Abstract
Background:
This study aimed to gain insight into the opinions and attitudes about, and potential barriers and facilitators to lung cancer screening (LCS) among healthcare professionals in Estonia. It also aimed to determine knowledge gaps that could be addressed when planning next steps toward a national LCS program.
Methods:
A cross-sectional, web-based survey was conducted in June to August 2023 among primary care providers (PCPs), pulmonologists, radiologists, oncologists, and thoracic surgeons in Estonia. Differences between PCPs and other specialists were analyzed with regard to their knowledge, beliefs and attitudes toward LCS.
Results:
About 146 healthcare professionals responded, 57% were family physicians. Less than half of all respondents considered existing evidence or international recommendations sufficient to support national LCS implementation, with uncertainty higher among PCPs. Adjusted analyses revealed that the PCPs had substantially higher odds of responding “Do not know” concerning international recommendations (aOR 5.06; 95% CI 1.97–13.85), and were far less likely to agree to assigning main responsibility for LCS participation to family physicians (aOR 0.10; 95% CI 0.02–0.40). PCPs also demonstrated greater uncertainty about the costs and labor intensity in LCS.
Conclusion:
This study reveals substantial variation in LCS knowledge, attitudes, and certainty across healthcare profession(al)s, highlighting the need for targeted training. Although for most professionals the benefits of LCS outweigh potential harms, structural constraints and uncertainty should still be carefully considered. Despite limited generalizability, study findings support evidence-informed planning and have already been considered in the Estonian LCS pilot study, the first step toward a national LCS program.
Keywords
Significance for public health
Lung cancer screening (LCS) can reduce mortality through early detection, but its successful implementation depends on healthcare professionals’ support, knowledge, and engagement. This study provides the first comprehensive assessment of Estonian healthcare professionals’ perspectives on LCS prior to the launch of a national program. Identifying differences in the level of confidence, awareness, and perceived responsibility – especially comparing primary care providers and specialists – highlights the need for targeted training, communication strategies, and clear role definitions. These insights are critical to minimizing barriers and enhancing provider-driven screening uptake. The findings have already informed Estonia’s LCS pilot study and provided essential input for nationwide planning. By addressing the healthcare providers knowledge gaps and professional concerns early, public health authorities can foster an effective, equitable, and well accepted LCS program – potentially increasing screening uptake and reduce lung cancer mortality.
Introduction
The global burden of lung cancer (LC) is substantial. In 2020, LC accounted for 11.4% (2.2 million) of all new cancer cases and 18% (1.8 million) of all cancer deaths in the world. 1 In Europe, the proportions of new LC cases of all new cancer diagnoses and deaths were slightly higher, with corresponding rates 11.8% and 19.8%, respectively. 2 In Estonia, each year around 800 people are diagnosed and 600 people die from lung cancer.3,4 Among men, lung cancer incidence has declined since the 1990s, primarily due to substantial reduction in squamous cell carcinoma and small cell lung cancer, that has outweighed the increasing incidence of adenocarcinoma and large cell carcinoma. In women, LC incidence for all major histological types, except for small cell LC, has increased. 5 During last decades, LC 5-year survival has increased, especially for localized LC. 6 In 2016–2020 the age-standardized 5-year relative LC survival in men was 18% and in women 30%. 7
European expert groups recommend initiating lung cancer screening (LCS) programs in European countries, as the effectiveness of screening has been scientifically proven.8,9 A reduction of at least 20% in lung cancer mortality has been demonstrated in two large randomized controlled trials using low-dose computed tomography (LDCT) screening.10,11 Clinical trials on LCS have also been conducted in Europe, and pilot programs are underway in several countries, including the United Kingdom, Germany, Italy, Norway, and Spain.12,13 A few countries, for example, Croatia, Hungary, Poland, and the Czech Republic, are already running a national LCS program.14–19
Compared to the ongoing national screening programs (e.g. breast, cervical and colorectal cancer screening), in LCS greater commitment is required from healthcare professionals, as the inclusion criteria involve not only age and gender, but also other risk factors like detailed smoking history have to be assessed. 20 Several studies have been conducted to map the knowledge, attitudes, and practices of healthcare professionals, most in the US among primary care clinicians and pulmonologists.21–25 In Europe, there are still only a few such studies.26,27 Understanding the knowledge, opinions, and attitudes of healthcare professionals involved in recruiting people for screening (such as family physicians and nurses), as well as those interacting with patients during or following the screening process, can play an important role in the effective planning and implementation of a screening program.
