Research shows complexity of shared decision-making about lung cancer screening

Key takeaways:

• Most patients were unaware of the potential risks of LCS.
• PCPs were hesitant about discussions and final decisions regarding LCS.
• More research on the impact of comorbidities on LCS outcomes is needed.

Patients with multimorbidity and limited life expectancy are often unaware of the risks of lung cancer screening, and clinicians might be hesitant to discuss it, according to a pair of studies published in the Annals of Family Medicine.

Taken together, the research shows the complexity of shared decision-making regarding lung cancer screening (LCS) — both for patients and providers.

Most patients unaware of potential harms of LCS

The U.S. Preventive Services Task Force recommends annual LCS in adults aged 50 to 80 years who have a history of smoking a pack a day for the last 20 years and currently smoke or quit smoking in the past 15 years. The USPSTF also recommends that LCS be discontinued if the patient develops a health problem that significantly limits life expectancy.

Adverse effects of LCS screening in patients with marginal benefit can include false-positive results, anxiety in patients that arise from the findings and subsequent tests and procedures.

“Yet patients with multiple comorbidities and self-reported poor health are actually more likely to undergo screening than healthier patients,” Eduardo R. Núñez, MD, MS, an assistant professor at the University of Massachusetts Chan Medical School-Baystate, and colleagues wrote. “Little is known about the perspectives of patients with multiple comorbidities and limited life expectancy, or what considerations factor into their decision-making regarding LCS.”

The researchers interviewed 40 participants (mean age, 70 years; 95% men) with multimorbidity and limited life expectancy and who were recruited from six Veterans Health Administration (VA) facilities after discussing LCS with their clinicians.

Of the cohort, 26 participants agreed to VA LCS after discussing it with their providers. Although 14 participants initially declined LCS, seven later received screening, either in the VA system or elsewhere.

Several factors influenced participants to choose LCS, which included:

• personal health and life goals;
• an opportunity to get their lungs checked, receive information and have peace of mind;
• regret over missing past LCS opportunities; and
• trust in their clinician’s recommendation.

In contrast, factors that did not influence participants’ decisions included their perceived health status and symptoms and their perception and knowledge of LCS harms.

“Many participants did not recall their clinician discussing possible LCS harms or additional testing (eg, annual screening, additional imaging tests, biopsy) after initiating LCS,” Núñez and colleagues wrote.

When the interviewers described the potential for additional evaluations or treatment, most participants said they would not pursue further screenings or treatment, especially if they were invasive or intensive.

The findings show “the importance of providing clear guidance and point-of-care tools to help clinicians identify and engage in shared decision-making with individuals who have marginal anticipated benefit from screening,” the researchers said.

PCPs hesitate with LCS conversations, decisions

Although shared decision-making could help inform patients of the risks from screening — ultimately preventing unnecessary or harmful outcomes — physicians may be hesitant to have conversations about LCS.

Minal S. Kale, MD, MPH, an associate professor in the division of general internal medicine at Icahn School of Medicine at Mount Sinai, and colleagues noted that shared decision-making regarding LCS for patients with comorbidities means that primary care providers should “consider the nuances of each condition while keeping in mind a holistic view of the patient,” although the extent to which these comorbidities influence the PCPs’ considerations “remains unknown.”

In a qualitative study, the researchers conducted interviews with 15 PCPs affiliated with the Mount Sinai Health System between October 2020 through February 2021.

Three main themes emerged, the first of which was whether PCPs should discuss LCS with the patient.

PCPs said they used their clinical judgment — at times overriding USPSTF guidance — to determine whether a conversation would be beneficial. They made mental assessments that factored in the patient’s:

• current health;
• life expectancy;
• likelihood of following up on evaluations and treatments should they receive a cancer diagnosis; and
• quality of life.

The fact that PCPs are taking additional steps before discussing LCS suggests their “hesitancy in recommending this screening for this group,” the researchers said.

The second theme was that shared decision-making is not a simple discussion.

“Some PCPs were able to have open and objective discussions of the pros and cons, whereas others struggled with how to balance honesty with putting a thumb on the scales,” Kale and colleagues noted.

The third theme was that the decision to undergo LCS was ultimately up to the patient because most PCPs believed it was their role to advise on LCS rather than to make the final decision.

“The PCPs stated that the patients were the ones who had to live with the decision, and as such, it was theirs to make,” the researchers wrote. “PCPs deferring to patient opinions rather than providing education and counseling support also indicates reluctance to impose their own opinion.”

Kale and colleagues concluded that the findings were likely influenced by conflicting literature on LCS outcomes and a lack of evidence-based directions, and called for further research on how comorbidities impact LCS benefits and risks.

“Efforts should be made to streamline protocols and make LCS guidelines [clearer] for patients and clinicians,” they wrote.

References:

• Kale M, et al. Ann Fam Med. 2024;doi:10.1370/afm.3080.
• Lung cancer: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening. Published March 9, 2021. Accessed March 25, 2024.
• Núñez E, et al. Ann Fam Med. 2024;doi:10.1370/afm.3081.