In-person and Telephonic Shared Decision-making Visits for People Considering Lung Cancer Screening: An Assessment of Decision Quality

Lung cancer screening program factors that influence psychosocial outcomes: A systematic review

OBJECTIVES

Lung cancer screening (LCS) programs are being designed and implemented globally. Early data suggests that the psychosocial impacts of LCS are influenced by program factors, but evidence synthesis is needed. This systematic review aimed to elucidate the impact of service-level factors on psychosocial outcomes to inform optimal LCS program design and future implementation.

METHODS

Four databases were searched from inception to July 2023. Inclusion criteria were full-text articles published in English that reported an association between any program factors and psychosocial outcomes experienced during LCS. Study quality was appraised, and findings were synthesised narratively.

RESULTS

Thirty-two articles were included; 29 studies were assessed at high or moderate risk of bias. Study designs were RCT (n = 3), pre-post (n = 6), cross-sectional (n = 12), mixed-methods (n = 1), and qualitative (n = 10) studies, and conducted primarily in the USA (n = 25). Findings suggested that targeted interventions can improve smoking-related or decisional psychosocial outcomes (e.g., smoking cessation interventions increase readiness/motivation to quit) but impacts of interventions on other psychological outcomes were varied. There was limited evidence reporting association between service delivery components and psychological outcomes, and results suggested moderation by individual aspects (e.g., expectation of results, baseline anxiety). Opportunities for discussion were key in reducing psychological harm.

CONCLUSIONS

Certain program factors are reportedly associated with psychosocial impacts of LCS, but study heterogeneity and quality necessitate more real-world studies. Future work should examine (a) implementation of targeted interventions and high-value discussion during LCS, and (b) optimal methods and timing of risk and result communication, to improve psychosocial outcomes while reducing time burden for clinicians.

A protocol for a cluster randomized trial of care delivery models to improve the quality of smoking cessation and shared decision making for lung cancer screening

BACKGROUND

Patients eligible for lung cancer screening (LCS) are those at high risk of lung cancer due to their smoking histories and age. While screening for LCS is effective in lowering lung cancer mortality, primary care providers are challenged to meet beneficiary eligibility for LCS from the Centers for Medicare & Medicaid Services, including a patient counseling and shared decision-making (SDM) visit with the use of patient decision aid(s) prior to screening.

METHODS

We will use an effectiveness-implementation type I hybrid design to: 1) identify effective, scalable smoking cessation counseling and SDM interventions that are consistent with recommendations, can be delivered on the same platform, and are implemented in real-world clinical settings; 2) examine barriers and facilitators of implementing the two approaches to delivering smoking cessation and SDM for LCS; and 3) determine the economic implications of implementation by assessing the healthcare resources required to increase smoking cessation for the two approaches by delivering smoking cessation within the context of LCS. Providers from different healthcare organizations will be randomized to usual care (providers delivering smoking cessation and SDM on site) vs. centralized care (smoking cessation and SDM delivered remotely by trained counselors). The primary trial outcomes will include smoking abstinence at 12-weeks and knowledge about LCS measured at 1-week after baseline.

CONCLUSION

This study will provide important new evidence about the effectiveness and feasibility of a novel care delivery model for addressing the leading cause of lung cancer deaths and supporting high-quality decisions about LCS.

CLINICALTRIALS

GOV PROTOCOL REGISTRATION

NCT04200534 TRIAL REGISTRATION: ClinicalTrials.govNCT04200534.

Research Priorities for Interventions to Address Health Disparities in Lung Nodule Management: An Official American Thoracic Society Research Statement

Background: Lung nodules are common incidental findings, and timely evaluation is critical to ensure diagnosis of localized-stage and potentially curable lung cancers. Rates of guideline-concordant lung nodule evaluation are low, and the risk of delayed evaluation is higher for minoritized groups. Objectives: To summarize the existing evidence, identify knowledge gaps, and prioritize research questions related to interventions to reduce disparities in lung nodule evaluation. Methods: A multidisciplinary committee was convened to review the evidence and identify key knowledge gaps in four domains: 1) research methodology, 2) patient-level interventions, 3) clinician-level interventions, and 4) health system-level interventions. A modified Delphi approach was used to identify research priorities. Results: Key knowledge gaps included 1) a lack of standardized approaches to identify factors associated with lung nodule management disparities, 2) limited data evaluating the role of social determinants of health on disparities in lung nodule management, 3) a lack of certainty regarding the optimal strategy to improve patient-clinician communication and information transmission and/or retention, and 4) a paucity of information on the impact of patient navigators and culturally trained multidisciplinary teams. Conclusions: This statement outlines a research agenda intended to stimulate high-impact studies of interventions to mitigate disparities in lung nodule evaluation. Research questions were prioritized around the following domains: 1) need for methodologic guidelines for conducting research related to disparities in nodule management, 2) evaluating how social determinants of health influence lung nodule evaluation, 3) studying approaches to improve patient-clinician communication, and 4) evaluating the utility of patient navigators and culturally enriched multidisciplinary teams to reduce disparities.