The primary objective of this study was to gain insights into the opinions and attitudes about, and other potential barriers and facilitators to LCS among healthcare professionals in Estonia. We also aimed to determine knowledge gaps that could be addressed when planning the next steps toward a national LCS program in Estonia, where a regional pilot study is running for the second year.
Methods
Study population
In this cross-sectional study, family physicians and family nurses (primary care providers, PCPs), pulmonologists, radiologists, oncologists, and thoracic surgeons in Estonia were surveyed. These specialties were chosen, based on involvement in LCS and/or becoming into contact with patients after detection of LC and/or any other important incidental findings in Estonia.
In 2022, according to the Estonian Health Statistics and Health Research Database, 28 there were 944 working family physicians (87% females, average age 55 years), 1604 family nurses (99% females, average age 45 years), 59 pulmonologists (83% females, average age 54 years), 209 radiologists (61% females, average age 49 years), 52 oncologists (69% females, average age 49 years), and 8 thoracic surgeons (25% females, average age 47 years) in Estonia. Considering all physicians in Estonia, 53% work in Harju County (including the capital Tallinn), 29% in Tartu County (including the county center Tartu), and 18% in other counties. Considering family physicians and nurses, 57% work in Harju County (including Tallinn), 16% in Tartu County (including Tartu), and 27% in other counties.
The study inclusion criteria were: being a practicing healthcare professional in Estonia, membership in an Estonian professional society of a specialty relevant to LCS (family physicians, family nurses, pulmonologists, radiologists, oncologists, thoracic surgeons), and ability to complete the survey in Estonian or Russian. The exclusion criteria were: health professionals not directly involved in LCS and incomplete responses; however, in this dataset all responses were complete.
Data collection and analysis
The survey questionnaire was sent to the Estonian health professionals through the email lists of respective professional societies at the beginning of June 2023. As family nurses do not have a professional society, they were attempted to reach through the family physicians’ society. Reminders to complete the questionnaire were sent at the end of June and in August. Data were collected until the end of August 2023. The responses, without recording personally identifiable information (including the computer IP address of the responder), were recorded, and the data were administered on the Research Electronic Data Capture (REDCap) platform (REDCap 13.4.13, Vanderbilt University) in the secure server of the University of Tartu. The survey platform was configured requiring a response to all questions before submission, and therefore all the submitted questionnaires were complete (with no data missing). No formal sample size calculation was performed, as the questionnaire was disseminated to all eligible healthcare professionals through their respective professional societies. The final sample size was therefore determined by the number of respondents during the data collection period.
Questionnaire
The study questionnaire was based on questionnaires used in similar surveys conducted in other countries.29–32 Also feedback obtained during the Estonian LCS pilot study, that is, from the focus group interviews conducted after the first year of the pilot study, was taken into consideration while developing the questionnaire (unpublished data). However, no formal psychometric validation or structured pre-testing (e.g. pilot testing or reliability assessment) of the Estonian and Russian language versions was conducted prior to data collection. The online self-administered questionnaire was anonymous.
