John Murphy, MDLinx | September 04, 2018
In physician-patient discussions about lung cancer screening, the quality of shared decision making is “poor” and physician explanations of the potential harms of screening are “virtually nonexistent,” according to a study. published recently in JAMA Internal Medicine.
Researchers also found that the amount of time spent discussing lung cancer screening was “minimal,” and that no decision aids were used in any of the patient encounters. Finally, physicians averaged less than 1 minute in discussing the issue.
“Although the sample was small, the results were stark and confirmed what we thought we would find,” said the study’s senior author Daniel Reuland, MD, MPH, director, University of North Carolina’s Carolina Cancer Screening Initiative, Lineberger Comprehensive Cancer Center, Chapel Hill, NC. “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 guidelines come from the US Preventive Services Task Force (USPSTF) and the Centers for Medicaid & Medicaid Services (CMS). The USPSTF recommends that shared decision making with a thorough discussion of benefits and harms should occur between clinicians and patients before initiating lung cancer screening with low-dose computed tomography (CT). CMS requires a shared decision-making visit that uses a decision aid for coverage of a lung cancer screening.
In this study, Dr. Reuland and colleagues analyzed transcripts of discussions of lung cancer screening, which they identified from a large database of conversations between doctors and patients provided by the private company Verilogue. Of 137 conversations that included relevant keywords, only 14 discussions specifically addressed lung cancer screening.
The researchers found that physicians’ efforts to engage patients in shared decision making for initiating lung cancer screening were “cursory at best.” Also, no conversations met “even basic skill criteria” for explaining the pros and cons of lung cancer screening.
“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,” said Dr. Reuland, who is also a professor at the UNC School of Medicine in the Division of General Medicine and Clinical Epidemiology. “Our fly-on-the-wall sample from real-world practice shows us that’s not happening.”
Previous research has identified both positives and negatives to lung cancer screening. The 2013 National Lung Screening Trial showed that lung cancer screening using low-dose spiral CT scan resulted in about 20% fewer lung cancer deaths compared with screening with chest X-ray among people at very high risk. However, the trial also identified potential harms of screening, including false positive findings, in which about 96% of lung nodules found on screening CT scans were not cancer. Because of this, many patients with abnormal results are referred for follow-up procedures that can be invasive but ultimately don’t find cancer.
“A lot of people undergo surveillance, additional scanning, and some people undergo invasive procedures who don’t have lung cancer,” Dr. Reuland said. “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. It’s important to talk about those potential harms and benefits with patients when deciding about screening.”
Although Dr. Reuland and coauthors analyzed only a small sample of physician-patient discussions, there’s no reason to believe that these conversations were atypical, observed Rita F. Redberg, MD, MSc, editor, JAMA Internal Medicine, in an accompanying editorial.
“One can imagine many reasons for the lack of shared decision-making discussions, including limited time for office visits, lack of education on shared decision making, and general lack of emphasis on the importance of discussing harms and benefits of cancer screening,” wrote Dr. Redberg, who is also professor, Department of Medicine, Division of Cardiology, University of California San Francisco, San Francisco, CA.
She added, “Evidence from other areas suggests that there are many instances where shared decision making is needed but is not happening as widely as necessary, including mammography, prostate cancer screening, knee replacement, and the choice of therapy between medical management and stenting for stable coronary artery disease.”
Dr. Reuland said better systems and infrastructure are needed to ensure that these conversations happen the way they should. He also noted that patient support for making complex decisions probably shouldn’t rely only on doctors who have limited time for each patient visit and a heavy patient load.
“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.”
This study puts the spotlight on the important work ahead in having informed discussions with patients, wrote Dr. Redberg. “Communications about actual harms and benefits of tests and treatments should be a part of the fabric of medicine, which will require continued work on medical education, culture, communication skills, and payment policies,” she concluded.
The study was funded in part by the North Carolina Translational and Clinical Sciences Institute.