Bringing Patients Into the Equation
The Importance of Shared Decision-Making When Determining Whether to Be Screened for Lung Cancer or Not
March 8, 2017
By: Gerard A. Silvestri, MD, MS, FCCP
Most Americans believe in screening for commonly diagnosed cancers as much as they believe in mom and apple pie. While we often think about the upside of cancer screening (finding disease early and treating with an increased likelihood of cure), we rarely think about the downside of screening (managing false-positive scans).
Often, recommendations are made by primary care providers and, without too much thought, patients generally follow them. However, screening for lung cancer using a low-dose CT scan will be different in that reimbursement for a screening visit requires a shared decision-making encounter prior to the performance of the screen.
In this month’s issue of CHEST, Mazzone and colleagues provide a glimpse into their screening program and how important this process may be to patients and providers alike in Impact of a Lung Cancer Screening Counseling and Shared Decision-Making Visit.
The National Lung Screening Trial
Before reviewing the findings of this study, a brief review of the National Lung Screening Trial (NLST) is warranted. The study randomized more than 50,000 patients to either receive a low-dose chest CT scan or a chest radiograph. The patients were between the ages of 50 to 74, had a 30-pack-year history of smoking, were either a current smoker or a former smoker, had quit within the last 15 years, and were generally well-enough to undergo surgery for a screen-detected cancer. They reported a 20% relative risk reduction in lung cancer death. Expressed another way, 300 patients would need to be screened to avoid one lung cancer death, which is similar to the reduction in mortality for breast cancer screening with mammography.
Once the US Preventive Services Task Force gave a B recommendation for screening, the Center for Medicare and Medicaid Services (CMS) provided a coverage statement that included the requirement for a shared decision-making visit, something previously not required for commonly screened cancers.
What is the shared decision-making visit? The idea behind shared decision-making is that the clinician and patient review the risks and benefits of the medical intervention under discussion, questions are asked and answered, and together a final decision is made that is congruent with the patient’s internal preferences. Studies have shown that when this process is followed patients have less decisional regret afterwards.
Shared Decision-Making in Action
The paper by Mazzone and colleagues illustrate the shared decision-making process in action. There are several important take-home messages. First, a little more than 5% of patients who initially came in to be screened did not proceed to have a CT scan, suggesting they either didn’t meet screening criteria or, after getting a better understanding of the risks and benefits of the test, decided it just wasn’t worth it for them. Second, prior to the shared decision-making session, patients had a poor understanding of the eligibility criteria, the risks, or the harms associated with screening. Third, after a full shared decision-making visit, their knowledge about screening increased dramatically, suggesting that the visit provided value to the patient.
What’s the Benefit?
One interesting aspect of this study was the fact that the researchers provided each patient with an individualized risk for developing lung cancer and thus how much they might benefit from screening. Why is this so important? While the number needed to screen to save one life from lung cancer is about 300 screens, that number varies dramatically based on a patient’s age and smoking history. For example, for individuals at low risk for developing lung cancer, 5,000 similar patients would need to be screened to save a life and that group would have a high false-positive rate; while for individuals who are not low risk, screening just 60 persons would avoid a lung cancer death with few false-positive rates. Clearly that knowledge might influence how a patient views the decision to be screened.
While this paper highlights the importance of a shared decision-making visit, it is unclear whether or not the components included in this institution’s shared decision-making process will be adopted in community settings. One can hope they will be because keeping patients informed and part of the process will produce a high-quality screening visit and is likely to lead to better outcomes down the road.
Read the study Impact of a Lung Cancer Screening Counseling and Shared Decision-Making Visit.
Gerard A. Silvestri, MD, MS, FCCP, is the current CHEST President. He is also a Hillenbrand Professor of Thoracic Oncology and Vice Chair of Medicine for Faculty Development in the Department of Medicine at the Medical University of South Carolina.