Dr. Lisa Carter-Harris develops LungTalk, a computer tailored decision aid

By Mary Hardin

Wednesday, November 1, 2017

Some decisions should not be rushed. Marriage. Buying a home. College. Lung screening. Lung screening? Yes, said Lisa Carter-Harris, Ph.D., APRN, the developer and scientist behind LungTalk, a computer-tailored decision support tool.

Dr. Carter-Harris, an assistant professor in the Indiana University School of Nursing and researcher at the Indiana University Melvin and Bren Simon Cancer Center, and her team are experts in designing tools to facilitate shared decision making for patients and physicians. They have created and are testing LungTalk to help current and former smokers and their health care providers make informed decisions about lung screening.

Suitably named, LungTalk is a 10-minute video that can be accessed on a computer or tablet in the privacy of one’s home or in the patient waiting room before an appointment while there is time to organize thoughts and evaluate the important content. Listening and digesting the LungTalk message before a doctor’s appointment saves time and reduces stress for both busy physicians and possibly anxious patients.

“There is more involved with deciding to screen for lung cancer than a simple yes or no answer,” said Dr. Carter-Harris.

Lung screening is a relatively new cancer screening option. In 2013, the U.S. Preventive Services Task Force issued a recommendation for annual screening with low-dose computed tomography (CT) in adults between the ages of 55 and 80 years who have a 30-pack-year smoking history and currently smoke or had quit smoking within the past 15 years.

That recommendation came in response to the National Lung Screening Trial, the largest randomized clinical trial to date, that enrolled 53,000 current or former smokers. Half the study participants received annual low-dose CT and the other half underwent annual chest X-ray. The study revealed that a low-dose CT scan found lung cancer earlier and reduced mortality by 20 percent.

Annually, 158,000 Americans die from lung cancer, which is more than all those who succumb to the next three most common cancers -- breast, colon and prostate -- combined. There are approximately 220,000 new cases of lung cancer diagnosed in the United States annually, according to the American Lung Association, which recommends lung cancer screening. If half of the 8.6 million Americans who qualify as high risk for lung cancer received annual screening, nearly 13,000 lung cancer deaths could be prevented, the ALA reports.

More than 1 million Hoosier adults are current smokers. In Indiana, 20.6 percent of adults smoke, compared to the national average of 17.5 percent, according to figures released by the Indiana State Department of Health for 2015, the latest year reported. Indiana has the dubious distinction of being one of the 11 states with the highest incidence rates for lung and bronchus cancer, according to the Centers for Disease Control and Prevention. Indiana is among the 12 states, including tobacco-producers Kentucky, Tennessee, West Virginia and North Carolina, with the highest death rates from lung and bronchus cancer.

“Prior to 2013 there was no approved way to screen for lung cancer,” Dr. Carter-Harris said. “If there’s a test that can decrease mortality by 20 percent, why wouldn’t you screen?”

“If there’s a test that can decrease mortality by 20 percent, why wouldn’t you screen?”Lisa Carter-Harris, Ph.D.

That rhetorical question seems simple enough, but there are issues to consider, said Dr. Carter-Harris, and that is why LungTalk was created. In 2015, Medicare and the Affordable Care Act began covering lung screening with a caveat – for insurance to pay, shared decision making between a patient and health care provider is required. That, said Dr. Carter-Harris, was “exciting for researchers in my area” because it was the first time such an edict was applied through insurance coverage.

Agreeing to a lung scan seems like a no-brainer, until patients know all the facts. Frequently, the lung scan reveals something that requires follow up. In a recent study of more than 4,500 scans, nearly 55 percent required a follow-up procedure. If a suspicious spot is discovered, a full-dose CT scan is usually recommended and inconclusive results can lead to a biopsy.

“There are risks associated if a biopsy is required and individual insurance plans vary on coverage,” said Dr. Carter-Harris. “These are issues patients need to know and comprehend and that amount of information can be difficult to process in a brief clinical appointment.”

