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Editorials: Point and Counterpoint |

POINT: Should Only Primary Care Physicians Provide Shared Decision-making Services to Discuss the Risks/Benefits of a Low-Dose Chest CT Scan for Lung Cancer Screening? Yes FREE TO VIEW

John D. Goodson, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

Harvard Medical School and Massachusetts General Hospital, Boston, MA

CORRESPONDENCE TO: John D. Goodson, MD, Wang 625, Massachusetts General Hospital, 15 Fruit St, Boston, MA 02114


Copyright 2016, . All Rights Reserved.


Chest. 2017;151(6):1213-1215. doi:10.1016/j.chest.2016.11.057
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Published online

Modern primary care continues to evolve as a specialty with a broad agenda. What began as a profession focused on day-to-day problem identification and management now includes disease prevention and health promotion. The physician fee schedule issued annually by the Centers for Medicare & Medicaid Services provides payment for these added responsibilities. For Medicare patients, the Initial Preventive Physical Examination (also known as the “Welcome to Medicare” visit) and the Annual Wellness Visits were specifically designed to provide physician payment to complete the full medical history and determine appropriate screening, vaccination, and lifestyle recommendations. Most recently, the Medicare Access and CHIP Reauthorization Act establishes a value-based paradigm based, in part, on the premises of disease prevention and health promotion.

Proactive doctoring is fundamental to the disease prevention and health promotion agenda. However, like much of medicine, the screening agenda is complicated because the evidence base remains unstable. Mammograms for years have been the most widely promoted of all screening tests. This most sacred of screening practices has been challenged.,,, Prostate-specific antigen screening for prostate cancer vaulted to the top of the screening agenda only to fall into the “questionable value” category.,

Low-dose CT (LDCT) scanning for the early identification of potentially curable lung cancer has now achieved a toehold in the top tier of screening tests. The US Preventive Services Task Force guidelines call for annual LDCT scanning for adults aged 55 to 80 years who have > 30 pack-years of exposure who currently smoke or have quit within the last 15 years. A word of caution: experience to date would indicate that being in the top tier is never enough to ensure a permanent position.

We in primary care are left with the day-to-day task of presenting the patients with screening recommendations in the midst of what turns out to be a remarkably uncertain world. First, as noted, the year-to-year variability in recommended screening tests can be confusing to both patients and their physicians. What is accepted as routine can become unnecessary as more data are collected and the benefits of widespread screening are reassessed. Historically, each new screening test has its own devoted cadre of supporters who develop testing strategies, conduct research, and then promote value. It is only later, in some cases decades later, that independent data analysis or further prospective trials begin to question the value of the original recommendations. These changes are not unexpected. Generalizability lies at the core of any clinical study’s value. Clinical investigation involves patient recruitment and selection, a predictable source of bias. With time and repeated study, these biases get sorted out.

Second, screening requires consistent performance over time so that one patient derives benefit. The concept of number needed to treat, which is the number of patients that must be treated the same way over a specified period of time for one patient to derive benefit (while the others who were treated do not derive benefit), applies to screening as well. For example, the number needed to screen over 9 years to avert one death with prostate cancer screening is approximately 2,400. For screening to work, an entire community of physicians and other nonphysician providers must consistently deliver the same message to each and every eligible patient. If thousands of physicians are consistent about their messaging, the net population benefit can be substantial. The numbers for colonoscopy are relatively good: 27 life-years will be added for every 100 patients screened every 10 years for 25 years (ages 50-75 years) with colonoscopy. Of course, this scenario means that a few of those 100 patients will have early colon cancer detected and treated, and many will have polyps harvested that would not have become cancerous. Those with consistently normal findings participate as fellow travelers, not knowing if their fate is to be cancer-free or not.

So how does the screening agenda fit with day-to-day patient care? The messaging about screening per se must be consistently delivered by all physicians regardless of specialty. For primary care physicians to promote screening without support from their nonprimary care colleagues makes our day-to-day work that much harder. In practice, screening is delivered in the context of continuous patient care. The motivational skills required by doctoring the asymptomatic patient with hypertension who must take medications are the same skills required to convince a patient to undergo a screening test. Furthermore, screening must be presented when the timing is right. Patients with multiple concurrent unstable diseases are unlikely to add screening to their testing agenda. Screening must always be intertwined with diagnostic and treatment requirements. This approach is the “art” of primary care, knowing when to introduce the screening discussion. In many cases, the conversation is ongoing and may begin months or years before the test is ordered so that the patient can begin to understand the value. Screening is not a “one-off” process.

Finally, there is the more complicated question of concurrencies. The very patients for whom LDCT scanning applies are also the very same patients whose life expectancy is compromised by coronary artery disease and chronic lung disease. Such factors are not easily quantified and, ultimately, it will be the physicians who know their patients best who will be in the position to prioritize the screening agenda based on the expected progression of the individual patient’s health status.

Effective screening requires years of commitment. For the primary care physician, this process means consistent messaging for every impaneled patient. This approach must be matched with each patient’s willing participation in sequential testing. For LDCT scanning, an individual could have 25 years of annual screening.