The developed questionnaire “Healthcare Professionals Survey: Attitudes and Perceptions Related to Lung Cancer Screening Among Family Physicans, Family Nurses, and Other Specialists Dealing with Lung Cancer” consisted of 15 questions, which can be divided into five topics: (1) Sociodemographic information (7 questions, Supplemental Table 1 questions 1–7), (2) Knowledge of and opinion about current LCS evidence (2 questions, Supplemental Table 1 questions 8–9), (3) Knowledge of and opinion about LCS criteria and methods (4 questions, Supplemental Table 1 questions 10–11, 14–15), (4) Importance of different topics in LCS related counseling (1 question and 13 statements, Supplemental Table 1 question 12), (5) LCS barriers and facilitators to LCS (1 question and 14 statements, Supplemental Table 1 question 13). Quantitative variables (age, years of experience, and number of LC patients seen per month) were collected in predefined categories and analyzed as categorical variables. Knowledge and attitudinal items were measured on 5-point Likert scales and analyzed as ordered categorical variables without collapsing the categories. The entire questionnaire is presented in Supplemental Table 1, Appendix.
The questionnaire was disseminated through national professional societies to maximize accessibility across all relevant health professionals. Nevertheless, voluntary participation may have introduced selection bias, as health professionals with a greater interest in the topic or higher digital engagement were more likely to participate.
To minimize response bias, the questionnaire was fully anonymous and no identifiable information was collected. In the introductory section of the web-based questionnaire, participants were informed that participation was voluntary, responses would be collected anonymously, IP addresses would not be recorded, and that by proceeding with the questionnaire they were providing informed consent to participate in the study. Given the anonymous and minimal-risk nature of the study, written (signed) informed consent was not required, as approved by the ethics committee.
Ethics statements
The study was approved by the Research Ethics Committee of the University of Tartu (376/T-29; April 17, 2023).
Data analysis
Descriptive statistics were used to characterize participants’ sociodemographic characteristics and their knowledge, opinions, and attitudes regarding LCS. Fisher’s exact test was applied to assess bivariate associations between medical specialty (PCPs vs other specialists) and categorical outcomes. Subgroup analyses were limited to comparisons between PCPs and other specialists, reflecting the central role of PCPs in patient enrollment and initial assessment within the ongoing Estonian LCS pilot study, as well as the limited sample sizes of individual specialist groups.
Multivariable logistic regression was used to assess whether the observed differences remained significant after adjustment for potential confounders. All adjusted models included sex, age group, years of professional experience, and prior participation in the LCS pilot study as covariates. The healthcare profession(al) group served as the reference category in all the regression analyses. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Outcomes with extremely sparse cell counts were not modeled or, when models failed to converge, results were interpreted cautiously.
For all analyses, p value < 0.05 was considered statistically significant. All statistical analyses were conducted using R-4.2.2 and RStudio-2023.12.1-402. The reporting of this study conforms to the STROBE statement, 33 with the completed checklist provided in Supplemental Table 5 in the Appendix.
Results
Study participants
Our final sample included 146 healthcare professionals (131 physicians and 15 family nurses), of whom 87% (n = 127) were female (Table 1). All variables had complete data, with no missing responses. As the questionnaire was disseminated through professional societies, the exact number of healthcare professionals who received the invitation could not be determined, and therefore the overall response rate and reasons for non-participation could not be assessed. A little over half of the study participants were older than 50 years (56%) and had worked in their field for over 20 years (54%). Also, more than half (57%) were family physicians. Most of the study participants (70%) worked in the two largest counties – Harju and Tartu, where the two largest cities, Tallinn and Tartu, are located. This also applies to the biggest professional group among the study participants, that is, the family physicians and nurses, with 66% and 67% (respectively) working in those two regions.
Characteristics of study participants, overall, and by specialty.
PCP: primary care provider.
Of the study participants, 82% reported seeing less than five cases of LC per month. Already, 16% had participated as researchers in the feasibility and/or pilot study of the LC screening project, conducted in Tartu and Tartu County between 2021 and 2023.
