The American Journal of Managed Care
July 2024
Volume 30
Issue 7
Pages: e198-e202

Patient Satisfaction With Letter-Based Communication of LCS Pulmonary Nodule Results

Patients were satisfied with receiving their lung cancer screening (LCS) pulmonary nodule results via letter and considered the amount of information provided in the letter appropriate.


Objective: To analyze patient satisfaction with letter-based communication of lung cancer screening (LCS) pulmonary nodule results.

Study Design: Prospective randomized controlled trial of LCS between May and December 2019.

Methods: All participants came from a prospective randomized controlled study on pulmonary nodule results in LCS with low-dose CT (LDCT) to analyze patient satisfaction, perception of information received via letters, preferred methods of receiving results, and dissatisfaction-related characteristics.

Results: A total of 153 patients were detected to have pulmonary nodules among 600 recruited participants in the lung cancer high-risk group screened using LDCT. Most of the patients were satisfied with receiving pulmonary nodule results via letters (78.4%; n = 120) and agreed that the letters contained an appropriate amount of information (83.7%; n = 128). Univariate logistic regression analysis revealed that satisfaction was related to age (OR, 0.905; 95% CI, 0.832-0.985), education level (OR, 0.367; 95% CI, 0.041-3.250), no family history of cancer (OR, 0.100; 95% CI, 0.011-0.914), and the number of nodules (OR, 6.028; 95% CI, 1.641-22.141). Of the patients who reported dissatisfaction with letter-based communication (7.2%; n = 11), the most common reasons cited were that they contained insufficient patient education materials and that it was difficult to comprehend the medical terminology. The majority of participants (61.4%; n = 94) reported that they would prefer the letter-based communication. No correlation was identified between satisfaction and gender, smoking status, alcohol consumption, risk factors, nodule size, or nodule location.

Conclusions: Patients were generally satisfied with receiving their LCS pulmonary nodule results via letters, reporting that the letters included adequate information about their diagnosis and follow-up steps. This may provide a basis for feasible result communication via letters for cancer screening programs in underdeveloped regions in China.

Am J Manag Care. 2024;30(7):e198-e202.


Takeaway Points

There is no evidence about the influence of communication methods on the satisfaction of patients with pulmonary nodules in China. In this study, we analyzed patient satisfaction with letter-based communication of pulmonary nodule results of lung cancer screening and investigated the characteristics related to dissatisfaction to provide a feasible approach for the communication of large-scale screening results in China in the future.


Lung cancer is a disease with a high mortality rate that can be reduced by early detection with lung cancer screening (LCS) using low-dose CT (LDCT).1 Encouraging outcomes from the National Lung Screening Trial and NELSON studies have led to LDCT becoming the gold-standard method for LCS in Europe and the US, and it has gained popularity in China in recent years.2-5 As rates of LCS have increased, so, too, have rates of false-positive results, especially in the detection of pulmonary nodules. Studies also show that millions of patients experience pulmonary nodules each year,6 and stress, anxiousness, and distress are commonly reported symptoms after receiving this diagnosis.7,8

With the help of LCS implementation, the detection rate of pulmonary nodules has increased from 8% to 51%.9,10 Although there is ongoing research about patient education as part of joint decision-making before they undergo LCS, there is comparatively little published to inform best practice methods of follow-up communication to inform patients about their LCS results.11 A pilot trial of a letter-based communication tool found that it helped to relieve anxiety and distress, having subsequent impact on patient perception and expectation of diagnosis and treatment strategies.8,12 The methods to convey the screening results may vary across health care settings, mainly including face-to-face consultation, telephone calls, letters, text messages (SMS), and emails.13-16 A systematic review of breast cancer and cervical cancer screening in the US showed that letter-based communication of results could reduce anxiety; however, as economical and efficient as it might be, it was at the expense of patient comprehension and satisfaction.17,18 Dickson et al previously reported that written communication methods for results were satisfactory for the majority of patients with pulmonary nodules detected on LDCT in the United Kingdom.19 However, a certain proportion of patients reported that due to the lack of opportunities to raise questions, receiving results by letters left them confused and concerned, thus contributing to their preference of LCS follow-up by phone calls instead.20 There is a lack of evidence to indicate the influence of communication methods on the satisfaction of patients with pulmonary nodules in China. Our study was to assess patient satisfaction with letter-based communication of pulmonary nodule results of LCS and investigate factors contributing to patient dissatisfaction, testing a feasible approach for large-scale LCS result communication.


