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Lung cancer screening shared decision-making not up to par
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Physicians discussing initiating lung cancer screening with eligible patients did not adequately explain potential harms of screening, such as overdiagnosis, or use decision aids, according to a study published in JAMA Internal Medicine.
Another study, also published in JAMA Internal Medicine, revealed that overdiagnosis of lung cancer is common among patients who are screened via low-dose CT.
Shared decision-making
“The US Preventive Services Task Force recommends that shared decision-making involving a thorough discussion of benefits and harms should occur between clinicians and patients before initiating lung cancer screening with low-dose computed tomography,” Alison T. Brenner, PhD, MPH, from the University of North Carolina School of Medicine, and colleagues wrote. “The Centers for Medicare & Medicaid Services require a [shared decision-making] visit using a decision aid as a prerequisite for [lung cancer screening] coverage. However, little is known about how [shared decision-making] about [lung cancer screening] occurs in practice.”
To address this gap in knowledge, Brenner and colleagues assessed the quality of 14 discussions between primary care or pulmonary care physicians and eligible patients (mean age, 63.9 years) about lung cancer screening.
Specifically, the researchers measured communication behaviors for shared decision-making using the Observing Patient Involvement in Decision Making (OPTION) scale which ranges from 0 (no evidence of shared decision-making) to 100 points (highest level of shared decision-making). They also examined time spent discussing lung cancer screening during visits and evidence of decision aid use.
Data indicated that for all the lung cancer screening conversations, the mean total OPTION score was 6. The minimum skill criteria for most of the shared decision-making behaviors were not met by any of the conversations.
Lung cancer screening was widely recommended by physicians, but they almost never discussed the harms of screening, such as false positives or overdiagnosis, with their patients. Use decision aids or other patient education materials when discussing lung cancer screening was not observed.
Discussions lasted for a total mean of about 13 minutes. Roughly 1 minute, or 8%, of this time was spent discussing lung cancer screening.
“We believe these preliminary findings should engender a more pressing discussion among clinical leaders, policymakers and researchers about how to meaningfully involve patients in [lung cancer screening] decisions,” Brenner and colleagues concluded. “Until more is known, we believe that guideline and policymakers should not assume that recommending [shared decision-making] for cancer screening decisions with a ‘tenuous balance of benefits and harms,’ like [lung cancer screening], will protect patients who would value avoiding screening harms.”
Overdiagnosis of lung cancer
In a separate study, Bruno Heleno, MD, PhD, from the University of Copenhagen, Denmark, and colleagues investigated the incidence of overdiagnosis of lung cancer by screening CT among 4,104 current or former smokers aged between 50 and 70 years (mean age, 57.3 years; 55.3% men) who participated in the Danish Lung Cancer Screening Trial.
Participants were randomly assigned to receive five annual low-dose CT screenings or no screening.
Heleno and colleagues found that at least one off-protocol chest CT was performed in 20.3% of participants (n = 416) in the control group during either the trial (7.4%) or follow-up (12.9%) period, compared with 16.5% of participants (n = 338) in the screened group during follow-up.
Overall, lung cancer was diagnosed in 96 participants in the screened group and 53 participants in the control group. Receiving a low-dose CT scan was associated with an increase in the absolute risk for lung cancer by 2.1 percentage points. The researchers estimated that overdiagnosis occurred in 67.2% of the cancers detected by screening CT.
“The estimate of overdiagnosis in the [Danish Lung Cancer Screening Trial] was larger than what has been previously reported, but the screened group could have started with a higher baseline risk of lung cancer. ... Practice should not be changed immediately; however, it is crucial that the remaining trials report their estimates of overdiagnosis because this is a critical outcome for screening participants,” Heleno and colleagues concluded. – by Alaina Tedesco
Disclosure: The authors report no relevant financial disclosures.
Perspective
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Rohit Kumar, MD
In the study by Brenner and colleagues, the researchers have tried to assess the quality of shared decision-making for lung cancer screening by use of a validated tool called OPTION score. They found decision-making discussions to be cursory at best with no discussion about the harms of screening.
This study is extremely limited by the small numbers and so it will be inappropriate to draw strong conclusions about the generalized quality of shared decision-making visits.
It is valuable to note that within the study, higher quality of shared decision-making was directly related to the total duration of patient visit. This probably is the most important observation that makes a case that shared decision-making visits should be separate from a general visit to the PCP or pulmonologist, so a physician can spend adequate time presenting a balanced view of screening.
For shared decision-making to be of high quality, the following steps may prove beneficial:
1. Educating physicians and community via community events raising awareness about lung cancer screening. This method makes it more likely for patients to approach their providers about discussing screening, which makes it more patient preference-centric and, hence, likely to generate a complete discussion of benefits and harms.
2. During a general visit with their PCP or pulmonologist, lung cancer screening may be first mentioned and the patient provided with decision aids, so that patient gets a chance to learn more about screening. A follow-up visit or phone call to then discuss details is likely to be of higher quality.
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