Shared Decision Making and Screening: An Ongoing Dialogue Informed by Data

March 15, 2015

A state of equipoise now exists for various surgical options in the treatment of early lung cancer, underscoring the need for shared decision making.

Minimally invasive thoracic resection has been reported to reduce the cost and morbidity of lung cancer surgery. The evidence supporting this position is outlined in a review article in this issue of ONCOLOGY.[1] The importance of this information has recently escalated, as the Centers for Medicare and Medicaid Services (CMS) finally agreed to provide reimbursement for low-dose CT screening in high risk cohorts.[2] This new strategy for the early detection of lung cancer will more frequently find early-stage cancers than in the past, and this may represent the most favorable setting for employing minimally invasive surgical techniques.

The final CMS coverage decision requires shared decision making, including “the use of one or more decision aids.”[2] This stipulation arises out of a desire to ensure that the appropriate discussion of relevant information regarding potential benefits and harms of screening routinely occurs. This requirement is intuitively appealing, and sharing procedural information is considered to be an inherent part of the relationship between healthcare providers and their patients. However, with regard to the lung cancer screening process, no evidence exists that any benefit is derived from the requirement to use a decision aid tool.

What will perhaps prove far more helpful to such discussions in the long run will be the routine capture of data about all aspects of the management of patients who undergo screening. The surgical management of patients in the National Lung Screening Trial (NLST) was not specified in the study protocol, and so the favorable results of that trial emerged from a patchwork of community standards from the various sites involved in the NLST. Going forward, the opportunity exists to create prospective registries designed to more completely capture relevant prognostic information that will be able to inform future discussions about the optimal surgical intervention.[3,4]

As noted in the review, a state of equipoise now exists for various surgical options in the treatment of early lung cancer,[1] underscoring the need for shared decision making. Because varying risks are associated with nearly each aspect of the surgical decision, including type of surgery, extent of surgery, and even extent of staging, the need to solicit patient preference is great. This will presumably lead, in turn, to even more variation in the procedures being performed. Capturing this information-as well as other information not previously captured (especially details regarding the imaging findings)-in prospective registries should result in highly useful data regarding relative benefits and harms under different conditions.

As suggested by the Lung Cancer Alliance Framework Process, a new approach is needed in which care providers are dynamically committed to a range of best-practice and related quality provisions that are documented and followed for outcomes, thus allowing for protocols to be continuously updated based on knowledge derived from these registries.[5] Other imaging issues related to quality control features are inherent to the new American College of Radiology CT accreditation program, which requires use of Lung–RADS or a similar structured reporting and management system.[6] With this new advocacy-driven, continuously evolving quality approach, responsible implementation of lung cancer screening is on much firmer footing.

Financial Disclosure:Dr. Yankelevitz is a named inventor on a number of patents and patent applications relating to the evaluation of diseases of the chest, including measurement of nodules. Some of these are owned by Cornell Research Foundation (CRF). As an inventor named on these patents, Dr. Yankelevitz is entitled to a share of any compensation which CRF may receive from its commercialization of the patented products. Dr. Mulshine has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1. Cheng AM, Wood DE. Current status of minimally invasive reserction of ealy lung cancers. Oncology. 2015;29:160-6.

2. Centers for Medicare and Medicaid Services. Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N). Available from: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274. Accessed February 26, 2015.

3. Aberle D, Adams A, Berg C, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409.

4. Mulshine JL, D’Amico TA. Issues with implementing a high-quality lung cancer screening program. CA Cancer J Clin. 2014;64:352-63.

5. Lung Cancer Alliance. National framework for excellence in lung cancer screening and continuum of care. Available from: http://www.lungcanceralliance.org/assets/docs/am-i-at-risk/NationalFramework.pdf. Accessed February 18, 2015.

6. Kazerooni EA, Armstrong MR, Amorosa JK, et al. ACR CT accreditation program and the lung cancer screening program designation. J Am Coll Radiol.2015;12:38-42.