Participants and Study Design

We conducted a prospective randomized controlled trial of LDCT-based LCS between May and December 2019,5 in which patients with pulmonary nodules who met the inclusion criteria for receiving letter-based communication of results were recruited in this study (eAppendix Figure [eAppendix available at]). The inclusion criteria were as follows: The screening result of LDCT indicated a pulmonary nodule (the imaging manifestations were isolated or multiple diameters ≤ 3 cm around the lungs, with increased focal, round-like solid, or subsolid density), the patients were enrolled within 3 months of receiving the LDCT screening results via letters, and all patients were adults who spoke Chinese or an Anhui dialect. The exclusion criteria were as follows: Patients had other tumor diseases or had a mental illness or cognitive impairment. Based on the LCS guidelines in China, the eligible LCS population includes patients aged 50 to 75 years with at least 1 of the following high-risk factors: (1) a smoking history of at least 30 pack-years (current smoker or former smoker with ≤ 15 years since quitting), (2) a nonsmoker exposed to passive smoking at home (from a family member) or in the workplace (from a colleague) for more than 20 years, and (3) a nonsmoker with a family history of lung cancer.21 The Medical Ethics Committee of Lu’an Hospital of Anhui Medical University approved this study, which was registered in the Chinese Clinical Trial Registry (ChiCTR1900023197) with informed consent obtained prior to study participation.

Disclosing a Pulmonary Nodule Result

Following the completion of LDCT and film reading of the results, the detected pulmonary nodules were managed according to guidelines22 and mutually discussed by imaging experts and clinical experts (2 radiologists with more than 10 years of experience, 2 medical oncologists, and 1 thoracic oncologist). The screening results were enclosed in a follow-up form (including whether there was any abnormality, specific abnormality, follow-up information, contact information, etc) (eAppendix Table 1), which was placed in an envelope together with the CT report, and the patients were notified by SMS/telephone that they would receive the letters at the designated time and place. Noncalcified nodules with a diameter greater than 4 mm were regarded as positive results. In addition to pulmonary nodules, abnormalities suggestive of clinically significant conditions and minor abnormalities were documented. Screening results were communicated to the participants within 4 weeks. The patients were expected to contact their doctors via phone calls or in person if any question arose.

Satisfaction Results

Patients receiving LDCT were then surveyed by researchers via a face-to-face or telephone interview and their responses were captured using a previously verified Likert satisfaction scale.23 The primary outcome of the research was to determine the proportion of patients who were satisfied with the communication of pulmonary nodule results via letters. The secondary objectives included assessing patients’ perception of the amount of information and their preferred method of result communication. For the list of survey questions, please refer to eAppendix Table 2. If a patient could not complete the questionnaires independently (eg, due to frailty or illiteracy), the researcher would read and fill out the survey for them.

Data Analysis

We used SPSS 25.0 software (IBM) for data analysis. Measurement data that conformed to the normal distribution were expressed as mean (SD), whereas those that did not conform to the normal distribution were expressed as median (IQR). Descriptive data were presented using frequency and percentages. Multiclassification logistic regression analysis was used to analyze the relationship between satisfaction with letter communication and demographics/pulmonary nodules, and a P value of less than .05 was considered significant (2 sided).


Between May and December 2019, 900 participants were enrolled in the prospective randomized controlled trial, and 600 participants completed the LDCT scanning (eAppendix Figure). Among them, 153 participants were screened for pulmonary nodules and included in the analysis. The mean (SD) age of the participants was 58.8 (7.173) years, and 30% of participants were older than 65 years. Most participants were men (66.7%; n = 102), and the proportion of participants with an education level of primary school or below was 35.3% (n = 54), reflecting the low educational level of our sample. A large proportion (69.9%; n = 107) were current or former smokers, 3.3% (n = 5) had a family history of cancer, and 30.7% (n = 47) of participants were exposed daily to kitchen fumes (Table 1).

The pulmonary nodules were mostly single nodules (73.2%; n = 112), mainly located in the right lung (60.1%; n = 92), with a mean (SD) diameter of 6.55 (3.556) mm, and 24.2% (n = 37) were larger than 8 mm. Most nodules had clear edges (60.8%; n = 93) and were either circular or oval (89.5%; n = 137). The most common CT appearance was solid nodules (67.3%; n = 103), followed by ground-glass nodules (31.4%; n = 48) (Table 2).

