Outlook: Newsletter of the Society of Behavorial Medicine

Fall 2021

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Shared Decision Making in the Context of Lung Cancer Screening: Liability or Asset?

Jamie L. Studts, PhD✉ and Margaret M. Byrne, PhD✉; Health Decision Making SIG


Following publication of the landmark National Lung Screening Trial in 2011,1 nearly every relevant authoritative organization developed recommendations or practice guidelines in support of implementing low-dose computed tomography (LDCT) for lung cancer screening among eligible individuals. Alongside these recommendations and guidelines, public policy groups, professional societies, advocacy organizations, and other guideline-developing entities endorsed informed or shared decision making (SDM) as the preferred platform for engaging candidates in discussions regarding the option to pursue lung cancer screening. Even the sole organization that withheld an endorsement of lung cancer screening recommended using SDM to discuss the lung cancer screening opportunity with candidates.2

The guidelines published by the US Preventive Services Task Force and other organizations dramatically changed the lung cancer landscape,3 but they were not the only significant policy change. After conducting a National Coverage Analysis, the Centers for Medical and Medicaid Services (CMS) issued a National Coverage Determination, which mandated coverage for Medicare beneficiaries—similar to the coverage endorsed by USPSTF and others.4 In issuing this determination, CMS took the unanticipated and unprecedented step of also mandating implementation and documentation of SDM in advance of screening in order for the service to be reimbursable by CMS. Following the CMS decision, most private insurance companies and the VHA followed suit.

Despite broad scale coverage, lung cancer screening rates among eligible individuals have not matched expectations,5-7 leading many to question the reason for this slow uptake. Whereas initial low screening rates might be blamed on limited access, the proliferation of lung cancer screening programs and access has largely ameliorated that early concern at least for individuals living in non-rural areas.8 Thus, the SDM mandate – and even the encouragement of SDM prior to screening – has quickly become one of the more commonly blamed barriers. In fact, some critics of SDM have even claimed that the CMS SDM mandate was purposefully adopted to suppress lung cancer screening uptake. Others take the less extreme, but still negative view that SDM is an unnecessary and time-consuming component which reduces clinician willingness to refer eligible individuals for screening. Opponents of SDM for lung cancer screening also point to the lack of SDM requirements or mandates for mammography or colorectal cancer screening.9 However, it is important to note that CMS has now adopted the SDM requirement for several other services, including implantable cardioverter-defibrillators.10

We believe that the analogy to other types of cancer screening and the critiques of SDM are of limited relevance and fail to account for a host of factors that make lung cancer screening a truly unique context. Within this context, person-centered approaches including SDM are a vital and essential element of the cancer screening algorithm. Not only is lung cancer screening new and complicated for both patients and providers,11 the community of individuals who are eligible (i.e., age 50 or older, 20+ pack/year history of cigarette use, not quit within the past 15 years, and asymptomatic) have long faced suboptimal treatment within many healthcare systems and settings. We cannot put aside the fact that these individuals have faced significant stigma, biases, and socioeconomic challenges to receiving optimal care.12, 13 Because of this, we believe that lung cancer screening candidates are in unique position – different from other cancer screening participants. They both deserve and need a patient-centered preparation to screening that provides a thorough understanding of the lung cancer screening process, the potential benefits, harms, and unknowns of the algorithm, and an appreciation of the importance of adherence to achieving both the personal and population health benefits of lung cancer screening.

Although data has yet to emerge to clearly define the assets and liabilities of SDM in the lung cancer screening context, we believe SDM to be a vital component of the process, one that enhances the likelihood of benefits and minimizes the potential for harm. Instead of working toward eliminating this service, the lung cancer community should support research and evaluation of practices for how to optimize delivery of SDM and other person-centered approaches. If – as we believe - SDM can help engage this oft-maligned and underserved community of individuals at increased risk for developing lung cancer, then it is a service worth fighting for – not against.

 

References

  1. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. Aug 2011;365(5):395-409. doi:10.1056/NEJMoa1102873
  2. American Academy of Family Physicians. Clinical Preventive Service Recommendation: Lung Cancer. Accessed May 3, 2020. https://www.aafp.org/patient-care/clinical-recommendations/all/lung-cancer.html
  3. Moyer VA, Force USPST. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. Mar 2014;160(5):330-8. doi:10.7326/M13-2771
  4. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Lung Cancer Screening with Low Dose Computed Tomography (LDCT (210.14). 2015.
  5. Huo J, Shen C, Volk RJ, Shih YT. Use of CT and Chest Radiography for Lung Cancer Screening Before and After Publication of Screening Guidelines: Intended and Unintended Uptake. JAMA Intern Med. 03 2017;177(3):439-441. doi:10.1001/jamainternmed.2016.9016
  6. Jemal A, Fedewa SA. Lung Cancer Screening With Low-Dose Computed Tomography in the United States-2010 to 2015. JAMA Oncol. 09 2017;3(9):1278-1281. doi:10.1001/jamaoncol.2016.6416
  7. Fedewa SA, Kazerooni EA, Studts JL, et al. State Variation in Low-Dose CT Scanning for Lung Cancer Screening in the United States. J Natl Cancer Inst. Nov 2020;doi:10.1093/jnci/djaa170
  8. Eberth JM, Bozorgi P, Lebrón LM, et al. Geographic Availability of Low-Dose Computed Tomography for Lung Cancer Screening in the United States, 2017. Prev Chronic Dis. Oct 4 2018;15:E119. doi:10.5888/pcd15.180241
  9. Mulshine JL, Yankelevitz DF, Pyenson B. Concerns related to benefits and harms of real-world shared decision-making for lung cancer screening. American Health & Drug Benefits. 2021;https://www.ahdbonline.com/issues/2021/september-2021/3148-concerns-related-to-benefits-and-harms-of-real-world-shared-decision-making-for-lung-cancer-screening
  10. Merchant FM, Dickert NW, Howard DH. Mandatory Shared Decision Making by the Centers for Medicare & Medicaid Services for Cardiovascular Procedures and Other Tests. JAMA. Aug 21 2018;320(7):641-642. doi:10.1001/jama.2018.6617
  11. Kinsinger LS, Anderson C, Kim J, et al. Implementation of Lung Cancer Screening in the Veterans Health Administration. JAMA Intern Med. 03 2017;177(3):399-406. doi:10.1001/jamainternmed.2016.9022
  12. Hamann HA, Ver Hoeve ES, Carter-Harris L, Studts JL, Ostroff JS. Multilevel Opportunities to Address Lung Cancer Stigma across the Cancer Control Continuum. J Thorac Oncol. 08 2018;13(8):1062-1075. doi:10.1016/j.jtho.2018.05.014
  13. Carter-Harris L, Gould MK. Multilevel Barriers to the Successful Implementation of Lung Cancer Screening: Why Does It Have to Be So Hard? Ann Am Thorac Soc. Aug 2017;14(8):1261-1265. doi:10.1513/AnnalsATS.201703-204PS