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Identifying Possible Work-Related Lung Cancer in the Clinical Setting – Getting Started
RS2006-DG02
Final Report Date: June 2008
| Principal Investigators: | Linn Holness & Irena Kudla (St. Michael's Hospital, Ontario) |
| Co-investigators: | Victor Hoffstein (St. Michael's Hospital, Ontario), Gary Liss (University of Toronto, Ontario) |
For more information about this project, please contact Dr. Linn Holness or Ms. Irena Kudla.
Issue
An estimated 9% to 15% of lung cancer may be work-related but most of these are not reported to workers’ compensation boards. Factors contributing to the under-reporting of occupational disease include clinicians’ lack of related knowledge, time constraints, administrative bureaucracy and a lack of clear referral routes. This study evaluated using a patient questionnaire to obtain information about lung cancer patients’ work exposures, and interviewed clinical team members about barriers and facilitators to assessing potential work-relatedness.
Key findings
- A questionnaire aimed at obtaining information about workplace exposures that may be associated with lung cancer is feasible in a clinical setting.
- Forty-one percent of the patients interviewed by the clinical occupational hygienist had potentially related workplace exposures, and were referred to an occupational health clinic for further investigation.
- Clinicians working in a lung cancer clinic setting recognize that some lung cancers may be associated with work. However, there are several barriers to clinicians identifying potentially related workplace exposures, including a lack of knowledge and training about occupational exposures associated with lung cancer, time constraints, a focus on treatment and management, complexity of the workers’ compensation system and the lack of easy referral to expert occupational medicine resources.
- An intervention study addressing the barriers and facilitators of recognizing and reporting possible work-related lung cancer should be undertaken.
Objectives
- To test whether it is feasible to use a standardized exposure questionnaire for lung cancer patients in clinical settings
- To identify perceptions of barriers and facilitators to implementing a workplace exposure assessment tool, from the perspective of the health care team and worker
Method
Twenty-nine patients with primary lung cancer attending a lung cancer clinic completed a focused exposure questionnaire. A clinical occupational hygienist also conducted interviews by telephone with 17 of the patients. If it was determined that the worker’s exposure might include agents associated with lung cancer, the worker was provided with information about filing a workers compensation claim and was referred to an occupational health clinic for further investigation.
Structured interviews were conducted with seven clinicians, including five physicians and two nurses from a lung cancer clinic in Toronto and a lung cancer clinic in Hamilton. The interviews focused on identifying barriers and facilitators to taking patients’ occupational history.
Results
Approximately half of the patients completing questionnaires reported having worked in unhealthy conditions and having been exposed to dusts, chemicals and fumes. Thirty-two percent thought that their problem was related to their work.
The most common exposures reported were asbestos (29%), solvents and wood dust (24%), and man-made mineral fibers (21%). Exposure to second hand smoke (prior to non-smoking bylaws) was experienced by 72% of participants.
In the occupational hygiene interviews with 17 of the patients, over half reported that their workplace had been unhealthy and they had exposure to dusts, chemicals and fumes, and 20% thought that their problem was related to work.
A total of 41% of the patients interviewed by the clinical occupational hygienist had potentially related workplace exposures. These patients were given information about how to file a workers compensation claim and were referred to an occupational health clinic for further investigation.
All of the clinical staff interviewed noted that they recognize that some lung cancers may be associated with work.
Barriers to clinicians investigating and reporting work-related lung cancer included: lack of knowledge and training about occupational exposures associated with lung cancer, time constraints, focus on treatment and management, complexity of the workers’ compensation system and lack of easy referral to expert occupational medicine resources.
Facilitators to clinicians investigating and reporting work-related lung cancer included: a patient completed exposure questionnaire, clear and simple referral criteria for clinicians and the availability of occupational medicine expertise to investigate the cases.
Conclusions
A questionnaire is feasible for collecting exposure information in lung cancer clinical settings. The questionnaire should be simplified, and it is preferable that it be completed by the patient. Clinicians identified the need for an efficient method to assess questionnaire responses to determine if a referral is necessary.
The time and knowledge constraints of clinical staff make it impractical to complete a detailed investigation of work-relatedness in that setting. Instead, a clear and accessible system of referral to occupational medicine expertise is needed.
Future directions
Building on findings of the pilot, a strategy to increase the reporting of possible work-related cancers can be developed, implemented and evaluated.
The next step is to conduct an intervention study. This could include the use of a modified patient-completed questionnaire, a method for easy clinical interpretation of the questionnaire and a clear referral source for further investigation.
Publications
St Michael’s Hospital Occupational Medicine Rounds – October 22, 2008.