In a viewpoint perspective published in JAMA on March 9, 2021, a University of North Carolina Lineberger Comprehensive Cancer Center researcher and two other experts endorsed the Center for Medicare & Medicaid Services’ (CMS) requirement for a patient and their doctor to engage in a shared discussion of benefits and harms before proceeding with a low-dose spiral computed tomography (LDCT) scan as a method for preventing lung cancer death. An accompanying evidence report detailed the benefits and harms from screening, suggesting that shared decision-making between a patient and their health care professional is crucial in ensuring screening is used optimally and with fully informed consent.
“In our view, CMS should continue to require, as well as pay for, shared decision-making, including associated tobacco counseling, for people being considered for annual lung cancer screening because having yearly CT screening is a consequential decision,” said Daniel Reuland, MD, MPH, one of the review authors, a member of the UNC Lineberger Comprehensive Cancer Center, and a professor in the division of General Medicine and Clinical Epidemiology at UNC School of Medicine. “Patients should understand the benefits, harms and costs involved, and their values and preferences should be considered. Because the decision-making process can be time-consuming, we also think shared decision-making could be done by trained, non-physician staff.”
The experts note that during the COVID-19 pandemic many people have effectively received medical advice through technology such as Skype and Zoom. Therefore, they recommend that CMS continue to pay for counseling delivered by telehealth. In addition, if the patient is a current smoker, they said a professional should counsel that quitting smoking is by far the most important thing the patient can do to stay healthy.
The United States Preventive Services Task Force, the main evaluator of evidence for preventive strategies, now recommends low-dose CT screening for people 50 to 80 years old with a 20 pack-year smoking history. The new recommendations expand the group of people eligible for screening from the initial recommendations in 2013, and includes more Black people, which research has shown have a higher risk of developing lung cancer at earlier ages and with less tobacco exposure. The viewpoint authors believe shared decision-making is more important than ever as it can promote patient engagement, tobacco cessation and screening adherence, which in turn may lead to greater health equity.
As part of standard practice, Reuland, who is also a research fellow at UNC’s Cecil G. Sheps Center for Health Services Research, believes that a physician should explicitly ask about the patient’s informed values and preferences regarding key tradeoffs of screening and use that information to reach a decision that makes sense for the patient. He also advocates for the use of decision aids, which are tools that can be used to help inform patients by making the essential issues clear and easy to understand.
Reuland said good, shared decision-making is a process that takes time to establish, regardless of whether it is face-to-face or via telehealth. Studies and improvement efforts are underway to learn how to optimize shared decision-making. Indeed, Reuland and others at UNC have recently tested a video decision-making tool and found it increases understanding of the balance between risks and benefits in patients eligible for screening.
“It is important to note that shared decision-making is advisable for all patients considering initiation of annual lung cancer screening, based on ethical grounds, regardless of whether or not they have Medicare or Medicaid. To my knowledge, non-CMS third-party payers will reimburse for this counseling,” Reuland said.
Authors and Disclosures
In addition to Reuland, the paper’s other authors are Richard M. Hoffman, MD, MPH, University of Iowa Carver College of Medicine, and Robert J. Volk, PhD, University of Texas MD Anderson Cancer Center.
Reuland has received grants from the National Cancer Institute; he is also a member of the National Lung Cancer Roundtable (NLCRT) Shared Decision Making working group. Hoffman is a member of the NLCRT Shared Decision Making working group. Volk has received grants from NCI and the Cancer Prevention and Research Institute of Texas during the conduct of the study; he is a member of the NLCRT Shared Decision Making Task Group and has received reimbursement for travel expenses to the annual meeting of the NLCRT.