LCS evidence
According to the opinion of less than half of the study participants (39%), there is currently enough research evidence to build a national LCS program on (Table 2). Similarly, only 38% of the study participants thought that there are enough recommendations from international professional organizations to initiate LCS. However, more than half of the study participants still did not have an opinion about these questions. PCPs indicated more often that they do not know, while other specialists were more inclined to believe that there is sufficient evidence and international recommendations to start screening.
Opinion on current evidence of LCS, overall, and by specialty; multivariate analysis other specialists versus PCPs.
PCP: primary care provider.
The p value corresponds to Fisher’s exact test comparing PCPs and other specialists answer by answers.
adjusted for sex, age, years of experience and previous participation in LCS feasibility and/or pilot study.
In the adjusted model (Table 2) including sex, age, years of experience and prior LCS pilot study participation, PCPs were more likely than other specialists to answer “Do not know” (aOR 4.35, 95% CI 1.68–11.9, p = 0.003). In the full sample, sex, age, and professional experience were not associated with uncertainty, while non-participation in the pilot study showed a non-significant trend toward increased uncertainty (aOR = 2.9, p = 0.059). Among PCPs, the effect was stronger: non-participation in the pilot study was significantly associated with higher odds of uncertainty (aOR = 3.23, 95% CI 1.02–10.8, p = 0.049). For the comparison between “No” and “Yes” responses in Q8 (enough research evidence), the number of respondents selecting “No” (n = 11) was too small to produce stable multivariable estimates. Therefore, no reliable conclusions can be drawn about the differences between PCPs and other specialists for this response category.
Considering whether there are sufficient international recommendations to support initiation of a national LCS program, in adjusted analyses, PCPs had over fivefold higher odds of selecting “Do not know” rather than “Yes” (aOR = 5.06; 95% CI 1.97–13.85; p = 0.001). Compared with other specialists, PCPs did not have significantly different odds of selecting “No” rather than “Yes” regarding whether sufficient international recommendations exist (aOR = 0.87, 95% CI 0.02–4.54, p = 0.506).
LCS program criteria and methods
Majority of the study participants (82%) stated that individuals should be included in the screening, using a validated LC risk score (see Supplemental Table 2, Appendix). Statistically significantly (p = 0.005) more PCPs would involve individuals to LCS based solely on smoking compared to other specialists. Considering the age criteria for involving people in the LCS, the most common response (42%) was that both an lower and upper age limit should be defined. The study participants were equally divided between those who believed that smoking cessation counseling should definitely be part of the screening program, and those who thought it should be voluntary (45% and 44% respectively).
An equal proportion of the study participants considered that the individuals themselves and a national screening center should be responsible for individuals’ participation in the screening (38% and 36%, respectively). A significant difference (p = 0.008) between PCPs and other specialists occurred regarding who should be responsible for ensuring individuals’ participation in the screening. PCPs preferred that the responsibility would lie with the individuals themselves or the national screening center, whereas other specialists also saw an important role for the family physician and nurse.
In the adjusted model (Table 2), PCPs showed a tendency to more often attribute responsibility for participation in LCS to individuals themselves, compared to other specialists (aOR = 2.41; 95% CI 0.99–6.20; p = 0.058), although this association did not reach statistical significance. In contrast, PCPs were markedly less likely than other specialists to state that family physicians should be responsible (aOR = 0.10; 95% CI 0.02–0.40; p = 0.002), reflecting that this view was expressed almost exclusively by other specialists. No significant differences were observed between PCPs and other specialists in assigning responsibility to a centralized screening center (aOR = 1.37; 95% CI 0.56–3.43; p = 0.50). The remaining categories – pulmonologist, oncologist, other, and do not know – could not be analyzed properly due to small cell counts.
