Abbreviations and Acronyms:CT (computed tomography), LDCT (low-dose computed tomography), PET (positron emission tomography), SDM (shared decision making)
Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N).
|Steps of the lung cancer screening journey||Parties involved||Status quo in SDM in lung cancer screening|
|Ideal/high-quality SDM||Changes to status quo required to implement ideal/high-quality SDM|
|Referral of a person at risk (ie, a “healthy” patient) to a lung cancer screening counseling and SDM visit||The patient is informed that he or she should be referred for lung cancer screening because he or she is a smoker/former smoker|
Screening is presented as desirable. Potential harms of screening are not mentioned.
Eligibility for lung cancer screening is often insufficiently assessed (eg, no calculation of pack-years for smoking history, no use of a lung cancer risk calculator)
|The patient and referring physician recognize the patient's elevated risk of lung cancer|
To deal with this risk, the clinician emphasizes that smoking cessation is the most effective way of reducing lung cancer risk. The clinician also reveals the possibility of lung cancer screening. The situation is further clarified using a lung cancer risk calculator.
If the patient is interested in lung cancer screening and is potentially eligible to participate in the program, the patient can be referred to participate in a conversation about risks and benefits of lung cancer screening with an expert clinician
|Eligibility for lung cancer screening is assessed using a risk calculator|
Being eligible for lung cancer screening is not framed as desirable but as an indicator of high lung cancer risk
The eligible patient is given a choice to be referred to an expert clinician to explore risks and benefits of lung cancer screening further rather than being told that he or she should have lung cancer screening
The importance of smoking cessation is emphasized if the patient is still smoking
|Lung cancer screening counseling and SDM visit||Determination of eligibility for lung cancer screening using ≥1 lung cancer risk calculators is at the core of the consultation|
Being eligible for lung cancer screening might be presented as desirable (although it indicates a high risk of lung cancer). If patients are not eligible for screening, they feel like they are missing out on something that would help them.
If the patient is eligible, it is assumed that screening is the option preferred by the patient. Informed consent is obtained.
The patient receives information about the risks and benefits of lung cancer screening (eg, brochure, video, slide show)
The patient is asked whether he or she needs help with smoking cessation; if so, he or she is given informational material/contact details of smoking cessation services
|If the risk of lung cancer is too low, the clinician explains to the patient that screening is not an option because its potential harms would exceed the benefits in people at low lung cancer risk|
If eligible, clinician and patient work together to determine whether lung cancer screening makes intellectual, emotional, and practical sense given the patient's overall personal and medical situation, as well as their informed preferences and values
A conversation aid, designed to facilitate the conversation between clinician and patient and to support the communication of evidence, is used to support communication about the relative benefits and harms of screening or not using tailored estimates of risk and state-of-the art information design
The importance of smoking cessation is emphasized. Practical help for smoking cessation (nicotine replacement therapy, etc) is offered.
|Assessment of the patient's eligibility for lung cancer screening is no longer at the core of the consultation|
Clinician and patient engage in a process together to determine whether lung cancer screening is the right option for the patient
High-quality information about lung cancer screening/a decision aid is used to inform the deliberation process between clinician and patient and is not just independently presented to the patient
The patient knows that smoking cessation is more effective than lung cancer screening to prevent dying of lung cancer. Practical help for smoking cessation is offered.
|Discussion of the results of lung cancer screening||The radiology report of LDCT recommends further management/follow-up using a predetermined algorithm|
The primary care physician is left alone to implement the recommendations from the algorithm. The algorithm may be purposefully vague such as to suggest a PET/CT scan or tissue sampling depending on the probability of malignancy and comorbidities.
The patient is informed about investigations planned to assess potentially suspicious nodules further
|An expert clinician associated with the lung cancer screening program reviews the results of the LDCT, including the radiology report, and either advises the primary care physician on further management/follow-up screening (if no major abnormality is found) or schedules a consultation with the patient to discuss possible investigation of a suspicious nodule|
If a nodule looks potentially suspicious for cancer, a pulmonologist and the patient deliberate the pros and cons of different management options (eg, surveillance with serial CT, nonsurgical biopsy, surgical resection) to arrive at a decision about further investigation that aligns with the patient's context, values, and preferences
|Radiology recommendations for lung nodule management based on algorithms are reviewed by an expert clinician who will advise the primary care physician about the follow-up process|
If further investigation of a suspicious finding is potentially indicated, a pulmonologist and the patient engage in a process together to determine the best way to proceed for the patient
Supplemental Online Material
- Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N).Last updated February 5, 2015. Accessed August 9, 2017)
- What is shared decision making? (and what it is not).Acad Emerg Med. 2016; 23: 1320-1324
- Reduced lung-cancer mortality with low-dose computed tomographic screening.N Engl J Med. 2011; 365: 395-409
- Counterpoint: should only primary care physicians provide shared decision making services to discuss the risks/benefits of a low dose chest CT for lung cancer screening? no.Chest. 2017; 151: 1215-1217
- Crossing the Quality Chasm: A New Health System for the 21st Century.National Academy Press, Washington, DC2001
- Peering into the black box: a meta-analysis of how clinicians use decision aids during clinical encounters.Implement Sci. 2014; 9: 26
- The effectiveness of patient navigation to improve healthcare utilization outcomes: a meta-analysis of randomized controlled trials.Patient Educ Couns. 2017; 100: 436-448
Grant Support: This work was supported by an Australian National Health and Medical Research Council fellowship (APP1123733) (C.C.D.).
Potential Competing Interests: Dr Midthun receives research funding from Integrated Diagnostics Inc and Exact Sciences Corp, as well as royalties for authorship/editing from UpToDate.