POINT: Can Shared Decision-Making of Physicians and Patients Improve Outcomes in Lung Cancer Screening? Yes

The American Cancer Society National Lung Cancer Roundtable strategic plan: Current challenges and future directions for shared decision making for lung cancer screening

Shared decision making (SDM) between health care professionals and patients is essential to help patients make well informed choices about lung cancer screening (LCS). Patients who participate in SDM have greater LCS knowledge, reduced decisional conflict, and improved adherence to annual screening compared with patients who do not participate in SDM. SDM tools are acceptable to patients and clinicians. The importance of SDM in LCS is emphasized in recommendations from professional organizations and highlighted as a priority in the 2022 President's Cancer Panel Report. The updated 2022 national coverage determination from the Centers for Medicare & Medicaid Services reaffirms the value of SDM in offering LCS to eligible beneficiaries. The Shared Decision-Making Task Group of the American Cancer Society National Lung Cancer Roundtable undertook a group consensus process to identify priorities for research and implementation related to SDM for LCS and then evaluated current knowledge in these areas. Priority areas included: (1) developing feasible, adaptable SDM training programs for health care professionals; (2) understanding the impact of alternative health system LCS models on SDM practice and outcomes; (3) developing and evaluating new patient decision aids for use with diverse populations and in varied settings; (4) offering conceptual clarity about what constitutes a high-quality decision and developing appropriate quality measures; and (5) studying the use of prediction-augmented screening to support SDM in practice. Gaps in current research in all areas were observed. The authors conclude with a research and implementation agenda to advance the quality and implementation of SDM for persons who might benefit from LCS.

Preferences for Decision Control among a High-Risk Cohort Offered Lung Cancer Screening: A Brief Report of Secondary Analyses from the Lung Screen Uptake Trial (LSUT)

Background. Personal autonomy in lung cancer screening is advocated internationally, but health systems diverge in their approach, mandating either shared decision making (with a health care professional) or individual decision making. Studies of other cancer screening programs have found that individual preferences for the level of involvement in screening decisions vary across different sociodemographic groups and that aligning approaches with individual preferences has the potential to improve uptake. Method. For the first time, we examined preferences for decision control among a cohort of UK-based high-risk lung cancer screening candidates ( N = 727). We used descriptive statistics to report the distribution of preferences and chi-square tests to examine associations between decision preferences and sociodemographic variables. Results. Most (69.7%) preferred to be involved in the decision with varying degrees of input from a health care professional. Few (10.2%) wanted to make the decision alone. Preferences were also associated with educational attainment. Conclusion. These findings suggest one-size-fits-all approaches may be inadequate in meeting diverse preferences, particularly those placing sole onus on the individual.

Highlights

Preferences for involvement in decision making about lung cancer screening are heterogeneous among high-risk individuals in the United Kingdom and vary by educational attainment. Further work is needed to understand how policy makers might implement hybrid approaches to accommodate individual preferences and optimize lung cancer screening program outcomes.

Assessing information available for health professionals and potential participants on lung cancer screening program websites: a cross-sectional study (Preprint)

Background

Lung cancer is the leading cause of cancer death worldwide. The US Preventive Services Task Force (USPSTF) updated recommendations for lung cancer screening in 2021, adjusting the age of screening to 50 years (from 55 years) and reducing the number of pack-years used to estimate total firsthand cigarette smoke exposure to 20 (from 30). With many individuals using the internet to find health care information, it is important to understand what information is available for individuals contemplating lung cancer screening.

Objective

This study aimed to assess the eligibility criteria and information available on lung cancer screening program websites for both health professionals and potential screening participants.

Methods

A descriptive cross-sectional analysis of 151 lung cancer screening program websites of academic (n=76) and community medical centers (n=75) in the United States with information for health professionals and potential screening participants was conducted in March 2021. Presentation of eligibility criteria for potential screening participants and presence of information available specific to health professionals about lung cancer screening were the primary outcomes. Secondary outcomes included presentation of information about cost and smoking cessation, inclusion of an online risk assessment tool, mention of any clinical guidelines, and use of multimedia to present information.