Among primary care physicians, lack of prior participation in the LCS pilot study was consistently associated with less certainty and more external attribution of responsibility. PCPs who had not participated, were significantly more likely to assign responsibility for ensuring participation in LCS to a national screening center (aOR 3.99, 95% CI 1.21–16.50), and were also more likely to report uncertainty regarding the sufficiency of international evidence (aOR 3.23, 95% CI 1.02–10.82). Other covariates (sex, age, years of experience) were not significantly associated with any of the outcomes in the adjusted models.
Counseling individuals regarding LCS
When counseling individuals regarding LCS, study participants considered the following topics to be very important: patient’s individual risk for LC, benefits of early detection of LC, importance of smoking cessation and options for supporting it (see Supplemental Table 3, Appendix). Considering different specialties, statistically significant differences (p < 0.05) in opinions only appeared regarding smoking cessation and the options supporting it as topics in counseling LCS participants. Compared to other specialists, PCPs considered the smoking cessation topic more important part of LCS.
LCS barriers and facilitators
The majority of study participants (75%) agreed that the benefits of LCS are important enough to justify its implementation (see Supplemental Table 4, Appendix). Compared to other specialists, PCPs were less inclined to strongly agree, with a higher proportion expressing uncertainty regarding this matter. However, the majority of all study participants agreed that the benefits of LCS for individuals outweigh the potential harms (89%), and that it is likely that individuals are interested in participating in the screening (84%). There was a tendency to agree (63%) that the limited availability of computed tomography scans hinders the implementation of screening. Other specialists agreement with this statement was stronger than that of the PCPs.
There was a statistically significant difference (p = 0.001) in the perspectives on screening costs. PCPs were more inclined to respond with uncertainty, whereas other specialists did not perceive screening implementation overly costly. In the adjusted analysis (Table 2), meaningful associations were observed only for two response categories. PCPs had significantly lower odds of selecting “Somewhat agree” (aOR 0.35, 95% CI 0.13–0.96, p = 0.042), indicating that they were less likely than specialists to express moderate concern about the cost of LCS. Conversely, PCPs had substantially higher odds of selecting “Do not know” (aOR 28.87, 95% CI 6.64–194.25, p < 0.001), reflecting markedly greater uncertainty about the economic implications of LCS. For the remaining response categories, adjusted models could not produce stable estimates due to very small cell counts, and no conclusions can be drawn for these categories.
Study participants’ opinions diverged statistically significantly (p = 0.010) on whether conducting screening tests would be too labor-intensive or not. Once again, PCPs were more uncertain (they couldn’t say), while other specialists tended to agree more that screening would be too labor-intensive. In the adjusted analysis, for most response categories, PCPs and specialists did not differ in their perceptions of whether LCS is too labor-intensive. PCPs were significantly less likely than specialists to strongly agree that LCS is overly labor-intensive (aOR 0.29, 95% CI 0.08–0.97). In contrast, they were substantially more likely to respond “do not know” (aOR 49.2, 95% CI 6.15–1426), indicating markedly greater uncertainty about the operational burden of LCS among PCPs. Responses in the intermediate categories (“somewhat agree” and “somewhat disagree”) did not differ by specialty
Discussion
In this cross-sectional study, the results of a survey among Estonian healthcare professionals about their knowledge, opinions and attitudes related to LCS are reported, being the first attempt to map their perspective in Estonia. Study participants demonstrated good knowledge of the subject matter. However, opinions about the barriers and facilitators of LCS varied. Slightly more than half of the study participants were not sure whether there are currently sufficient research evidence and/or international recommendations to initiate a LCS program in Estonia. This uncertainty was significantly more pronounced among PCPs, who were more likely than other specialists to respond “Do not know,” even after adjustment for demographic and professional factors. Although this finding is based on a sample with a very low response rate, and is therefore unlikely to be representative of all PCPs, it is consistent with previous studies showing that physicians often consider the evidence supporting LCS to be adequate,22,30 while PCPs in particular have also reported knowledge gaps regarding the LCS evidence base.26,34 Non-participation in the national LCS pilot study further increased uncertainty, particularly among PCPs, suggesting that direct involvement in LCS-related initiatives may enhance confidence in the evidence base. When the NLST study was published, all major concerned professional organizations/societies in the USA introduced recommendations for LCS. The American Family Physicians Association made their screening recommendation only in 2021. 35 This may refer to PCPs having been somewhat more cautious regarding the evidence on LCS. This pattern of uncertainty highlights the importance of clear and centrally coordinated communication of updated evidence and guidelines, which in the Estonian context is closely intertwined with targeted training activities.
