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Counseling visit impacts patients’ decision to undergo lung cancer screening
A centralized counseling and shared decision-making visit impacts patient knowledge of eligibility criteria for lung cancer screening, as well as the benefits and harms of screening with low radiation dose chest CT scan, according to study results.
Consequently, the visits help promote value-based decisions about screening, researchers concluded.
Lung cancer screening guidelines require patients to attend a counseling and shared decision-making visit with a physician prior to screening. However, the impact of this visit on an individual’s understanding of and decision to undergo screening had not been evaluated.
Peter J. Mazzone, MD, MPH, FCCP, director of the lung cancer program and director of education for the Respiratory Institute at Cleveland Clinic, and colleagues developed a centralized counseling and shared decision-making visit for the institution’s lung cancer screening program.
The program included patient education about the eligibility for screening, supported by a narrated slide show, individualized risk assessment with a decision-aid and time for questions.
Researchers surveyed 423 consecutive patients prior to the visit, immediately after the visit and then 1 month after the visit to assess the impact of the visits on patients’ screening knowledge.
Results showed 125 consecutive patients completed the initial survey, 122 completed the post-visit survey and 113 patients completed the 1-month follow-up survey.
Prior to their initial visit, patients had a poor level of understanding about age eligibility criteria, (8.8%), smoking eligibility criteria (13.6%), the benefits of screening (55.2%) and the harms of screening (38.4%).
Immediately after the visit, results showed improvements in knowledge for all questions (P = .03 to P < .0001).
Knowledge decreased at the 1-month follow-up visit, yet remained higher than levels prior to counseling visits. Overall, 5.4% of patients who participated in the visit opted not to undergo screening.
HemOnc Today spoke with Mazzone about the findings, as well as the impact of counseling and shared decision-making visits for people who are considering undergoing lung cancer screening.
Question: How did the idea for this study come about?
Answer: Lung cancer screening is relatively new. As part of the evolution of how it was implemented, Medicare mandated a counseling and shared decision-making visit with the patient before they had the screening scan performed. The reason for doing so was because the balance of benefits and harms of lung cancer screening is somewhat tenuous. There are more benefits than harms of screening, but there are harms. When we screen people for lung cancer, they are healthy to begin with, so we want to avoid as much harm as possible. With this in mind, Medicare thought that — before a patient has this screening test performed — patients should know as much as possible about the benefits and harms in order to make a decision that fits their values. So, this rule came out, but nobody quite knew how to conduct this counseling and shared-decision making visit, as well as what the impact of this visit will be. We set up the visit as we think it should be conducted, and we performed this study to see if it was having the impact that we had hoped.
Q: What did the overall findings suggest?
A: The findings suggested that people came to that visit without a lot of knowledge about lung cancer screening. They did not know much about the screening age eligibility criteria or the smoking [history] eligibility criteria. They also knew very little about the benefit and harms of screening. We found that the visit we had put together allowed them to know much more about the benefits and harms and why they were eligible for screening or not. This knowledge helped them make a decision that they were more comfortable with. When looking at about 1 month after this initial visit, we found that at least some of the knowledge they had gained had lasted during this period of time, although their answers were not as accurate as they were immediately after the visit. We also evaluated — based on patients’ education level — whether we were helping everybody or just those who were more educated entering the visit. At all time points, those who had less formal education seemed to have a little less knowledge about the questions we were asking. However, everyone, regardless of their education level, had about the same amount of benefit from the visit.
Q: What is the potential impact of your study?
A: Our hope is that it can first confirm the value of the counseling and shared-decision making visit. The only reason we are able to do this is because Medicare and other insurers will now pay for this visit. By providing information that this is helping our patients know what they are getting into, and make decisions that are best for them, we hope that the provision to pay for these visits is maintained over time. It also may represent a model for other programs that are just being implemented to look at how to do this. We have learned that not everyone has the right answers after the visits, so we have to keep studying how we deliver this information, and whether there are more effective ways for us to help our patients make good decisions.
Q: Were any of your findings surprising?
A: Our program is a bit different from some. We have a centralized program where patients are identified by their primary care doctors and then they come to our program for this visit. Other programs across the country may have the primary care physician lead this discussion with their patients. So, people who come to our program have already had somewhat of a discussion about lung cancer screening with their primary provider. Despite this, we found that baseline level of knowledge about the benefits and harms of screening was rather poor. This surprised me.
Q: Can you describe the value of this counseling and shared-decision making visit for people considering undergoing lung cancer screening?
A: Lung cancer screening — and any cancer screening, for that matter — is different from getting a test because you have a symptom and are not feeling well, or receiving a medicine because you are not feeling well. For lung cancer screening, only a very small portion of everyone who is screened will benefit from being screened, whereas everyone is exposed to the potential harms of screening. This situation is different enough from what we normally do that patients really need to be involved in these decisions. Any one person may value the benefit so much more than the harms that they are willing to be screened, whereas someone else may feel that the harms are too much for them to take on. It is very important that we involve our patients in the decision to be screened. – by Jennifer Southall
Reference:
Mazzone PJ, et al. Chest. 2016;doi:10.1016/j.chest.2016.10.027.
For more information:
Peter J. Mazzone, MD, MPH, FCCP, can be reached at Cleveland Clinic, 9500 Euclid Ave., A90, Cleveland, OH 44195; email: mazzonp@ccf.org.
Disclosure: Mazzone reports no relevant financial disclosures.