Screen the Lungs!

By Brian Shim

Making the Decision to Screen: How can we make things easier for patients?

Previously on Screen the Lungs!, we introduced some of the salient barriers that challenge lung cancer screening at the systems, provider, and patient levels. In this blog, I will discuss some of the challenges that patients face in the decision-making process when they consider lung cancer screening options, and consider some of the ways in which we can make those decisions easier.

Introduction

For every patient considering low-dose CT lung cancer screening, there are a wide variety of factors that must be carefully considered in order to ensure a value-concordant decision. Patients, with the help of their healthcare providers, must carefully consider the risks and benefits of CT scanning, the burden of potentially invasive follow-up procedures for positive findings, false-positive cases, over-diagnosis, comorbidities, and personal preferences.

The complexity of these many considerations are widely exacerbated by patients’ limited health literacy (the ability to understand health information needed to make appropriate health decisions), as well as health numeracy (the ability to comprehend and use numerical information in medical decision-making). These limitations very commonly challenge patients and can seriously compromise decision-making and increase decisional conflict – especially among patients with lower educational or socioeconomic backgrounds.

It should be expected that healthcare providers who are involved in the lung cancer screening process, such as primary care physicians, thoroughly discuss the available interventions with their patients and help each patient come to the best decision possible for them.

Shared Decision-Making

Indeed, current recommendations for screening require a dedicated shared decision-making (SDM) discussion between each patient and a healthcare practitioner before entering a lung cancer screening (LCS) program. However, it has been widely documented that the administration of these individualized SDM discussions is highly inconsistent and uncommon.

During 2015, only 10% of Medicare patients enrolled in an LCS program were documented to have been provided an appropriate SDM visit with their physician. Most LCS-related SDM visits have also been demonstrated to be quite poor, as many patient-provider conversations fail to meet the minimum skill criteria expected of a standard SDM visit.

Given that poor knowledge about LCS among healthcare providers has been identified as one of the most prominent barriers to SDM, strong efforts must be made to educate PCPs about Low Dose Computed Tomography (LDCT) LCS, including its risks and benefits, eligibility guidelines, and insurance coverage.

It is also essential that PCPs and LCS specialists undergo more thorough training in the communication skills essential to strong SDM. Online educational programs utilizing case-based training modules have been previously tested by some groups: these initiatives demonstrate a strong potential to efficiently improve provider competency in SDM discussions.

SDM training programs should focus on the key components of effective patient-provider conversations. These include appropriate communication of risks and benefits, a thorough exploration of patient values, mutual negotiation of a course of action, and an assessment of patient comprehension after discussion. Training should also address diverse patient backgrounds and emphasize the overarching goal of patient-centered decision-making – even if it potentially leads to a decision not to screen.

Patient Decision Aids

Patient-facing LCS resources and patient decision aids (PDAs) are also an essential part of the SDM process. Currently, PDAs nationwide are highly inconsistent, and in many cases, inappropriate for many patients with low education levels and limited health literacy. The majority of patient-facing LCS resources are written for native English speakers, and in more complex language than the reading level recommended by the American Medical Association.

When readily accessible and efficient and effective in relaying the appropriate information, PDAs are very effective tools in the SDM process. Good PDAs are able to increase overall patient understanding of LCS, clarify individual preferences, improve accurate perceptions of the potential benefits and risks, and decrease decisional conflicts. Ultimately, improving PDAs and their integration into the LCS process improves active decision-making and elicits more value-concordant decisions to screen.

PDAs should be designed around the key identified qualities that help patients in the decision-making process. These include a clear framing of risks and benefits, concise language, and non-stigmatizing messaging. To accommodate the needs of a wider range of patient backgrounds, PDAs should also be tailored to a community, be culturally sensitive, and be made accessible to patients with lower health literacy and numeracy. These resources should be provided to all patients that are eligible for LCS, and emphasized throughout the active screening and SDM process.

Key Take-Away Points:

A decision to undergo lung cancer screening (LCS) requires consideration of a wide range of complex factors
Decisions to screen should be individualized, patient-value-concordant decisions
Providers should be better trained to consistently engage individualized shared decision-making (SDM) conversations to discuss whether LCS is right for their patients
Appropriate, accessible, sensitive patient decision aids (PDAs) are very effective tools for LCS education and should see improved development