Most (82%) participants agreed that individuals should be included in the screening, using a validated LC risk score. More PCPs would involve individuals to LCS based solely on smoking status/history, compared to other specialists. Opinions about LCS participants’ age limit varied, but 42% of study participants thought both the lower and upperage limit should be defined. The variation in opinions about LCS target group reflects the variation in international recommendations. Since the publication on The National Lung Screening Trial in 2011 10 presenting reduction in mortality and the first recommendations supporting LCS implementation, the age limits, smoking history definition and use of a validated LC risk score as inclusion criteria for LCS have been subject to constant change.36,37 Hence, it is somewhat understandable that there are discrepancies or even gaps in physicians’ knowledge, as also proposed by authors in other studies.22,24
Opinions varied regarding mandatory versus voluntary smoking cessation counseling, with PCPs, compared to other specialists, considering it a more important part of LCS. Although in some countries, smoking cessation counseling is a mandatory part of the LCS program, in others optional, in general the opinion that smoking cessation counseling should be part of LCS program, prevails.26,38 In Estonia, free smoking cessation counseling is available and conducted by different healthcare professionals or specialists in counseling centers across the country.
Participation in cancer screening is a shared decision-making process and should be based on the informed consent, provided by the participating individual. According to healthcare professionals in the study reported here, the most important topics to discuss with the individuals before referring them to LCS, were: survival rates based on the LC stage at detection, patient’s individual risk for LC, benefits of early detection of LC and importance of smoking cessation and options supporting it. Shared decision-making and individual counseling require healthcare professionals’ sufficient training on those topics and materials to share with individuals, that is, support counseling.
The study participants stated almost equally that either the individuals themselves or a national screening center should be responsible for the participation of the individuals in screening. This finding contrasts with several previous studies in which PCPs more often considered primary care specialists to be responsible for screening initiation, implementation and follow-up.27,30 In the present study, however, PCPs were significantly less likely than other specialists to assign responsibility to family physicians. Instead, the PCPs tended to assign responsibility on the individual or on a centralized screening structure, suggesting a more externalized perception of responsibility. Importantly, PCPs who had not participated in the national LCS pilot study, were more likely to assign responsibility to a national screening center and to express uncertainty, indicating that direct involvement in pilot activities strengthens confidence that LCS can be feasibly implemented through primary care. However, this observation is based on a study with a very low response rate, and may thus not be representative of all the PCPs. In Estonia, the so far conducted LCS feasibility and pilot studies have been led physicians and researchers, however the implementation of a national screening program needs a central management as stated in the screening cost-effectiveness analyses. 39 Also, other studies conclude that centralized coordination is needed. 34
The tendency of PCPs to defer responsibility to individuals or a centralized screening structure may also reflect the structural constraints of the primary care system in Estonia. Family physicians operate under substantial time constraints, increasing administrative workload, and limited consultation time, which may reduce their capacity to take on additional responsibilities such as LCS eligibility assessment, counseling, and follow-up. In addition, uncertainty regarding reimbursement mechanisms and resource allocation for LCS-related activities in primary care may also contribute to preferring centralized coordination. In this context, deferring responsibility may reflect/show a pragmatic response to system-level constraints rather than lack of professional engagement.
