dropout or failure to complete the intervention. Among them, 26 participants (17.1%) successfully quit smoking, of whom 25 (96.2%) maintained smoking abstinence at follow-up, and only 1 individual relapsed (Supplementary material: Figure 2).

As part of the baseline assessment, participants were also asked about their motivations for enrolling in the lung cancer screening program. The most frequently reported reason was prevention (Prevention, n = 705 mentions), followed by smoking-related concerns (Tobacco, n = 123) and desire to quit smoking (Quit Smoking, n = 30), as well as general health concerns (Health, n = 60). Other motivations included COPD (COPD, n = 22), recommendation or referral (Referral, n = 21). A word cloud visualization was created to highlight the frequency of each motivation (Supplemental Material: Figure 3).

Discussion

Implementing a lung cancer screening program in Brazil is a significant challenge, especially due to its continental dimensions and limited resources. In this study, we report the implementation of a teleconsultation modality for delivering LDCT reports in the Barretos lung cancer screening probram.¹² Our pilot experience with approximately 800 participants demonstrated the success of this approach in a low and middle-income country (LMIC).

There was positive acceptance and high adherence to this type of medical care, which optimizes and ensures that participants received their reports, thus avoiding traveling to the hospital facilities. Only a small proportion (5.8%) of participants preferred attending face-to-face consultations, who were mostly men, older, with less than 8 years of education. These results align with several studies that indicate difficulties in this demographic group in accessing telemedicine platforms.^27,28 The main reasons raised by face-to-face consultation group were related to internet connectivity, absence of a contact telephone number, need to reschedule the teleconsultation, and refusal of this approach.

These findings highlight persistent barriers such as fear and resistance to technology, especially among older individuals and those with lower levels of education. Importantly, those who reported a lack of internet access or absence of a contact phone number tended to choose in-person consultations rather than refusing technology. This trend underscores that structural and socioeconomic barrier (eg, affordability of devices, limited connectivity, digital exclusion) are key factors not merely fear or technophobia.²⁹ A national study reported that around 30% of Brazilian households lacked internet access in 2022, especially in rural areas and among older, low-income individuals.^29,30 While discomfort with telemedicine is sometimes described, qualitative research in Brazil suggests it often relates to low digital literacy and insufficient user support rather than inherent fear.³¹

To address the concern that high teleconsultation use might be attributable to self-selection bias, we emphasize that our pilot study was embedded within a large-scale screening program that actively recruited participants through structured community outreach and referrals from primary care units, rather than relying solely on self-referred individuals. This approach enabled the inclusion of a demographically diverse cohort, including individuals from underserved regions, helping to mitigate bias toward highly motivated or tech-savvy users. The high uptake of teleconsultation across this heterogeneous population suggests that this modality may be acceptable and feasible on a scale, provided that infrastructural and educational barriers are addressed.

To strengthen the relevance of our findings beyond this initial cohort, we discuss national data on internet access, health disparities, and digital health adoption in Brazil. These contextual elements underscore the broader applicability of teleconsultation strategies, especially in low- and middle-income countries (LMICs) facing similar infrastructural limitations. In this sense, our findings may inform the integration of scalable and equitable LCS programs into public health systems such as Brazil’s SUS.

Barrier analyses in the Brazilian context frequently highlight issues such as unclear legal frameworks, fragmented regulations, multiple platform systems, and professional resistance to change all of which hinder telemedicine adoption.^29,32 Therefore, addressing these barriers is crucial to securing equitable access to telemedicine services and maximizing their potential benefits in healthcare delivery.^33,34

It is well recognized that lung cancer screening represents a timely opportunity to provide encouragement and emphasize the importance of smoking cessation to screening participants.^35-39 The interest in participating in the prevention program also demonstrates an interest in taking care of one’s health.³⁹ Our results were quite promising, as most screening participants expressed a desire to quit smoking, and all received brief counseling, with 17.1% reporting smoking cessation for at least 1 year. This outcome is significantly higher than the expected annual rate 3 to 7% among those who quit smoking in the general population.^40,41 These results corroborate studies that have found an association between participation in lung cancer screening and smoking cessation and observed that the motivation to quit smoking increases during this period.^35,36,42

Patient engagement is increasingly supported by digital tools, such as mobile health applications and online platforms. In Brazil, the 2019 National Health Survey found greater use of health apps among younger, more educated individuals in urban areas, highlighting digital inequities.⁴³ These innovations expand the doctor-patient relationship beyond traditional consultations, but they also bring challenges such as managing new data and the need to guide patients in the effective use of those tools.^33,44 Although our program does not include wearable devices, understanding the adoption and limitations of digital health tools is critical for designing inclusive and scalable screening programs.

