Lung Cancer Screening Delivery in a Decentralized Program: Patient and Provider Perspectives

IntroductionLung cancer is the leading cause of cancer-related death in Alabama, where screening uptake remains well below national benchmarks. Decentralized screening programs, in which referring providers manage eligibility identification, referrals, and follow-up without dedicated coordination infrastructure, are common across clinical settings. Yet the relationship between program design and delivery outcomes in decentralized contexts has received little attention. This study examined how a decentralized lung cancer screening program delivered screening across each step of the pathway, from patient identification through annual follow-up. The goal was to identify where and how program design produced gaps in delivery from the perspectives of patients and providers.MethodsThis qualitative study used semi-structured interviews conducted between July 2023 and May 2024 at an academic medical center in Alabama as part of a larger explanatory sequential mixed methods study. Fifteen patients who had completed screening and six providers representing primary care, pulmonology, and radiology participated. Interviews explored screening awareness, decision-making, and program delivery processes. Transcripts were analyzed using the Consolidated Framework for Implementation Research (CFIR) and constant comparative method. Reporting followed the COREQ guideline.ResultsDelivery failures were structural and concentrated at the front end of the screening pathway. Eligibility identification depended on incidental patient exposure rather than systematic outreach. Referrals reflected individual provider initiative rather than standardized workflows. Result tracking and nodule follow-up fell to ordering providers without dedicated support. Coverage gaps and geographic distance compounded these determinants.ConclusionReduced uptake in this decentralized program pointed largely to structural barriers. Closing the implementation gap may require program design changes and proactive outreach that does not depend on the clinical encounter to begin.