LungTalk is not the only decision support tool available, but many are cumbersome and not as straight forward as LungTalk. “We wanted to go beyond just the option of lung cancer screening, and educate patients about their overall lung health,” she said.

LungTalk is tailored by smoking status and provides an overview of lung health and the effect of nicotine on the lungs in lay language. Narrated by Dr. Carter-Harris, the video has visuals to assist individuals with understanding the function of the lung and how the screening process works. For current smokers, LungTalk has a brief game embedded that is meant to help smokers move forward toward wanting to make a quit attempt. It concludes with a tailored printout of things the patient wants to discuss with his or her physician that serves as a reminder and helps them start the conversation about lung screening.

LungTalk has been tested in the Indianapolis community and soon will be available in a pilot study in local primary care clinics. That step will take about six months, and then Dr. Carter-Harris and her team will follow up with those who participated to see what effect LungTalk had on their actions and outcomes.

“We think this is rather novel because the other programs available don’t tailor by smoking status and our previous research suggests messaging can have a role in patient perceived stigma. We want to empower patients to engage with their physicians and discuss lung screening.”
Lisa Carter-Harris, Ph.D.

“We think this is rather novel because the other programs available don’t tailor by smoking status and our previous research suggests messaging can have a role in patient perceived stigma. We want to empower patients to engage with their physicians and discuss lung screening,” she said.

Funding for LungTalk came from an IUPUI DRIVE Grant, an IU Simon Cancer Center American Cancer Society Institutional Research Pilot Grant and an IU School of Nursing Pilot Grant.

Members of the LungTalk development team are Susan Rawl, Ph.D., professor of nursing at the IU School of Nursing and co-director of the Cancer Prevention and Control research program at the IU Simon Cancer Center; Nasser Hanna, M.D., IU School of Medicine professor of medicine and a specialist in thoracic oncology; DuyKhanh Ceppa, M.D., an assistant professor of surgery at the IU School of Medicine and director of the IU Health Lung Screening Clinic; Robert Comer, M.S., research associate at the IU School of Informatics and Computing; and Jon Macy, associate professor in the School of Public Health and interventionist to promote smoking cessation at IU Bloomington.

Nursing students learn research skills while refining LungTalk

Six nursing honors students are learning the ins and outs of research while helping to fine-tune LungTalk, a digital tool designed to prepare patients to discuss lung screening with their health care providers.

The students are working under the guidance of Lisa Carter-Harris, Ph.D., APRN, an assistant professor in the IU School of Nursing and a researcher at the Indiana University Melvin and Bren Simon Cancer Center, who developed the computer-tailored decision support tool.

With a $458,000, three-year National Cancer Institute grant, Dr. Carter-Harris is able to mentor the students in data collection and analysis while pursuing information to make LungTalk more useful as a decision support tool.

The NCI grant is an Academic Research Enhancement Award designed to support outstanding research while offering opportunities to students to stimulate biomedical or behavioral science career interest.  

The students assisted with analyzing data from a survey that was completed by more than 500 current and former smokers. The questions helped researchers understand factors that influenced individual decisions to screen or not screen for lung cancer.

The survey participants are then sorted by 10 different benchmarks based on what influenced their decision about lung screening. Individuals from each of the groups will be interviewed by the students and those answers and the survey responses will help Dr. Carter-Harris make changes to LungTalk to better serve its audience.

“We are interested in the diverse perspectives on screening behavior,” she said. “We will use the information from the surveys and interviews to create better patient education about screening and to make LungTalk more beneficial to patients and clinicians.” 

Dr. Carter-Harris said projects like this make her work very gratifying – she is helping patients make decisions that will affect their health while mentoring future researchers, who also will make an impact on the health of others.

The students involved in the project are: Karlie Branson, Candice Elkins, Matthew Fields, Olivia McMahan, Sara Perez, and Lucy Straber.

By Mary Hardin