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Shared Decision Making for Lung Cancer Screening

Shared Decision Making for Lung Cancer Screening - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Preventive Health, Related


Shared-Decision Making References for Lung Cancer Screening
RECOMMENDATION: Medicare Requirements:
It is recommended to complete annual low-dose
computed tomography (LDCT) screening in
asymptomatic patients who exhibit all of the high
risk factors.1-3 (USPSTF Grade B)
High risk factors for lung cancer include:
ξ Age 55-80 years AND
ξ 30 pack-year smoking history AND
ξ Current smoker or smoking cessation
< 15 years ago
Reference: UW Health Preventive Health Care Guideline
Medicare provides coverage to patients aged 55-77 years who also meet the
additional high risk factors outlined on the left. In addition, Medicare requires a lung
cancer screening counseling and shared-decision making visit which includes
documentation of the following:
- Determination of eligibility criteria (age, absence of symptoms of lung cancer,
and smoking pack-years or number of years since quitting);
- Shared decision-making, including use of one or more decision aides, to
include benefits/harms of screening, follow-up diagnostic testing, over-
diagnosis, false-positive rate, and total radiation exposure;
- Counseling on the importance of adherences to annual screening, impact of
comorbidities and ability or willingness to undergo diagnosis and treatment;
- Counseling on the importance of maintaining cigarette smoking abstinence or
smoking cessation (if current smoker)
Reference: https://www.cms.gov/medicare-coverage-database/details/nca-
decision-memo.aspx?NCAId=274
COUNSELING TOPICS:
ξ Smoking cessation
ξ Adhere to annual screening (ongoing process)
ξ Impact of comorbidities
ξ Ability/willingness to undergo diagnosis and treatment
EXPECTED BENEFIT OF SCREENING:
Early detection and treatment resulting in a reduction of lung cancer mortality (20%).2
POTENTIAL HARMS OF SCREENING:
ξ High false positive rate: The National Lung Screening Trial (NLST) demonstrated that over 3 years,
24.2% of all scans were positive and 39.1% of those screened had at least one positive result.2
However, the vast majority (96.4%) of lung nodules that are detected are benign. 2
ξ False negatives: A negative LDCT result does not guarantee the absence of cancer. In the NLST,
fewer that 1 in 1000 had a cancer diagnosed in the year following a negative scan. 2
ξ Over-diagnosis: Cancers which are detected may not be the ultimate cause of death.
ξ Follow-up diagnostic testing: A positive LDCT result may require additional testing including follow-
up LDCT, bronchoscopy, biopsy, or surgery.4
ξ Radiation exposure: The table below describes the level of radiation exposure during screening.
Table 1. Radiation Exposure Comparison for LDCT
Procedure Type
(Single Scan)
Approximate Radiation
Dose
Comparable background
radiation
Additional lifetime risk of fatal cancer for patients over the
age of 50
Chest CT < 3.0 mSv 1-3 years Low (1 in 10, 000 to 1 in 1,000)
Chest Low Dose CT 1.5 mSv 6-18 months Very Low (1 in 100,000 to 1 in 10,000)
Chest X-Ray 0.1 mSv 10-30 days Minimal (1 in 1,000,000 to 1 in 100, 000)
Additional information on radiologic exposure can be found at http://www.radiologyinfo.org/en/safety/?pg=sfty_xray
References:
1. Moyer VA, Force USPST. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-338.
2. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409.
3. Oken MM, Hocking WG, Kvale PA, et al. Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. JAMA. 2011;306(17):1865-
1873.
4. Network NCC. Non-Small Cell Lung Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)2015: http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf
PATIENT DECISION AIDS:
ξ www.shouldiscreen.com
ξ Healthwise
ξ www.HealthDecision.org
ξ National Cancer Institute (English)
ξ National Cancer Institute (Spanish)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org