Protocol for a randomized controlled trial of the Enhanced Smoking Cessation Approach to Promote Empowerment (ESCAPE) digitalized intervention to promote lung health in high-risk individuals who smoke

Low dose computed tomography (LDCT) is an effective screening test to decrease lung cancer deaths. Lung cancer screening may be a teachable moment helping people who smoke to quit, which may result in increased benefit of screening. Innovative strategies are needed to engage high-risk individuals in learning about LDCT screening. More precise methods such as polygenic risk scores quantify genetic predisposition to tobacco use, and optimize lung health interventions. We present the ESCAPE (Enhanced Smoking Cessation Approach to Promote Empowerment) protocol. This study will test a smoking cessation intervention using personal stories and a lung cancer screening decision-aide compared to standard care (brief advice, referral to a quit line, and a lung cancer screening decision-aide), examine the relationship between a polygenic risk score and smoking abstinence, and describe perceptions about integration of genomic information into smoking cessation treatment. A randomized controlled trial followed by a sequential explanatory mixed methods approach will compare the efficacy of the interventions. Interviews will add insight into the use of genomic information and risk perceptions to tailor smoking cessation treatment. Two-hundred and fifty individuals will be recruited from primary care, community-based organizations, mailing lists and through social media. Data will be collected at baseline, 1, 3 and 6-months. The primary outcomes are 7-day point prevalence smoking abstinence and stage of lung cancer screening at 6-months. The results from this study will provide information to refine the ESCAPE intervention and facilitate integration of precision health into future lung health interventions. Clinical trial registration number: NCT0469129T.

Lung cancer screening at the VA: Past, present and future

Lung cancer is responsible for more deaths annually in the United States than breast, prostate and colon cancers combined. Lung cancer screening with annual low-dose computed tomography reduces lung cancer mortality in high-risk patients through early detection. The incidence of lung cancer is higher in the veteran population compared to the general population due, in part, to the prevalence of tobacco use. Early detection of lung cancer is therefore an important goal of the Veterans Health Administration (VHA), the largest integrated health care system in the United States. The following will review previous and current initiatives undertaken by the VHA to implement and expand access to lung cancer screening and will highlight target areas of interest to improve uptake and quality of lung cancer screening. Through these initiatives and programs, the VHA aims to provide high quality and equitable access to lung cancer screening for all Veterans that incorporates research that will improve outcomes and potentially inform and optimize the practice of Lung cancer screening across the United States.

Stakeholder Research Priorities to Promote Implementation of Shared Decision-Making for Lung Cancer Screening: An American Thoracic Society and Veterans Affairs Health Services Research and Development Statement

Rationale: Shared decision-making (SDM) for lung cancer screening (LCS) is recommended in guidelines and required by Medicare, yet it is seldom achieved in practice. The best approach for implementing SDM for LCS remains unknown, and the 2021 U.S. Preventive Services Task Force calls for implementation research to increase uptake of SDM for LCS. Objectives: To develop a stakeholder-prioritized research agenda and recommended outcomes to advance implementation of SDM for LCS. Methods: The American Thoracic Society and VA Health Services Research and Development Service convened a multistakeholder committee with expertise in SDM, LCS, patient-centered care, and implementation science. During a virtual State of the Art conference, we reviewed evidence and identified research questions to address barriers to implementing SDM for LCS, as well as outcome constructs, which were refined by writing group members. Our committee (n = 34) then ranked research questions and SDM effectiveness outcomes by perceived importance in an online survey. Results: We present our committee's consensus on three topics important to implementing SDM for LCS: 1) foundational principles for the best practice of SDM for LCS; 2) stakeholder rankings of 22 implementation research questions; and 3) recommended outcomes, including Proctor's implementation outcomes and stakeholder rankings of SDM effectiveness outcomes for hybrid implementation-effectiveness studies. Our committee ranked questions that apply innovative implementation approaches to relieve primary care providers of the sole responsibility of SDM for LCS as highest priority. We rated effectiveness constructs that capture the patient experience of SDM as most important. Conclusions: This statement offers a stakeholder-prioritized research agenda and outcomes to advance implementation of SDM for LCS.