The majority of study participants agreed that the benefits from the screening justify its implementation, but it was evident that the agreement of PCPs was not as strong as that of other specialists. However, all the study participants agreed that the benefits of LCS for the participating individuals outweigh the potential harms. A similar study has revealed that most family physicians agree that the benefits of LCS outweigh the harms. 25 However, in another study, when comparing PCPs and pulmonologists, the latter were more inclined to perceive LCS beneficial for participating individuals. 32
In the study, there was a tendency to agree (63%) that the limited availability of computed tomography hinders the implementation of the screening. Also a study by Tuckey et al has revealed the concern about unavailability of computed tomography. 31 Most study participants agreed that other factors (e.g. adverse effects, too time-consuming for individuals) are not important barriers to implementing LCS. Opinions regarding potential barriers, such as the cost and labor-intensity of LCS, varied across cross different healthcare profession(al)s. In particular, PCPs (compared to other specialists) expressed markedly greater uncertainty about the economic implications of screening. However, this observation should be interpreted with caution, as it is based on low response rate, and may not be generalizable to all PCPs. While other specialists generally did not perceive LCS implementation as overly costly, PCPs were substantially more likely to report uncertainty rather than express either agreement or disagreement, indicating limited confidence in assessing the cost-related aspects of LCS implementation. Other studies have presented clinicians’ (more often PCPs’) concerns about the time limits in a visit, inadequate staffing, costs to the participating individual, LCS cost-effectiveness and issues with insurance coverage.22,29,30,32,34 In Estonia, where insurance covers the screening and 94% of people are insured, the cost for the individual in most cases is not an issue. 40
In Estonia, steps toward a national LCS program began with a feasibility study in 2021 in three primary care practices in Tartu, the second-largest city and medical care center in Estonia. 41 After that, a regional pilot study was launched in Tartu County (which comprises 10% of the Estonian population) in 2022, and is now in its third year. In this study, 21% of the responding PCPs had already participated in either the feasibility or the pilot study, and thus had some experience with LCS. The ongoing Estonian LCS pilot study achieved a high participation rate of 79% in its first year, 42 indicating effective recruitment through PCPs.
Most of the study participants worked in Estonia’s two most populous counties, Harju and Tartu County, where the country’s two third stage hospitals are located, and the healthcare network is more developed, making higher representation of these areas expected. Although family physicians practice across the entire country, also a substantial proportion of participating PCPs originated from these two regions. Notably, PCPs from Tartu County were overrepresented in the study, which may reflect their closer involvement in LCS-related research activities and the pilot study, as well as greater exposure to academic and clinical discussions on the topic. The majority of participants reported seeing fewer than five lung cancer patients per month, which is consistent with the study population being largely composed of family physicians. This is further supported by national figures, as approximately 800 new lung cancer cases are diagnosed annually in Estonia, while nearly 940 family physicians are currently in practice.4,28
This study has several limitations. Firstly, the overall participation rate was low, particularly among family nurses and radiologists (<5%) and family physicians and oncologists (approximately 10%), which may have introduced selection bias and limits the generalizability of the findings to these groups. In contrast, the participation rates were higher among pulmonologists (50%) and thoracic surgeons (60%), which may partly reflect their stronger involvement in planning and conducting LCS in Estonia (the pilot study) so far. The response rate in web-based surveys among healthcare professionals tends to be low,43,44 and in the current study it was similar to other LCS surveys conducted among physicians.27,32 Secondly, because the questionnaire was disseminated through professional societies, the exact number of health professionals who received the invitation could not be determined. Not all health professionals are members of these societies, while some members may be retired or working abroad; therefore, the denominator is imprecise, and the true response rate may have been somewhat higher than calculated. Consequently, the exact overall response rate and reasons for non-participation remain unknown, which further limits generalizability of the study results. Thirdly, the response rate was likely most influenced by the questionnaire distribution method, as the state registry of health professionals does not allow contacting them