Navigating Complexity: Understanding Variations in Lung Cancer Screening Decision-Making

Despite guidance on lung cancer screening (LCS) acknowledging how comorbidities may influence these decisions—with well-known comorbidities in the space including cardiovascular disease, chronic obstructive pulmonary disease, and smoking history—researchers have found significant variation in the shared decision-making process that considers the risk-benefit ratios of comorbidities.

Because of this, they suggest in Annals of Family Medicine that future research should focus on optimizing the classification of LCS’ risks and benefits among patients with complex comorbidities who are eligible for screening per US Preventive Services Task Force guidance.¹

The complex decision-making process for lung cancer screening was investigated through interviews with 15 primary care physicians and their feedback on how they approached decisions in patients with a complex medical history | Image Credit: kimly- stock.adobe.com

“Uncertainty by [primary care physicians] in referring patients for LCS likely reflects their confusion about its benefits due to complicated recommendations,” lead author Minal Kale, MD, MPH, said in a statement. “Protocols should be streamlined and guidelines made clearer for both physicians and patients if we’re going to increase adoption of LCS for this high-risk population.”²

The investigators conducted 15 semistructured video interviews with primary care physicians (PCPs) from Mount Sinai Health System–affiliated internal medicine practices that focused on 3 themes overall: discussing/not discussing lung cancer screening, the shared decision-making process is not easy, and it’s the patient’s ultimate decision to screen or not. These interviews were conducted between October 2020 and February 2020; the 15 PCPs accounted for 70 low-dose CT scans, they had a mean (SD) practice history of 15 (14) years, 60% were female PCPs, and the most common form of lung screening education was continuing education in 67%.

Under the first theme of discussing or not discussing screening, the PCPs reported their mental health cost-benefit analyses for patients considered self-reported patient health, life expectancy, and quality of life and whether patients had the support and cognitive ability to be able to follow up should LCS find something. PCPs reported they were less likely to suggest LCS if there was a high disease burden, believing a patient may need to focus on another condition; they tended to predict life expectancy using subjective metrics from the patient history; and they inferred patient behavior from current and past trends, without considering if a cancer diagnosis would influence behavior.

For the second theme of shared decision-making is not easy, the PCPs interviewed reported how progress and roadblocks intersect after deciding to discuss LCS with their patients. They reported being able to openly discuss the pros and cons of screening and how they influenced their shared decision-making with patients, such as acknowledging these conversations are stressful, presenting the possibility of cure or diagnosis, asking patients what they want to do or hope to accomplish with treatment, and considering patient frailty status and if treatment is something they really want.

When discussing the final theme that the ultimate decision is up to the patient, the study authors highlighted that most of the PCPs they interviewed relayed feeling they played more of an advisory role for the patient to make the final LCS decision. Because patients have to live with a decision—even if it’s a decision the PCP disagrees with—it’s theirs to make.

The authors also noted that not only did the conversations PCPs have with their patients about screening differ by content when they had to consider complex comorbidities, but the PCPs took extra steps with these patients before even initiating a discussion about LCS and they used clinical judgement instead of engaging all patients in the shared decision-making process per US Preventive Services Task Force guidance—ultimately delaying these conversations. In addition, LCS discussions were more likely to occur with patients thought to be more likely to adhere to recommendations and have a high quality of life.

Recommendations on how to improve shared decision-making about LCS include conducting future research encompassing real-world data and modeling studies on how comorbidity history affects these decisions, understanding PCP selection bias in shared decision-making, and analyzing outcomes data from involving care team members beyond the PCP.

“Our findings support the call for continued research to determine the impact of comorbidities on LCS risks and benefits as well as its clinical application,” the study authors concluded. “PCPs need more evidence-based information on LCS in cases of complex comorbidities to be able to effectively conduct shared decision-making with this population.”

References

1. Kale MS, Morgan O, Wisnivesky W, Schnur J, Diefenbach MA. Challenges addressing lung cancer screening for patients with multimorbidity in primary care: a qualitative study. Ann Fam Med. 2024;22(2):103-112. doi:10.1370/afm.3080
2. Mount Sinai study calls for major changes in the way people with comorbidities are selected by physicians for lung cancer screening. News release. Mount Sinai Health System. March 26, 2024. Accessed April 1, 2024. https://www.mountsinai.org/about/newsroom/2024/mount-sinai-study-calls-for-major-changes-in-the-way-people-with-comorbidities-are-selected-by-physicians-for-lung-cancer-screening