Screening itself engenders uncertainty. For the patient, there is the apprehension that something will be found. If the test result is negative, there is reassurance value, although few patients truly appreciate the lack of precision around test specificity. A negative test result does not guarantee good health, it just improves the probability. More importantly, indeterminate results create their own levels of uncertainty. The nodule that requires 3-month follow-up must both be presented as a potentially worrisome finding and followed through to conclusion (either resolution or further testing). A clear abnormality triggers an even more complicated set of discussions. This outcome is the middle ground of screening that becomes the work of primary care. Maintaining continuous relationships with patients over time around other medical conditions allows the physician to tap into the legacy that comes from an established relationship. If the patient whose low back pain, psoriasis, and coronary artery disease also has an indeterminate CT finding, I am much more credible with my recommendation of watchful waiting than I would be without an existing relationship that demonstrated my commitment to their health. Such relationships are not exclusive to primary care, but they are essential for continuous and effective screening. Screening programs must be developed in the context of the continuum of patient care.

Discussions around the value of screening have included the concept of “shared decision-making.” This topic has engendered a variety of tools and requirements for decision support. I would argue that the process is much more complicated because in practice, managing the consequences of decision-making can be much more challenging than the decision-making moment.

As physicians, we share our commitment to the health and well-being of the patients. To be effective, we must collaborate with one another. We must be consistent with our messaging that screening works, that the benefits of consistent screening require all patients to undergo tests on a consistent and repetitive basis knowing that only a small fraction ultimately derive any survival improvement, and that a small number of patients with indeterminate or abnormal findings will enter into a zone in which our best communication and doctoring skills will be necessary to manage the uncertainty we have created.

For all physicians who participate in the nation’s screening agenda, the question is the same: Are you willing to adopt the repetitive practice patterns demanded by effective screening and to deal with the consequences of uncertainty? If the answer is yes, then join your fellow physicians. However, to join this effort, ask if you have a sufficiently robust infrastructure to ensure your own consistent performance, a nuanced understanding of each patient’s concurrent social and medical issues, and the strong relationships with your patient required to skillfully manage the difficulties that arise from indeterminate test results. Placing this onus of responsibility back on another physician is just offloading professional work onto someone else.

References

Nelson H.D. .Pappas M. .Cantor A. .et al Harms of breast cancer screening: systematic review to update the 2009 US Preventive Services Task Force Recommendation. Ann Intern Med. 2016;164:256-266 [PubMed]journal. [CrossRef] [PubMed]
 
Nelson H.D. .Fu R. .Cantor A. .et al Effectiveness of breast cancer screening: systematic review and meta-analysis to update the 2009 US Preventive Services Task Force recommendation. Ann Intern Med. 2016;164:244-254 [PubMed]journal. [CrossRef] [PubMed]
 
Welch H.G. .Gorski D.H. .Albertsen P.C. . Trends in metastatic breast and prostate cancer—lessons in cancer dynamics. N Engl J Med. 2015;373:1685-1688 [PubMed]journal. [CrossRef] [PubMed]
 
Esserman L. .Shieh Y. .Thompson I. . Rethinking screening for breast cancer and prostate cancer. JAMA. 2009;302:1685-1692 [PubMed]journal. [CrossRef] [PubMed]
 
Qaseem A. .Barry M.J. .Denberg T.D. .et al Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2013;158:761- [PubMed]journal. [CrossRef] [PubMed]
 
de Koning H.J. .Meza R. .Plevritis S.K. .et al Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the US Preventive Services Task Force. Ann Intern Med. 2014;160:311- [PubMed]journal. [PubMed]
 
Bibbins-Domingo K. .Grossman D.C. .Curry S.J. .et al Screening for colorectal cancer—US Preventive Service Task Force recommendation statement. JAMA. 2016;315:2564-2574 [PubMed]journal. [CrossRef] [PubMed]
 
Gould M.K. . Who should be screened for lung cancer? And who gets to decide? JAMA. 2016;315:2279-2281 [PubMed]journal. [CrossRef] [PubMed]
 
Lee O.E. .Emanuel E.J. . Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368:6-8 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Nelson H.D. .Pappas M. .Cantor A. .et al Harms of breast cancer screening: systematic review to update the 2009 US Preventive Services Task Force Recommendation. Ann Intern Med. 2016;164:256-266 [PubMed]journal. [CrossRef] [PubMed]
 
Nelson H.D. .Fu R. .Cantor A. .et al Effectiveness of breast cancer screening: systematic review and meta-analysis to update the 2009 US Preventive Services Task Force recommendation. Ann Intern Med. 2016;164:244-254 [PubMed]journal. [CrossRef] [PubMed]
 
Welch H.G. .Gorski D.H. .Albertsen P.C. . Trends in metastatic breast and prostate cancer—lessons in cancer dynamics. N Engl J Med. 2015;373:1685-1688 [PubMed]journal. [CrossRef] [PubMed]
 
Esserman L. .Shieh Y. .Thompson I. . Rethinking screening for breast cancer and prostate cancer. JAMA. 2009;302:1685-1692 [PubMed]journal. [CrossRef] [PubMed]
 
Qaseem A. .Barry M.J. .Denberg T.D. .et al Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2013;158:761- [PubMed]journal. [CrossRef] [PubMed]
 
de Koning H.J. .Meza R. .Plevritis S.K. .et al Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the US Preventive Services Task Force. Ann Intern Med. 2014;160:311- [PubMed]journal. [PubMed]
 
Bibbins-Domingo K. .Grossman D.C. .Curry S.J. .et al Screening for colorectal cancer—US Preventive Service Task Force recommendation statement. JAMA. 2016;315:2564-2574 [PubMed]journal. [CrossRef] [PubMed]
 
Gould M.K. . Who should be screened for lung cancer? And who gets to decide? JAMA. 2016;315:2279-2281 [PubMed]journal. [CrossRef] [PubMed]
 
Lee O.E. .Emanuel E.J. . Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368:6-8 [PubMed]journal. [CrossRef] [PubMed]
 
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