Patient Decision Aid for Lung Cancer Screening in Smokers: Is It Effective?

A randomized, clinical study compared the efficacy of a patient decision aid (PDA) about lung cancer screening versus a standard educational material (EDU) regarding decision-marking outcomes among smokers.

“Guidelines about lung cancer screening are consistent in emphasizing the importance of patients making an informed decision within the context of receiving smoking cessation services for people who continue to smoke,” the researchers explained. “The Centers for Medicare & Medicaid Services (CMS) has financially covered lung cancer screening using LDCT since 2015, but the CMS guidelines require a patient counseling and shared decision-making visit using patient decision aids (PDAs) before screening referral. The requirement to use PDAs for CMS reimbursement of lung cancer screening is unprecedented. There is a need for PDAs to support informed decision-making about lung cancer screening using LDCT, yet few tools have been developed and none have been evaluated in comparative trials.”

The researchers chose to reach patients through tobacco quitlines because quitting smoking is essential to lung cancer screening programs, and smokers are at a significantly increased risk of lung cancer. Thirteen state tobacco quitlines were used to identify current and recent tobacco quitline clients. Clients were eligible or the study if they were aged between 55 and 77 years, spoke English, and had a 30+ pack-year smoking history; those with a history of lung cancer were excluded. Quitline staff members asked prospective participants if they wanted to learn about lung cancer screening, and those who expressed interest received the toll-free telephone number and email address for the research team. Clients who had previously contacted the quitline were identified and received recruitment materials via mail.

Clients randomized to the PDA (n=259) watched a 9.5-minute narrated video titled, “Lung Cancer Screening: Is It Right For Me?” Information in the video included:

• eligibility for lung cancer screening and a calculation of tobacco pack-year smoking history
• lung cancer epidemiology and risk factors
• a video of a patient in a CT scanner
• icon arrays to graphically depict the magnitude of mortality reduction, false-positive results, and harms from invasive diagnostic procedures
• radiation exposure depicted within the context of other sources of radiation (eg, a screening mammogram)

Over the duration of the video, emphasis was placed on smoking cessation.

The EDU group (n=257) received a two-page brochure highlighting the following:

• eligibility for screening
• the harms and benefits of screening
• what to expect from undergoing a low-dose CT scan
• the costs of screening
• how to interpret the low-dose CT results
• the importance of smoking cessation
• where to find more information about lung cancer and screening

PDA Provides More Knowledge, Increases Preparedness

Among the 516 total clients, 370 (71.7%) were aged younger than 65 years. Most (n=320, 62.0%) were female, about a quarter (n=138, 26.7%) identified as black, about one in 10 (n=47, 9.1%) did not have health insurance, and less than half (n=226, 43.8%) had a high school education or lower.

A larger proportion of the PDA group compared to the EDU group was well-prepared to make a screening decision (67.4% vs. 48.2%; odds ratio [OR]=2.31; 95% confidence interval [CI], 1.56–3.44; P<0.001). Exactly half of the PDA patients felt informed about their screening choice compared to 28.3% of the EDU group (OR=2.56; 95% CI, 1.72–3.79; P<0.001); PDA patients were also more likely to be clear about their values related to the harms and benefits of screening (68.0% vs. 47.4%; OR=2.37; 95% CI, 1.60–3.51; P<0.001). At every follow-up assessment, the PDA group demonstrated more lung cancer screening knowledge than the EDU group. There were no significant between-group differences in intentions to be screened and screening behaviors.

The study was published in JAMA Network Open.

“A PDA delivered to persons seeking services from tobacco quit lines improved the quality of lung cancer screening decisions compared with EDU. These improvements were consistent with recommendations of professional societies regarding smokers making informed decisions about lung cancer screening,” the study authors concluded. They added, “Disseminating the PDA through tobacco quit lines could reach a large number of potentially eligible smokers in the United States. Carefully addressing the role of tobacco quit lines in distributing PDA support for lung cancer screening, given variable quit line funding, is necessary for broader dissemination and greater effect of the intervention.”