Doctor-Patient Discussions on Harms of Lung Cancer Screening 'Virtually Nonexistent'
Kristie L. Kahl
Despite national guideline recommendations, conversations between doctors and patients about the benefits and harms of lung cancer screening in those who are at high risk are not happening the way they should be.
In a study, published in JAMA Internal Medicine
, researchers found that the quality of the conversation about lung cancer screening was “poor” and discussion of the potential harms of screening was “virtually nonexistent.”
“We’re not taking a side as to whether lung cancer screening is good or bad, but there seems to be a consensus that we should be sharing these complex decisions with patients,” senior study author Daniel Reuland, M.D., MPH, director of UNC Lineberger’s Carolina Cancer Screening Initiative, said in a press release. “Our fly-on-the-wall sample from real-world practice shows us that’s not happening.”
In 2013, the US Preventive Services Task Force (USPSTF)
recommended for individuals aged 55 to 80 years to have annual screening using low-dose computed tomography based on smoking status: those have smoked a minimum of 30 pack-years, which amounts to 20 cigarettes per day each year for 30 years, and those who are still smoking or have only quit in the last 15 years.
Because of the potential harms of screening – including false positives – the USPSTF also recommended for physicians and patients to discuss the potential risks and benefits of screening
to promote shared decision making.
“A lot of people undergo surveillance, additional scanning, and some people undergo invasive procedures who don’t have lung cancer,” Reuland, who is also a professor at the UNC School of Medicine in the division of general medicine and clinical epidemiology, said in the release.
“The problem is weighing a small chance of benefit in the form of prolonged life versus a larger chance that a given patient will incur some kind of physical or psychological harm, plus out-of-pocket costs,” he added. “It’s important to talk about those potential harms and benefits with patients when deciding about screening.”
However, little is known about shared decision making and how this occurs in conjunction with lung cancer screening in practice.
Therefore, the researchers conducted a qualitative content analysis of transcribed conversations between primary care or pulmonary care physicians and 14 patients presumed to be eligible for lung cancer screening.
Of the patients, who were on average 64 years old, seven had Medicare and eight were current smokers. Half of these conversations occurred with a primary care physician.
To evaluate physician discussions, the researchers used OPTION scores – Observing Patient Involvement in Decision Making – for which the 14 conversations totaled only a score of 6 on a scale of zero to 100.
None of the conversations met the minimum skill criteria for eight of the 12 shared decision-making behaviors on the OPTION scale. In addition, physicians universally recommended for lung cancer screenings and discussions of harms associated with them were virtually nonexistent.
On average, total patient visit length was a little over 13 minutes and the average time spent actually discussing lung cancer screening was less than a minute, or a total of 8 percent of the total visit.
The researchers also noted there was no evidence that decision aids or other patient education materials for lung cancer screening were used.
“Although the sample was small, the results were stark and confirmed what we thought we would find,” Reuland said. “Shared decision making isn’t happening in practice as well as it should or as well as we’d like to think it is. There’s a big gap between what guidelines say and what actually happens.”
The researchers concluded that these findings highlight the need for a more “pressing discussion among clinical leaders, policy makers, and researchers about how to meaningfully involve patients in (lung cancer screening) decisions.”
Reuland added that better systems and infrastructure can help to ensure these conversations happen the way they should.
“We need to design systems that make patient care and medical decisions more informed and shared, and we need to take that responsibility seriously,” he said. “Issuing guidelines and payer-based regulations saying we should be doing shared decision-making is fine, but it isn’t enough. Among other things, we need more efficient and reliable ways of getting patients involved in these decisions.”
He added that the delivery of patient education using decision aids are equally as important. “Patient support for making complex decisions probably shouldn’t rely only on doctors with limited time for each patient visit and a lengthy visit agenda.”