Shared Decision Making for Lung Cancer Screening
Hidden challenges can block patients' access to life-saving screening. How can physicians support their patients in making informed decisions about their care?
Lung cancer screening is now recommended by the United States Preventive Services Task Force (USPSTF) and the Centers for Medicare and Medicaid Services (CMS) for a group of current and former smokers at high risk for lung cancer. However, before patients enter a screening program, they must have a shared decision making discussion with a qualified health care professional, such as a physician or nurse practitioner. But what exactly is shared decision making?
To aid in shared decision marking, a decision aid provides balanced, detailed information about each of the options to guide the discussion. Although decision aids and shared decision making are sometimes used in screening for prostate, colorectal, and breast cancer, these new guidelines represent the first time reimbursement has been tied to this type of communication.
A recent study of decision aids concluded that high-quality evidence shows the use of decision aides improved patient knowledge about options and reduced decisional conflict as compared to standard practice. Despite multiple studies showing the value of shared decision making to patient-centered care, decision aids and similar tools are not widely used in clinical practice.
Among the challenges to shared decision making in lung cancer screening are the lack of point-of-care decision aids, differing physician skill and comfort with shared decision making, and available time for shared decision making discussions. These obstacles are being addressed with provider toolkits, provider training, and alternate models in location and timing of the shared decision making discussion. For example, the ACR provides online screening decision aids around lung cancer screening.
Less apparent challenges also impact whether people are making truly informed decisions about lung cancer screening. The first of these is the stigma associated with smoking and lung cancer. In my lung cancer advocacy outreach, I have heard many say, "I don't want to get screened. If I get lung cancer it's my fault because I smoked." Other patients tell me, "I don't want to know. My wife/husband/kids would kill me." In a recent focus group I conducted with older current and former smokers, many commented on the stigma associated with smoking now, whereas when they were growing up smoking was the norm. People remember eating breakfast with a cigarette burning in the ashtray. Cigarettes were in all of the advertisements, in all of the magazines, on all of the TV commercials. The government even gave soldiers cigarettes as part of their rations. By the time the dangers of smoking were widely understood, many smokers were already addicted.
The stigma around smoking needs to be addressed in both decision aids and shared decision making discussions. It's important to include information about the history of smoking and the normalcy of smoking in the 60s, 70s, and into the 80s. In fact, more than 50 percent of men and close to 30 percent of women were smoking in 1965. Discussions should also take into account the lack of knowledge about the health effects of smoking until relatively recently as well as the billions spent by big tobacco companies on advertising targeting young people. Decision aids might also touch on the billions spent to both deny the addictiveness of cigarettes and simultaneously research how to make cigarettes more addictive. Only by addressing stigma directly will we help many at high risk of lung cancer move past the shame associated with tobacco use and make an informed decision.
Going hand in hand with the social stigma around smoking, many health care professionals have biases, both conscious and unconscious, against smokers. A study comparing implicit views about lung cancer vs. breast cancer showed patients, caregivers, and health care professionals all had similar implicit bias against lung cancer. Another study showed implicit bias in oncologists impacted the patient physician discussion. The patients in the study perceived that oncologists with implicit bias were less supportive. Additionally, patients were less confident in the oncologist's treatment recommendations. Since African-American men have 1.2 times the lung cancer mortality rates as white men , screening is even more important for that group.
Health care providers with implicit biases negatively affect the quality of the shared decision making discussion as well as the perception of support for screening by patients. In a study reporting on perceived barriers to lung cancer screening, focus group participants commented on feeling stigmatized by younger health care professionals. Patients felt these workers did not understand the historical context around smoking and were concerned about judgement around smoking choices.
Addressing the stigma associated with lung cancer for patients may help reduce health care professional implicit bias. One way to pinpoint these biases is through a self-evaluation. By being aware of our biases, we can guard against their effects when it comes to shared decision making discussions. If you find that your bias is especially strongly held, you may consider recommending the patient to another health care professional for the shared decision making discussion.
We need to recognize the impact of stigma and bias as associated with smokers and lung cancer. This cannot be a reason our patients choose not to get screened. Ignoring the real effects of stigma will result in a parody of shared decision making and an abandonment of the core principles of patient-centered care.