A Medicare policy requiring shared decision-making between primary care physicians and patients regarding whether to proceed with lung cancer screening may require further examination, according to a recent study published by Kale et al in the Annals of Family Medicine. The findings indicated that the policy may be in urgent need of new research, protocols, and guidelines to enable physicians to make more confident and informed decisions around which patients are suitable candidates for lung cancer screening.
Background
The policy of shared decision-making—enacted nearly 10 years ago to encourage the use of lung cancer screening—was intended to take into account the patient’s full health history. It was prompted by the fact that smokers may have an increased risk of not just lung cancer but also complex comorbidities such as cardiovascular disease, cerebrovascular disease, and chronic obstructive pulmonary disease from their tobacco exposure. The policy required counseling on the importance of adherence to annual lung cancer screening, impact of comorbidities, and ability or willingness to undergo diagnosis and treatment; however, it did not address the increasing prevalence of comorbidities or provide any guidance on how to assess the impact of comorbidities on screening, diagnosis, and treatment.
“The policy was added in 2015 for a well-intentioned reason, but unfortunately it’s caused a great deal of confusion over patient eligibility and may contribute to ambivalence among primary care physicians when it comes to recommending lung cancer screening to patients with complex comorbidities,” explained lead study author Minal Kale, MD, MPH, Associate Professor of Medicine (General Internal Medicine) at the Icahn School of Medicine at Mount Sinai. “Our study found that primary care physicians’ approach reflects a dearth of evidence-based guidance for lung cancer screening shared decision-making in patients with complex comorbidities,” she added.
Study Methods and Results
In the recent study, researchers conducted 45-minute videoconference interviews with 15 primary care physicians from internal medicine practices affiliated with the Mount Sinai Health System—with the goal of better understanding how primary care physicians factor comorbidities into their evaluation of the risks and benefits of lung cancer screening as well as into their shared decision-making conversations with patients.
From each of the interviews, the researchers found that primary care physicians may be predisposed to make subjective clinical judgments about a patent’s qualifications for lung cancer screening prior to approaching the patient rather than basing that determination on a shared discussion.
“Patients perceived as likely to adhere to treatment recommendations and as having a high quality of life were more likely to be advised to undertake lung cancer screening as opposed to those who had previously expressed frustration or dissatisfaction with their state of health and well-being,” revealed co–study author Juan Wisnivesky, MD, DrPH, the Drs Richard and Mortimer Bader Professor of Medicine and Chief of the Division of Internal Medicine at the Icahn School of Medicine at Mount Sinai. “Other patient characteristics shown by the study to influence physician judgments include life expectancy, presence of a support system, and expectations of and attitudes toward medical care,” he noted.
Conclusions
To counter the selection bias uncovered in the study, the researchers called for continued research to determine the impact of comorbidities on lung cancer screening risks and benefits as well as its clinical applications.
“Uncertainty by primary care physicians in referring patients for lung cancer screening likely reflects their confusion about its benefits due to complicated recommendations,” underscored Dr. Kale. “Protocols should therefore be streamlined and guidelines made clearer for both physicians and patients if we’re going to increase adoption of lung cancer screening for this high-risk population,” she concluded.
Disclosure: For full disclosures of the study authors, visit annfammed.org.
