What’s important is having a more balanced, nuanced conversation with patients. But is the American public ready for discussions of mortality rates or the changing calculus of risk/benefit ratios of screening as they age?
Nearly half of all American adults – 90 million people – have difficulty understanding and using health information, according to an Institute of Medicine report. In addition, the 2000 census counted 20 million people who speak poor English and 10 million who speak none.
The public is quite intelligent, but that part of the problem is that physicians don’t always know or understand the data. And if even when physicians understand the data, they often do not know how to communicate them in a way their patients can understand, says Dr. Bevers.
"That’s where there is a huge opportunity to create decision-making tools," she says.
With the help of communication experts, Dr. Bevers and her colleagues are developing a computerized tool that reviews the data from the National Lung Screening Trial (NLST) and spells out the benefits and harms of low-dose computed tomography screening for lung cancer in a very simplified fashion, using smiley faces for benefits and frowning faces for risks.
"It really advances my discussion when I walk in the room," said Dr. Bevers, a coinvestigator for the NLST. "I’m not explaining about the 20% mortality reduction, the associated harms. I’m now talking about: ‘What did you think about that?’ ‘What did you think about the harms?’ ‘How did it influence your decision about this?’ It’s a much more advanced discussion, and that’s helpful in a busy practice."
Another tool could then be used to walk patients through the next step of care to give physicians a sense of what concerns their patients most; for example, the risk of dying or that their cancer will return, she said.
The New Kid on the Block
Most experts agree that low-dose CT lung cancer screening is something of an anomaly in the cancer screening wars. Prior nonrandomized trials suggested a benefit with low-dose CT, but practice did not leapfrog the evidence. Only now that the randomized NLST has been completed is the screening machinery gearing up, but with significant questions about cost and high false-positive rates still unanswered (N. Engl. J. Med. 2011;365:395-409)
Moreover, CT lung screening would be an additional service offered to high-risk individuals, rather than the retraction of an entrenched screening practice.
The NCI has developed its own one-page, online NLST study guide for patients and physicians that provides specific data on low-dose CT vs. chest x-ray screening, "take-home" messages, and an educational component directing patients not to smoke.
"We don’t want to oversell the harms and undersell the benefits," said the NCI’s Dr. Kramer. "We don’t want the pendulum to swing completely in the opposite direction, and I think this sheet goes a long way."
In a busy primary care office, no doubt the various new recommendations will shift the conversation with patients, many of whom have been given the simple message for years to come back each year for their annual mammogram or PSA test. Depending on which recommendations their physicians advocate and what patients choose to follow, it will ultimately tip the balance sheet and outcomes data for years to come.
None of the physicians interviewed reported having relevant conflicts of interest.