Framing effects in decision aid-based lung cancer screening: a randomized clinical pilot trial in primary care

Background: The balance of risks and benefits associated with low-dose CT (LDCT) screening necessitates that high-risk individuals make informed decisions about lung cancer screening (LCS) based on their preferences. Patient decision aids (PDAs) can align these choices with patient values, and research indicates that message framing (gain vs. loss) significantly impacts decision-making. Despite extensive public health research on framing effects, there is limited understanding of how these messages can enhance LCS uptake. To address this gap, our research team developed the first LCS PDA in China, the LCS Loss-Gain Balance (LCS-LG-B), which integrates both gain-framed (emphasizing the benefits of healthy behaviors) and loss-framed (highlighting the costs of inaction) approaches. This study aims to investigate the effects of this PDA-based program on LCS behaviors among high-risk Chinese individuals. Methods: An intervention was designed around the LCS-LG-B to increase LDCT screening rates among high-risk individuals. This intervention included lung cancer risk assessments, education on lung cancer and LCS, shared decision-making exercises, and support for screening behaviors (e.g., smoking cessation resources, LCS information, and patient-doctor communication groups). A randomized clinical pilot trial was conducted with 72 high-risk lung cancer individuals in southeastern China from May 10, 2023, to February 10, 2024, with follow-up until October 10, 2024. Participants were randomly assigned to either the loss-framed or gain-framed version of the LCS-LG-B. Outcomes assessed at baseline (T0), immediately after the intervention (T1), and at one (T2), three (T3), and six months (T4) included LCS knowledge, health beliefs, decision conflict, self-efficacy, preparation, regret, and LDCT rates. Data were analyzed using a generalized linear mixed model and Chi-square tests, and the study is registered at the Chinese Clinical Trial Registry (ChiCTR2300071171). Findings: Sixty participants (30 from each group) completed all outcome measurements. Significant improvements were noted in decision conflict (F = 50.177, P < 0.001), self-efficacy (F = 57.505, P < 0.001), preparation (F = 45.599, P < 0.001), regret (F = 8.886, P < 0.001), LCS knowledge (F = 70.981, P < 0.001), health beliefs (F = 21.149, P < 0.001), perceived barriers (F = 20.020, P < 0.001), and perceived benefits (F = 3.098, P = 0.016). The mean perceived risk score was significantly higher in the loss-framed group at T2 (D = 1.533, P = 0.004), T3 (D = 1.900, P < 0.001), and T4 (D = 1.267, P = 0.017). However, there were no significant differences between groups in decision conflict, self-efficacy, preparation, regret, and LCS knowledge at T1, T2, T3, and T4 (P > 0.050). After the intervention, 12 participants (40.00%) in the loss-framed group underwent LDCT compared to 8 (26.67%) in the gain-framed group (χ2 = 1.200, P = 0.273). Interpretation: The LCS-LG-B addresses a research gap in Chinese LCS PDAs and is the first to apply cognitive framing in LCS decision-making. It effectively enhances LCS knowledge, health beliefs, decision quality, and LDCT rates among high-risk populations. This advancement supports informed LCS decisions and facilitates early lung cancer diagnosis. Future research should further explore the mechanisms and impacts of framing effects on LCS decision-making.