The results of the satisfaction survey are summarized in Table 3. Most participants (78.4%; n = 120) were content with receiving the results via letters, whereas 7.2% (n = 11) were dissatisfied. The main concerns were insufficient knowledge of pulmonary nodules and that the use of medical terminology in letters hindered their understanding of the results (eAppendix Table 3 and eAppendix Table 4). Some participants (3.3%; n = 5) reported no recollection of receiving the letters. The majority of patients (83.7%; n = 128) agreed that the letters contained the appropriate amount of information, stating that they would prefer letters from doctors (61.4%; n = 94); however, some expressed their wish to receive phone calls from their doctors (28.1%; n = 43) or to consult hospital doctors (5.2%; n = 8).

The results of logistic regression indicated that patient satisfaction with letter communication was markedly associated with age, education, family history of cancer, and number of nodules (Table 4). Participants who were older (OR, 0.905; 95% CI, 0.832-0.985), who had an education level of primary school or below (OR, 0.367; 95% CI, 0.041-3.250), and who had no family history of cancer (OR, 0.100; 95% CI, 0.011-0.914) were less likely to be satisfied with receiving the pulmonary nodule results via letters. In contrast, patients with a single nodule (OR, 6.028; 95% CI, 1.641-22.141) expressed higher satisfaction with letter communication. No significant association was found between satisfaction and gender, smoking status, alcohol consumption, risk factors, nodule size, or nodule location.


A prospective randomized controlled study was conducted on LCS using LDCT, and pulmonary nodules were detected in 153 (25.5%) of 600 patients. The results of the present study indicate there is a high level of patient satisfaction associated with receiving pulmonary nodule results via letter-based communication (78.4%). In addition, most participants agreed that the letter included an adequate amount of information (83.7%). Increased patient satisfaction with letter communication was associated with participants who had a family history of cancer. Decreased participant satisfaction was correlated with increased age, reduced education level, and increased number of nodules.

With the aging of the population, the communication preferences of older individuals are an underexplored but important topic. The current study found that decreased participant satisfaction with letters was associated with increased age. Aging can lead to declines in communication abilities and physical activities.24 Older Chinese individuals seem to prefer face-to-face communication, in which body movements and verbal communication promote mutual understanding to a great extent.

Decreased participant satisfaction with letters was found to be associated with reduced education level. Education is known to play a crucial part in an individual’s decision-making on health issues, and health education may greatly facilitate one’s understanding of the association between health behaviors and outcomes.25 Despite the remarkable progress of the education level of Chinese rural residents in recent years, it still lags behind the general Chinese population.26

Interestingly, participants with a family history of cancer showed higher levels of satisfaction, which might be attributable to increased familiarity with the subject matter from previous family experience. It is generally known that joint decision-making before LCS is of particular importance.11 Bhamani et al27 showed that the use of information booklets to prepare participants for potential LCS results and follow-up was a helpful adjunct to the written method of result communication for large-scale LCS programs, and participants who remembered receiving the booklets tended to be more satisfied with the process of result communication by letters. Better strategies are needed to inform patients of the potential risks of pulmonary nodules. Thus, it is necessary to carry out pulmonary nodule educational efforts before screening, provide brochures in the letters, and elaborate on the risks of lung cancer.

Our survey demonstrated that the majority of patients (61.4%) would choose letters as the communication method, which was consistent with the findings of Dickson et al.19 British participants in that research were shown to be highly satisfied with the letter communication of pulmonary nodule results in LCS, suggesting that it was their preferred method. However, some participants (28.1%) reported dissatisfaction with letter-based LCS follow-up, preferring results by telephone, which offered them the opportunities for verbal interactions with doctors. These were primarily older patients and those with a low education level who had insufficient knowledge of pulmonary nodules. No correlation was found between satisfaction and gender, smoking status, alcohol consumption, risk factors, nodule location, or nodule size. There is still immense potential to improve the effectiveness of result communication via letters. In the future, communication strategies for using letters can be enhanced by taking into consideration the patients’ age, education level, nodule size, and number of nodules.


The limitations of this study lie in the small sample size, the confined geographical region, and the recruitment of participants who were mostly less educated, thereby reducing the generalizability of the findings. Additionally, it lacked information about the influence of pulmonary nodules on the participants’ psychological factors. The time of waiting for results and the participants’ socioeconomic status were not taken into account either. The study also may be subject to recall bias, as the survey was conducted 3 months after patients received their LCS follow-up letters. Nevertheless, the application of reproducible study methods is evident in the present trial. The protocol devised in the present survey can serve as a reference for future research, and the follow-up letter and recruitment flowchart provided in the eAppendix can also be applied in the evaluation of study outcomes of larger sample sizes and diverse patient cohorts.