directly, and thus the researchers had to rely on professional societies in distributing the study questionnaire to their members via their e-mail lists. Voluntary participation may have led to overrepresentation of physicians with greater interest in LCS or higher digital engagement, potentially biasing the results toward more positive attitudes. In addition, no a priori sample size calculation was performed, as the survey was disseminated to all eligible professionals through their societies. Comparing the study sample to national healthcare workforce statistics indicates some degree of selection bias. PCPs from Tartu County were overrepresented relative to their national distribution, while PCPs from other regions were underrepresented, likely reflecting greater engagement of Tartu-based physicians in academic activities and the ongoing LCS pilot study. Consequently, participating PCPs may have had higher baseline awareness and exposure to LCS than the general PCP population. This selection pattern may have influenced the observed differences between PCPs and other specialists. However, it unlikely inflated the opinion gap. If anything, the overrepresentation of more engaged PCPs may have led to an underestimation of uncertainty and perceived barriers among PCPs on the national level, suggesting that the observed differences represent a conservative estimate of the true gap between healthcare profession(al)s. Future studies with higher and more geographically balanced participation would allow more precise estimation of profession(al) group differences, and strengthen the generalizability of the findings. Due to the small size of the subgroups, other healthcare profession(al)s were combined into a single “other specialists” group, which may have masked profession-specific differences and should be considered when interpreting the comparisons with PCPs. Finally, the survey was conducted during the summer vacation period, which may have further reduced participation. Yet, this choice was justified, as utilization of the results in designing the next step in LCS in Estonia (the second year of the pilot study) was planned.
This study offers valuable insights into Estonian healthcare professionals’ perspectives on LCS. The findings, while informative, should be interpreted with caution given the low and uneven participation rates and the uncertainty regarding the denominator of invited professionals, which may limit generalizability. Nonetheless, the results are broadly consistent with international evidence and provide useful input for planning screening implementation in Estonia and comparable healthcare settings.
Conclusion
The study reports results of a survey among Estonian healthcare professionals regarding their knowledge, opinions and attitudes related to LCS. Overall, the study participants demonstrated solid understanding of the subject matter; however, notable differences in perspectives and levels of certainty were observed between PCPs and other specialists. Awareness of these differing viewpoints can assist LCS organizers in tailoring further training and screening implementation strategies. Most healthcare professionals considered that the benefits of LCS outweigh its potential harms, and are sufficient to justify LCS implementation.
The findings of this study should be interpreted with caution due to the low response rates and uncertainty regarding the denominator of the invited professionals, potentially limiting the generalizability. Nevertheless, the results are largely consistent with international evidence, and have already informed the ongoing Estonian LCS pilot study, while also providing valuable input for the development of a future national LCS program in Estonia and similar healthcare systems in other countries.
Supplemental Material
sj-docx-1-phj-10.1177_22799036261439973 – Supplemental material for Lung cancer screening knowledge, opinions and attitudes among healthcare professionals in Estonia prior to national program initiation
Supplemental material, sj-docx-1-phj-10.1177_22799036261439973 for Lung cancer screening knowledge, opinions and attitudes among healthcare professionals in Estonia prior to national program initiation by Kadi Kallavus, Tanel Laisaar and Kaja-Triin Laisaar in Journal of Public Health Research
Footnotes
Acknowledgements
The authors have no additional acknowledgments to disclose.
Ethical considerations
The study was approved by the Research Ethics Committee of the University of Tartu (376/T-29; April 17, 2023).
Consent to participate
Written informed consent was not required due to the anonymous and minimal-risk nature of the study. Participants provided informed consent electronically by proceeding with the questionnaire.
Author contributions
Conceptualization, K.K., T.L., K-T.L; investigation, K.K.; methodology, K.K., T.L., K-T.L.; data curation, K.K., T.L.; formal analysis, K.K.; writing – original draft, K.K.; writing – review & editing, T.L., K-T.L. All authors have read and agreed to the published version of the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.*
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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