Shared decision-making conversations and smoking cessation interventions: critical components of low-dose CT lung cancer screening programs

Lung cancer remains the world’s deadliest cancer despite efforts to decrease smoking rates. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was shown to reduce lung cancer deaths by 20%. Screening with LDCT comes with potential harms including a high rate of false-positive test results, subsequent follow-up procedures, and radiation exposure. For some patients, the potential benefits associated with screening may be outweighed by the harms. The decision to screen must therefore take into consideration patients’ risk of developing lung cancer, comorbidities that may prevent diagnostic procedures or curative surgery, and their values and preferences regarding the benefits and harms of screening. A process called shared decision-making (SDM) is recognized as a crucial feature of LCS. SDM is a patient-centered approach where healthcare providers provide best clinical evidence and then work together with patients to discern if the screening process aligns with the patient’s values and preferences. Unfortunately, clinician SDM skills are often of poor quality which can lead to patients making uninformed decisions. Decision support tools that help patients make informed decisions and increase SDM on LCS are available. In 2015, the Centers for Medicare & Medicaid Services issued a coverage memo for LCS that contained an unprecedented requirement: an initial patient counseling and SDM visit with the use of at least one decision aid must occur for screening services to be reimbursed. This review focuses on SDM and suggests ways to increase the prevalence and effectiveness of SDM in LCS programs. Stopping smoking greatly reduces a person's risk for developing lung cancer, and smoking cessation messages in LCS guidelines from major medical organizations and interventions in LCS programs are explored. LCS has come of age; so too has SDM as it is an integral part of LCS programs.