Our research findings indicate that participants are generally satisfied with the results of pulmonary nodule testing conveyed by letters and agree that the letters offer a sufficient amount of information, which may support the feasibility of transmitting cancer screening results via letters in underdeveloped regions of China. Hopefully, these findings have implications in the implementation of clinical training, the improvement of physician-patient relationships, and the optimization of patient care. To increase levels of patient satisfaction for better adherence and outcomes, further improvement in communication strategies should be addressed.


The authors thank the personnel who participated in the study. They also thank Editage ( for English language editing.

Author Affiliations: Department of Oncology, Lu’an Hospital of Anhui Medical University (DW, RS, LH, RC, JS, WH, HZ, FR), Lu’an, Anhui, China; Department of Oncology, The First Affiliated Hospital of Anhui Medical University (DW), Hefei, Anhui, China.

Source of Funding: This work was supported by the Key Research and Development Program of Anhui (grant No. 201904a07020006), the Scientific Research Project of Lu’an Hospital of Anhui Medical University (grant No. 2020kykt30), and the Discipline Construction Fund of Lu’an Hospital of Anhui Medical University.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RS, FR); acquisition of data (DW, RS, RC, WH, HZ); analysis and interpretation of data (RS, LH, JS); drafting of the manuscript (DW); critical revision of the manuscript for important intellectual content (FR); statistical analysis (LH, RC, JS, HZ); provision of patients or study materials (RC, WH); obtaining funding (FR); administrative, technical, or logistic support (DW, JS, HZ); and supervision (LH, WH).

Address Correspondence to: Feng Rong, MD, Department of Oncology, Lu’an Hospital of Anhui Medical University, No.21 of Wanxi Avenue, Lu’an, 237005, Anhui, China. Email:


1. Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209-249. doi:10.3322/caac.21660

2. Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. doi:10.1056/NEJMoa1102873

3. de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382(6):503-513. doi:10.1056/NEJMoa1911793

4. Li N, Tan F, Chen W, et al; National Lung Cancer Screening Programme Group. One-off low-dose CT for lung cancer screening in China: a multicentre, population-based, prospective cohort study. Lancet Respir Med. 2022;10(4):378-391. doi:10.1016/S2213-2600(21)00560-9

5. Rong F, Shi R, Hu L, et al. Low-dose computed tomography for lung cancer screening in Anhui, China: a randomized controlled trial. Front Oncol. 2022;12:1059999. doi:10.3389/fonc.2022.1059999

6. Gould MK, Tang T, Liu ILA, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Respir Crit Care Med. 2015;192(10):1208-1214. doi:10.1164/rccm.201505-0990OC

7. Slatore CG, Horeweg N, Jett JR, et al; ATS Ad Hoc Committee on Setting a Research Framework for Pulmonary Nodule Evaluation. An official American Thoracic Society research statement: a research framework for pulmonary nodule evaluation and management. Am J Respir Crit Care Med. 2015;192(4):500-514. doi:10.1164/rccm.201506-1082ST

8. Slatore CG, Golden SE, Ganzini L, Wiener RS, Au DH. Distress and patient-centered communication among veterans with incidental (not screen-detected) pulmonary nodules: a cohort study. Ann Am Thorac Soc. 2015;12(2):184-192. doi:10.1513/AnnalsATS.201406-283OC

9. Wood DE, Kazerooni EA, Aberle D, et al. NCCN Guidelines Insights: lung cancer screening, version 1.2022. J Natl Compr Canc Netw. 2022;20(7):754-764. doi:10.6004/jnccn.2022.0036

10. Yang L, Zhang Q, Bai L, et al. Assessment of the cancer risk factors of solitary pulmonary nodules. Oncotarget. 2017;8(17):29318-29327. doi:10.18632/oncotarget.16426

11. Eberth JM, Zgodic A, Pelland SC, Wang SY, Miller DP. Outcomes of shared decision-making for low-dose screening for lung cancer in an academic medical center. J Cancer Educ. 2023;38(2):522-537. doi:10.1007/s13187-022-02148-w

12. Sullivan DR, Golden SE, Ganzini L, Hansen L, Slatore CG. ‘I still don’t know diddly’: a longitudinal qualitative study of patients’ knowledge and distress while undergoing evaluation of incidental pulmonary nodules. NPJ Prim Care Respir Med. 2015;25:15028. doi:10.1038/npjpcrm.2015.28