Screening for Lung Cancer: CHEST Guideline and Expert Panel Report

BACKGROUND

Low-dose chest CT screening for lung cancer has become a standard of care in the United States, in large part because of the results of the National Lung Screening Trial (NLST). Additional evidence supporting the net benefit of low-dose chest CT screening for lung cancer, and increased experience in minimizing the potential harms, has accumulated since the prior iteration of these guidelines. Here, we update the evidence base for the benefit, harms, and implementation of low-dose chest CT screening. We use the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not.

METHODS

Approved panelists reviewed previously developed key questions using the Population, Intervention, Comparator, Outcome format to address the benefit and harms of low-dose CT screening, and key areas of program implementation. A systematic literature review was conducted using MEDLINE via PubMed, Embase, and the Cochrane Library on a quarterly basis since the time of the previous guideline publication. Reference lists from relevant retrievals were searched, and additional papers were added. Retrieved references were reviewed for relevance by two panel members. The quality of the evidence was assessed for each critical or important outcome of interest using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Meta-analyses were performed when enough evidence was available. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and ungraded statements were drafted, voted on, and revised until consensus was reached.

RESULTS

The systematic literature review identified 75 additional studies that informed the response to the 12 key questions that were developed. Additional clinical questions were addressed resulting in seven graded recommendations and nine ungraded consensus statements.

CONCLUSIONS

Evidence suggests that low-dose CT screening for lung cancer can result in a favorable balance of benefit and harms. The selection of screen-eligible individuals, the quality of imaging and image interpretation, the management of screen-detected findings, and the effectiveness of smoking cessation interventions can impact this balance.

Lung Cancer Screening Knowledge, Perceptions, and Decision Making Among African Americans in Detroit, Michigan

INTRODUCTION

Previously, a web-based, patient-facing decision aid for lung cancer screening, shouldiscreen.com, was developed and evaluated. An initial evaluation was completed before the Medicare coverage decision and recruited a nondiverse sample of mostly former smokers, limiting the understanding of the potential effectiveness of the tool among diverse populations. This study evaluates shouldiscreen.com among African Americans in Metro Detroit.

METHODS

Using insights obtained from participatory workshops in this population, content changes to shouldiscreen.com were implemented, and this modified version was evaluated with a before-after study. Measures included knowledge of lung cancer screening, decisional conflict, and concordance between individual preference and screening eligibility. Surveys occurred between April and July 2018. Participants were contacted 6 months after the survey to assess subsequent screening behaviors. Analysis took place in 2019.

RESULTS

Data were collected from 74 participants aged 45-77 years, who were current/former smokers with no history of lung cancer. The average knowledge score increased by 25% from 5.7 (SD=1.94) before to 7.1 (SD=2.30) after (out of 13 points). Decisional conflict was halved between before and after. Concordance between individual preference and eligibility for screening increased from 22% (SD=41) to 35% (SD=47). Half of the participants felt uncomfortable answering surveys electronically and requested paper versions.

CONCLUSIONS

The use of the tool led to small improvements in lung cancer screening knowledge and increased concordance with current recommendations. Additional design modifications and modes of information delivery of these decision aids should be considered to increase their efficacy in helping populations with lower educational attainment and computer literacy.

Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement

Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.

Factors influencing lung cancer screening completion following participation in shared decision-making: A retrospective study in a U.S. academic health system

PURPOSE

Shared decision making (SDM) between patients and designated health professionals is recommended by several professional organizations prior to lung cancer screening by low dose CT (LDCT). This study seeks to identify factors, including characteristics of patients and referring clinicians, that influence LDCT screening completion following participation in SDM.

MATERIALS AND METHODS

This retrospective study consisted of n = 171 patients eligible for LDCT screening and who participated in SDM between 2016 and 2017 in one of two sites in Prisma Health, an academic health care delivery system in South Carolina. Patient characteristics included age, sex, race, body mass index, marital status, insurance, smoking status and history, family history of lung cancer, SDM site, and distance to screening site. Characteristics of referred clinicians included age, sex, race, specialty, years of practice, education, and residency. Descriptive statistics and multivariable generalized linear mixed models were used to compare effects of patient and referring clinician characteristics on LDCT completion.

RESULTS

A total of 152 patients (89%) completed LDCT screening after participation in SDM. SDM site (p = 0.02), longer distances to the screening site (p = 0.03), referrals from internal medicine clinicians (p = 0.03), and referrals from younger clinicians (p = 0.01) and from those with less years of experience (p = 0.02) were significantly associated with a lower likelihood of screening completion.

