Physicians may not be adequately explaining the harms and benefits of CT lung cancer screening to eligible smokers, according to an article published online August 13 in JAMA Internal Medicine.
In a preliminary qualitative analysis, senior author Dr. Daniel Reuland and colleagues from the University of North Carolina examined the transcripts of 14 conversations between patients and physicians about undergoing CT lung cancer screening exams. All of these interactions included a recommendation for screening, but few met the minimum criteria for effective shared decision-making communication behaviors, according to the researchers (JAMA Intern Med, August 13, 2018).
"We found that physicians' efforts to engage patients in shared decision-making about initiating lung cancer screening were cursory at best," the authors wrote. "Although the sample is small and these findings are clearly preliminary, they raise concerns that shared decision-making in practice may be far from what is intended by guidelines."
Shared decision-making required
Recent research has estimated that fewer than 2% of eligible individuals in the U.S. participate in CT lung cancer screening. This low uptake continues to confound researchers, who have demonstrated the potentially lifesaving benefits of undergoing the test in multiple trials such as the National Lung Screening Trial (NLST) and the International Early Lung Cancer Action Program (I-ELCAP).
Currently, the U.S. Preventive Services Task Force (USPSTF) recommends that eligible individuals only undergo screening after having a thorough discussion of the exam's potential harms and benefits with a physician, a process known as shared decision-making. The U.S. Centers for Medicare and Medicaid Services (CMS) also requires patients to complete a shared decision-making visit that involves a decision aid to qualify for reimbursement.
Seeking to shed light on the real-life application of shared decision-making, Reuland and colleagues examined 14 transcripts of conversations concerning lung cancer screening between physicians and eligible individuals between April 2014 and March 2018.
The researchers reviewed the conversations using the Observing Patient Involvement in Decision Making (OPTION) scale, which measures the extent to which clinicians involve patients in the decision-making process. The scale focuses on 12 key concepts that a physician could communicate to a patient, such as concerns about managing a health problem, ways to deal with the problem, and explanations of the pros and cons of the various options. They rated each one of these topics for every conversation according to whether and how clearly physicians relayed each concept.
In their analysis, Reuland and colleagues found that the physicians collectively made a poor attempt to engage the patients in shared decision-making; not a single conversation met the basic skill criteria of the OPTION scale for fully explaining the pros and cons of screening.
| Evaluation of shared decision-making consults for CT lung cancer screening | |
| Mean physician communication score on shared decision-making scale | 6/100 |
| No. of physicians who used decision aids | 0 |
| Mean time spent discussing screening | 59 seconds |
What's more, none of the physicians referenced decision aids or any patient education materials, even though half of the patients had Medicare and would only qualify for payment coverage if they first received a decision aid. In addition, the average amount of time the physicians spent discussing lung cancer screening was less than a single minute.
The study's findings point to the problems inherent with CT lung cancer screening, according to an accompanying editorial by Dr. Rita Redberg, a professor at the University of California, San Francisco and current editor of JAMA Internal Medicine. Redberg has frequently expressed skepticism of screening's benefits, and in 2014 she chaired a panel that advised that Medicare deny payment coverage for CT lung cancer screening. CMS ignored the recommendation in approving reimbursement.
"As we accrue more data on the benefits and harms from cancer screening, it is clear that the benefits do not always exceed the harms," Redberg wrote. "Informed consent [for lung cancer screening] should entail a discussion between the patient and the physician of risks and benefits of alternatives that elucidates each patient's preferences and goals, and include patients in the decision-making process."
Sample too small
Proponents of CT lung screening are pointing to flaws in the new study, however. One issue is its small sample size of 14 interactions involving only 10 unique physicians -- a limitation that the authors acknowledged.
But a deeper issue may lie with the shared decision-making tools themselves, many of which contain underestimates of survival and overestimates of harms, Dr. Frederic Grannis, formerly of the City of Hope Helford Clinical Research Hospital in Duarte, CA, told AuntMinnie.com. Most of today's decision aids include information specifically designed to sway people away from participating in lung cancer screening.
"The problem with shared decision-making is that it's deliberately designed to get physicians to have patients not undergo lung cancer screening," he said. "It has unproven benefit [for screening] but will definitely serve as a speed bump to slow lung cancer screening accrual in the U.S. -- a clever strategy that seems to be working."
Nevertheless, shared decision-making and decision aids are presently required for coverage of lung cancer screening. As a result, clinicians have been questioning to what extent this largely unknown process of shared decision-making contributes to the goal of providing accurate and appropriate information to individuals eligible for screening.
Reuland and colleagues suggested two measures that could improve the shared decision-making process: longer consult times and higher-quality decision aids.
"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," Reuland's group concluded. "Until more is known, we believe that guideline and policymakers should not assume that recommending shared decision-making for cancer screening decisions ... will protect patients who would value avoiding screening harms."
For his part, Grannis has prepared an updated decision aid for physicians and a separate one for patients, both of which he will present at the upcoming International Association for the Study of Lung Cancer (IASLC) World Conference on Lung Cancer in Toronto.