13. Kuroki LM, Zhao Q, Jeffe DB, et al. Disclosing a diagnosis of cancer: considerations specific to gynecologic oncology patients. Obstet Gynecol. 2013;122(5):1033-1039. doi:10.1097/AOG.0b013e3182a9bf42

14. Choudhry A, Hong J, Chong K, et al. Patients’ preferences for biopsy result notification in an era of electronic messaging methods. JAMA Dermatol. 2015;151(5):513-521. doi:10.1001/jamadermatol.2014.5634

15. Elder NC, Barney K. “But what does it mean for me?” primary care patients’ communication preferences for test results notification. Jt Comm J Qual Patient Saf. 2012;38(4):168-176. doi:10.1016/s1553-7250(12)38022-7

16. Leekha S, Thomas KG, Chaudhry R, Thomas MR. Patient preferences for and satisfaction with methods of communicating test results in a primary care practice. Jt Comm J Qual Patient Saf. 2009;35(10):497-501. doi:10.1016/s1553-7250(09)35068-0

17. Williamson S, Patterson J, Crosby R, et al. Communication of cancer screening results by letter, telephone or in person: a mixed methods systematic review of the effect on attendee anxiety, understanding and preferences. Prev Med Rep. 2018;13:189-195. doi:10.1016/j.pmedr.2018.12.016

18. Jibaja-Weiss ML, Volk RJ, Smith QW, Holcomb JD, Kingery P. Differential effects of messages for breast and cervical cancer screening. J Health Care Poor Underserved. 2005;16(1):42-52. doi:10.1353/hpu.2005.0018

19. Dickson JL, Bhamani A, Quaife SL, et al. The reporting of pulmonary nodule results by letter in a lung cancer screening setting. Lung Cancer. 2022;168:46-49. doi:10.1016/j.lungcan.2022.04.009

20. Wiener RS, Clark JA, Koppelman E, et al. Patient vs clinician perspectives on communication about results of lung cancer screening: a qualitative study. Chest. 2020;158(3):1240-1249. doi:10.1016/j.chest.2020.03.081

21. Yang W, Qian F, Teng J, et al; AME Thoracic Surgery Collaborative Group. Community-based lung cancer screening with low-dose CT in China: results of the baseline screening. Lung Cancer. 2018;117:20-26. doi:10.1016/j.lungcan.2018.01.003

22. Chinese Expert Group on Early Diagnosis and Treatment of Lung Cancer; China Lung Oncology Group. China national lung cancer screening guideline with low-dose computed tomography (2023 version). Article in Chinese. Zhongguo Fei Ai Za Zhi. 2023;26(1):1-9. doi:10.3779/j.issn.1009-3419.2023.102.10

23. Hudon C, Fortin M, Haggerty JL, Lambert M, Poitras ME. Measuring patients’ perceptions of patient-centered care: a systematic review of tools for family medicine. Ann Fam Med. 2011;9(2):155-164. doi:10.1370/afm.1226

24. Davis L, Botting N, Cruice M, Dipper L. A systematic review of language and communication intervention research delivered in groups to older adults living in care homes. Int J Lang Commun Disord. 2022;57(1):182-225. doi:10.1111/1460-6984.12679

25. Link BG, Phelan J. The social shaping of health and smoking. Drug Alcohol Depend. 2009;104(suppl 1):S6-S10. doi:10.1016/j.drugalcdep.2009.03.002

26. Wang Q, Shen JJ, Sotero M, Li CA, Hou Z. Income, occupation and education: are they related to smoking behaviors in China? PLoS One. 2018;13(2):e0192571. doi:10.1371/journal.pone.0192571

27. Bhamani A, Horst C, Bojang F, et al. The SUMMIT Study: utilising a written ‘next steps’ information booklet to prepare participants for potential lung cancer screening results and follow-up. Lung Cancer. 2023;176:75-81. doi:10.1016/j.lungcan.2022.12.006

Related Videos
Kelly Harris, APRN
Jessica K. Paulus, ScD, Ontada
Rachel Dalthorp, MD
Jessica K. Paulus, ScD, Ontada
Michael Thorpy, MD
Sindhuja Kadambi, MD, MS
Matthew Callister, MD
Rachel Dalthorp, MD
Rachel Dalthorp, MD
Related Content
CH LogoCenter for Biosimilars Logo