CONCLUSIONS

Several factors significantly associated with screening completion were identified. This information can assist with development of interventions to improve communication and decision-making between patients, clinicians, and SDM health professionals, and inform design of targeted decision aids embedded into SDM procedures.

Tools to Promote Shared Decision-Making in Lung Cancer Screening Using Low-Dose CT Scanning: A Systematic Review

BACKGROUND

Decisions about lung cancer screening are inherently complex and create a need for methods to convey the risks and benefits of screening to patients.

RESEARCH QUESTION

What kind of decision aids or tools are available to support shared decision-making for lung cancer screening? What is the current evidence for the effectiveness, acceptability, and feasibility of those tools?

STUDY DESIGN AND METHODS

We conducted a systematic review of studies and searched PubMed, MEDLINE, EMBASE, Cochrane Clinical Trials Register, and ClinicalTrials.gov from inception to December 2019 for studies that evaluated the effectiveness and acceptability of tools to promote shared decision-making for patients who are considering lung cancer screening.

RESULTS

After screening 2,427 records, we included one randomized control trial, two observational studies, 11 before/after studies of a decision aid or an educational tool. Fifteen distinct tools in various formats were evaluated in 14 studies. Most studies were of fair quality. Studies reported improvement in patients' knowledge of lung cancer screening (n = 9 studies), but improvements in specific areas of knowledge were inconsistent. Decisional conflict was low or reduced after the administration of the tools (n = 7 studies). The acceptability of tools was rated as "high" by patients (n = 7 studies) and physicians (n = 1 study). Low dose CT scan completion rates varied among studies (n = 6 studies).

INTERPRETATION

Evidence from 14 studies suggests that some elements of existing tools for lung cancer screening may help to prepare patients for decision-making by improving knowledge and reducing decisional conflict. Such tools generally are acceptable to patients and providers. Further studies that use consistent measures and reporting methods and assess relevant decisional and clinical outcomes are needed to determine the comparative effectiveness and feasibility of implementation of these tools.

CLINICAL TRIAL REGISTRATION

PROSPERO 2018 CRD4201874814.

Enhancing Success of Medicare's Shared Decision Making Mandates Using Implementation Science: Examples Applying the Pragmatic Robust Implementation and Sustainability Model (PRISM)

The Centers for Medicare and Medicaid Services (CMS) has mandated shared decision making (SDM) using patient decision aids for three conditions (lung cancer screening, atrial fibrillation, and implantable defibrillators). These forward-thinking approaches are in response to a wealth of efficacy data demonstrating that decision aids can improve patient decision making. However, there has been little focus on how to implement these approaches in real-world practice. This article demonstrates how using an implementation science framework may help programs understand multilevel challenges and opportunities to improve adherence to the CMS mandates. Using the PRISM (Pragmatic Robust Implementation and Sustainability Model) framework, we discuss general challenges to implementation of SDM, issues specific to each mandate, and how to plan for, enhance, and assess SDM implementation outcomes. Notably, a theme of this discussion is that successful implementation is context-specific and to truly have successful and sustainable changes in practice, context variability, and adaptation to context must be considered and addressed.

Low-Dose CT Screening for Lung Cancer: Evidence from 2 Decades of Study

Lung cancer remains the overwhelmingly greatest cause of cancer death in the United States, accounting for more annual deaths than breast, prostate, and colon cancer combined. Accumulated evidence since the mid to late 1990s, however, indicates that low-dose CT screening of high-risk patients enables detection of lung cancer at an early stage and can reduce the risk of dying from lung cancer. CT screening is now a recommended clinical service in the United States, subject to guidelines and reimbursement requirements intended to standardize practice and optimize the balance of benefits and risks. In this review, the evidence on the effectiveness of CT screening will be summarized and the current guidelines and standards will be described in the context of knowledge gained from lung cancer screening studies. In addition, an overview of the potential advances that may improve CT screening will be presented, and the need to better understand the performance in clinical practice outside of the research trial setting will be discussed. © RSNA, 2020.

Shared Decision-making and Lung Cancer Screening: Let's Get the Conversation Started

Screening with low-dose CT scan has been shown to reduce mortality from lung cancer in those at risk based on age and smoking history. While lung cancer screening (LCS) is recommended by the United States Preventative Services Task Force and many professional societies, it has been recognized that the decision to be screened is complex due to a close balance of risk and benefit; therefore, shared decision-making is considered an essential component of effective LCS. The Centers for Medicare and Medicaid Services provides coverage for LCS following a mandated shared-decision making (SDM) visit. Here we review the concept of SDM, facilitators and barriers, evidence and knowledge gaps, and novel considerations for SDM within LCS.