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Original Investigation
Less Is More
October 2018

Evaluating Shared Decision Making for Lung Cancer Screening

Author Affiliations
  • 1Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill
  • 2Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
  • 3Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
  • 4Department of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
  • 5Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill
JAMA Intern Med. 2018;178(10):1311-1316. doi:10.1001/jamainternmed.2018.3054
Key Points

Question  What is the quality of guideline-recommended shared decision making about lung cancer screening in clinical practice?

Findings  In this qualitative content analysis of 14 recorded and transcribed outpatient clinical encounters, the quality of shared decision making about lung cancer screening was poor, as rated by 2 independent observers using a validated shared decision making scale. Potential harms of screening were not adequately explained, and decision aids were not used.

Meaning  Despite recommendations, shared decision making for lung cancer screening in practice may be far from what is intended by guidelines.


Importance  The US Preventive Services Task Force recommends that shared decision making (SDM) involving a thorough discussion of benefits and harms should occur between clinicians and patients before initiating lung cancer screening (LCS) with low-dose computed tomography. The Centers for Medicare & Medicaid Services require an SDM visit using a decision aid as a prerequisite for LCS coverage. However, little is known about how SDM about LCS occurs in practice.

Objective  To assess the quality of SDM about the initiation of LCS in clinical practice.

Design, Setting, and Participants  A qualitative content analysis was performed of transcribed conversations between primary care or pulmonary care physicians and 14 patients presumed to be eligible for LCS, recorded between April 1, 2014, and March 1, 2018, that were identified within a large database.

Main Outcomes and Measures  Independent observer ratings of communication behaviors of physicians using the OPTION (Observing Patient Involvement in Decision Making) scale, a validated 12-item measure of SDM (total score, 0-100 points, where 0 indicates no evidence of SDM and 100 indicates evidence of SDM at the highest skill level); time spent discussing LCS during visits; and evidence of decision aid use.

Results  A total of 14 conversations about initiating LCS were identified; 9 patients were women, and 5 patients were men; the mean (SD) patient age was 63.9 (5.1) years; 7 patients had Medicare, and 8 patients were current smokers. Half the conversations were conducted by primary care physicians. The mean total OPTION score for the 14 LCS conversations was 6 on a scale of 0 to 100 (range, 0-17). None of the conversations met the minimum skill criteria for 8 of the 12 SDM behaviors. Physicians universally recommended LCS. Discussion of harms (such as false positives and their sequelae or overdiagnosis) was virtually absent. The mean total visit length of a discussion was 13:07 minutes (range, 3:48-27:09 minutes). The mean time spent discussing LCS was 0:59 minute (range, 0:16-2:19 minutes), or 8% of the total visit time (range, 1%-18%). There was no evidence that decision aids or other patient education materials for LCS were used.

Conclusions and Relevance  In this small sample of recorded encounters about initiating LCS, the observed quality of SDM was poor and explanation of potential harms of screening was virtually nonexistent. Time spent discussing LCS was minimal, and there was no evidence that decision aids were used. Although these findings are preliminary, they raise concerns that SDM for LCS in practice may be far from what is intended by guidelines.

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