Shared decision-making for lung cancer screening in a pre-implementation context: A mixed-methods study

Lung cancer screening with low-dose computed tomography is increasingly recommended as a strategy to reduce lung cancer mortality. In the context of such screening programmes, shared decision-making (SDM) is essential for informed participation, yet how it should be meaningfully implemented remains unclear.

We conducted a mixed-methods study combining a scoping review and an exploratory qualitative interview study. The scoping review examined how SDM is described and currently applied in lung cancer screening. Seven databases were searched from inception to February 2025. In parallel, semi-structured interviews were conducted with healthcare professionals (HCPs) (N = 22) and potentially eligible screening participants (PSPs) for lung cancer screening (N = 13) in Flanders, Belgium. This represents a pre-implementation context without a population-based lung cancer screening programme although policy attention is increasing. Interviews explored perceptions of decision-making and expectations regarding SDM. Qualitative data were analysed using the Qualitative Analysis Guide of Leuven (QuAGOL).

Thirty-five studies were included in the scoping review. Across studies, SDM in lung cancer screening was associated with improved knowledge, lower decisional conflict, and greater satisfaction, although implementation in real-world clinical practice often remained limited to information provision rather than deliberation. Interview findings complemented the scoping review, demonstrating substantial variation in PSPs' preferred decisional roles. While some PSPs preferred independent decision-making, others valued collaborative decision-making and professional guidance. Across both study components, reassurance, feeling listened to, and personalised support emerged as central aspects of decision-making. HCPs additionally identified important implementation barriers for SDM, including limited consultation time, workload pressures, insufficient training, and challenges related to health literacy and communication.

Effective integration of SDM in lung cancer screening requires flexible, adaptive approaches that accommodate diverse decisional needs and avoid procedural or "tick-box" implementation. Embedding SDM within existing care pathways and using complementary professional roles may enhance feasibility.

Screening programmes should provide flexible decision support and allow SDM to be distributed across HCPs and encounters, enabling guidance to be tailored to individual preferences and values.