Brazil has a national public health system, (Sistema Único de Saúde [SUS] in Portuguese).⁴⁵ To ensure the successful integration of a lung cancer screening program into the Brazilian public health system, it must demonstrate cost-effectiveness, considering the financial and logistical constraints inherent to a system of this scale in a low-and middle income (LMIC) country. In this context, teleconsultation may offer a practical, scalable, and cost-effective solution if coupled with strategies to bridge the digital divide, reduce inequalities in access, and support infrastructure expansion.²²

Despite our findings, our study has some limitations. As a cross-sectional observational study, it does not establish causal relationships but rather suggests associations that require confirmation in future longitudinal or interventional studies. The sample size, while adequate for descriptive analysis, may be underpowered to detect smaller effects or statistically significant differences in some outcomes. Smoking cessation was assessed by self-report without biochemical validation, which may lead to reporting bias. Although active recruitment strategies minimize self-selection bias, residual bias related to digital literacy and access cannot be completely excluded. Furthermore, the generalizability of our findings may be limited by the specific regional and health system context in Brazil, particularly in settings with different telemedicine infrastructure or socioeconomic characteristics.

Conclusion

Teleconsultation emerges as a viable method for delivering LDCT results and offering smoking cessation support in Brazil. It represents a scalable solution that may enhance accessibility and promote greater equity in lung cancer screening efforts, both in low- and middle-income countries and worldwide.

Supplemental Material

Supplemental Material - Teleconsultation for Delivering Low-Dose Computed Tomography Reports in a Mobile Lung Cancer Screening Program in a Low- and Middle-Income Country: A Cross-Sectional Study

Supplemental Material for Teleconsultation for Delivering Low-Dose Computed Tomography Reports in a Mobile Lung Cancer Screening Program in a Low- and Middle-Income Country: A Cross-Sectional Study by Fabiana de Lima Vazquez, Ludmila Pereira Barbosa dos Santos Carvalho, Anna Luiza Silva Almeida Vicente, Welinton Hirai, Carolina Lourenço Conceição, Eduardo Caetano Albino da Silva, Flávio Augusto Ferreira da Silva, Alexandre Arthur Jacinto, Rachid Eduardo Noleto de Nobrega Oliveira, José Elias Miziara, André Luiz Pinto, Leticia Ferro Leal1, Rodrigo Sampaio Chiarantano, Rui Manuel Reis in Cancer Control

Footnotes

Acknowledgments

We thank all members of the GTOP group (Translational Group of Pulmonary Oncology—Barretos Cancer Hospital, Brazil) for scientific discussion and suggestions.

ORCID iDs

Ludmila Pereira Barbosa dos Santos Carvalho

Rodrigo Sampaio Chiarantano

Rui Manuel Reis

Ethical Considerations

Consent to Participate

All participants provided written informed consent prior to enrollment, in accordance with Resolution No. 466/2012 of the Brazilian National Health Council.

Author Contributions

Fabiana de Lima Vazquez and Ludmila Pereira Barbosa dos Santos Carvalho contributed equally to the study design, data analysis, and manuscript drafting. Welinton Hirai and Anna Luiza Silva Almeida Vicente participated in data collection and statistical analysis. Carolina Lourenço Conceição were responsible for database organization and management. Eduardo Caetano Albino da Silva contributed to the histopathological evaluation of the cases. Flávio Augusto Ferreira da Silva, Alexandre Arthur Jacinto, Rachid Eduardo Noleto de Nobrega Oliveira, and José Elias Miziara supported clinical data interpretation and patient management. André Luiz Pinto assisted with coordination of the telemedicine process. Leticia Ferro Leal contributed to study supervision and review of the manuscript. Rodrigo Sampaio Chiarantano provided input regarding imaging methodology and interpretation. Rui Manuel Reis supervised the entire project, coordinated the research activities, and revised the final version of the manuscript. All authors read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by PRONON—PRONON/MS (Abordagens móveis e de tecnologia para prevenção primária e secundária de câncer—NUP: 25000.015000/2019-53) and Barretos Cancer Hospital. Rui Manuel Reis and Letícia Ferro Leal are supported by CNPq Productivity Fellowship. Ludmila Pereira Barbosa Dos Santos, Fabiana de Lima Vazquez and Anna Luiza Silva Almeida Vicente are supported by PRONON Fellowship.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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