Results

Eligibility criteria for lung cancer screening was included in nearly all 151 websites (n=142, 94%), as well as age range (n=139, 92.1%) and smoking history (n=141, 93.4%). Age was only consistent with the latest recommendations in 14.5% (n=22) of websites, and no websites had updated smoking history. Half the websites (n=76, 50.3%) mentioned screening costs as related to the type of insurance held. A total of 23 (15.2%) websites featured an online assessment tool to determine eligibility. The same proportion (n=23, 15.2%) hosted information specifically for health professionals. In total, 44 (29.1%) websites referred to smoking cessation, and 46 (30.5%) websites used multimedia to present information, such as short videos or podcasts.

Conclusions

Most websites of US lung cancer screening programs provide information about eligibility criteria, but this is not consistent and has not been updated across all websites following the latest USPSTF recommendations. Online resources require updating to present standardized information that is accessible for all.

Contemporary issues in the implementation of lung cancer screening

Lung cancer screening with low-dose computed tomography can reduce death from lung cancer by 20-24% in high-risk smokers. National lung cancer screening programmes have been implemented in the USA and Korea and are being implemented in Europe, Canada and other countries. Lung cancer screening is a process, not a test. It requires an organised programmatic approach to replicate the lung cancer mortality reduction and safety of pivotal clinical trials. Cost-effectiveness of a screening programme is strongly influenced by screening sensitivity and specificity, age to stop screening, integration of smoking cessation intervention for current smokers, screening uptake, nodule management and treatment costs. Appropriate management of screen-detected lung nodules has significant implications for healthcare resource utilisation and minimising harm from radiation exposure related to imaging studies, invasive procedures and clinically significant distress. This review focuses on selected contemporary issues in the path to implement a cost-effective lung cancer screening at the population level. The future impact of emerging technologies such as deep learning and biomarkers are also discussed.

A Comparison of Web-Based Cancer Risk Calculators That Inform Shared Decision-making for Lung Cancer Screening

INTRODUCTION

To align patient preferences and understanding with harm-benefit perception, the Centers for Medicare & Medicaid Services (CMS) mandates that providers engage patients in a collaborative shared decision-making (SDM) visit before LDCT. Nonetheless, patients and providers often turn instead to the web for help making decisions. Several web-based lung cancer risk calculators (LCRCs) provide risk predictions and screening recommendations; however, the accuracy, consistency, and subsequent user interpretation of these predictions between LCRCs is ambiguous. We conducted a systematic review to assess this variability.

DESIGN

Through a systematic Internet search, we identified 10 publicly available LCRCs and categorized their input variables: demographic factors, cancer history, smoking status, and personal/environmental factors. To assess variance in LCRC risk prediction outputs, we developed 16 hypothetical patients along a risk continuum, illustrated by randomly assigned input variables, and individually compared them to each LCRC against the empirically validated "gold-standard" PLCO risk model in order to evaluate the accuracy of the LCRCs within identical time-windows.

RESULTS

From the inclusion criteria, 11 calculators were initially identified. The analyzed calculators also vary in output characteristics and risk depiction for hypothetical patients. There were 13 total instances across ten hypothetical patients in which the sample standard error exceeded the mean risk percentage across all general samples and set standard calculations. The largest measured difference is 16.49% for patient 8, and the smallest difference is 0.01% for patient 2. The largest measured difference is 16.49% for patient 8, and the smallest difference is 0.01% for patient 2.

CONCLUSION

Substantial variability in the depiction of lung cancer risk for hypothetical patients exists across the web-based LCRCs due to their respective inputs and risk prediction models. To foster informed decision-making in the SDM-LDCT context, the input variables, risk prediction models, risk depiction, and screening recommendations must be standardized to best practice.

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.

“Farewell” to Prognosis in Shared Decision-Making

Whether because of a cultural pattern or personal preference, palliative care clinicians encounter persons approaching the end of life who wish to limit or forego prognostic information relating to their situation. This scenario has received attention in a recent motion picture as well as a newly available advance directive modification—the Prognosis Declaration form. The ordinary expectation for end-of-life shared decision-making with a capable person is clinician disclosure of the best effort at prognostic assessment. The optimal match between the expressed values, goals, and preferences of the person with available clinician expertise is hopefully achieved. For the clinician, a person’s choice to modify information disclosure and participation in shared decision-making represents a significant challenge of balancing key ethical principles of intervention with tolerance and compassion for these different preferences. Attention to communication strategies that elicit and appropriately reassess individual information and decision-making wishes, flexibility in information disclosure patterns with capable persons and their representatives, and recognition that a respect for autonomy includes the choice to opt out can approach this challenge while providing compassionate and ethical end-of-life care.