Shared Decision 'Virtually Absent' in Lung Cancer Screen Chat

Kristin Jenkins

August 13, 2018

When it comes to following US Preventive Services Task Force (USPSTF) recommendations for explaining the pros and cons of lung cancer screening (LCS) to patients at high risk, clinicians appear to be failing miserably, a small study shows.

Qualitative analysis of 14 audio-recorded physician-patient conversations about initiation of LCS revealed that on average, both primary care physicians and specialists spent less than 60 seconds discussing the harms and benefits of LCS with low-dose CT (LDCT).

Although all of the physicians recommended lung cancer screening, discussion of the potential for false positive results and overdiagnosis was "virtually absent," say Daniel S. Reuland, MD, MPH, of the University of North Carolina (UNC) School of Medicine, Chapel Hill, and colleagues.

During in-office visits that lasted slightly longer than 10 minutes, the quality of shared decision-making (SDM) was poor, the researchers say in a report published online August 13 in JAMA Internal Medicine.

"This finding is not surprising because explaining equipoise, listing options, explaining pros and cons, checking understanding, and then integrating preferences into a shared decision requires time," the study authors say.

In an accompanying editorial, Rita F. Redberg, MD, of the University of California, San Francisco, called the study findings "disappointing" and the mean total score of 6 of 100 for physician SDM skills, as measured on the validated 12-item OPTION (Observing Patient Involvement in Decision Making) scale, "clearly a failing grade."

Despite the small sample size, there is no reason to believe that these conversations were atypical, Redberg said.

The study authors describe physicians' efforts to engage patients in SDM about initiating LCS as "cursory at best."

Part of the problem is the setting of the conversation, the authors suggest: "It seems doubtful that meaningful deliberation about a decision as complex and consequential as initiating yearly CT scanning can occur as an ad hoc addition to a brief outpatient visit."

The study also showed that none of the physician-patient conversations met the minimum skill criteria for 8 of 12 SDM behaviors on the OPTION scale. As noted above, the mean total score for physician skill was 6 out of a possible 100.

Although these findings are preliminary, they are consistent with growing evidence that both clinicians and patients tend to overestimate the benefits of screening tests and treatments and to underestimate the potential harms, the authors say. The new results also "raise concerns that SDM for lung cancer screening in practice may be far from what is intended by guidelines."

In 2013, the USPSTF recommended that physicians thoroughly discuss the benefits and harms of lung cancer screening with LDCT for patients aged 55 to 80 years who had a minimum 30 pack-year history of smoking, as well as those who are still smoking or who have quit in the past 15 years.

The researchers point out that the Centers for Medicare & Medicaid Services requires an outpatient visit that documents shared decision-making using one or more decision aids as a prerequisite for coverage.

There's a big gap between what guidelines say and what actually happens. Dr Daniel Reuland

"There's a big gap between what guidelines say and what actually happens," said Reuland in a press release issued by the UNC Lineberger Comprehensive Cancer Center. "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."

Rueland, who is director of the UNC Lineberger's Carolina Cancer Screening Initiative, said that systems should be designed "that make patient care and medical decisions more informed and shared, and we need to take that responsibility seriously."

PCPs and Pulmonolgists

For the study, the researchers used the Verilogue database, which contains thousands of recordings of US patient-physician interactions. The team analyzed transcribed discussions between primary care and pulmonary care physicians and 14 patients during in-office visits between April 1, 2014, and March 1, 2018.

The patients included nine women and five men (mean age, 64 years). Half of the patients were on Medicare, and 50% were current smokers.

Two independent observers used the OPTION scale to rate clinician skill in discussing the benefits and harms of lung cancer screening with LDCT. The observers also calculated how much time clinicians spent discussing lung cancer screening during outpatient visits and looked for evidence that decision aids or other patient education material were used.

The mean total visit time was 13.07 minutes with physicians who spent a mean time of 0.59 minutes (8% of the total visit time) talking about lung cancer screening. Half of the recorded conversations were conducted by primary care physicians.

On a scale of 0 to 4, the mean SDM behavior item scores ranged from 0 to 0.79. None of the conversations met baseline skill criteria for 8 of 12 key communication behaviors. The necessary talking points included overdiagnosis, false positives, and the potential for additional imaging or invasive diagnostic procedures.

In her editorial, Redberg says the poor results are not novel. Shared decision-making "is lacking in other clinical scenarios," including mammography, prostate cancer screening, knee replacement, and stable coronary artery disease.

"Communications about actual harms and benefits of tests and treatments should be a part of the fabric of medicine," she added.

Redberg pointed out that none of the clinicians mentioned lung cancer screening's 98% false positive rate, the possibility that additional testing could lead to biopsy or lobectomy, and the small increased risk for cancer from radiation following LDCT.

"One can imagine many reasons for the lack of SDM discussions, including limited time for office visits, lack of education on SDM, and general lack of emphasis on the importance of discussing harms and benefits of cancer screening," she said.

Data from the National Health Interview Survey show that most people who undergo screening for lung cancer do not fall into the recommended groups, she said. "[T]hus their harms of LDCT, including radiation exposure, will likely exceed the benefits."

The study was funded by the North Carolina Translational and Clinical Sciences Institute. Dr Reuland and coauthors have disclosed no relevant financial relationships. Dr Redberg is editor of

JAMA Intern Med. Published online on August 13, 2018. Abstract, Editorial


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