This study considers how patients with multimorbidity who would receive marginal benefits from lung cancer screening (LCS) conceptualize their health and make decisions about LCS. Researchers recruited 40 participants with multimorbidity and limited life expectancy (predicted one-year risk of hospitalization or death) to interview from six Veterans Health Administration (VA) health centers. The participants met the following criteria: (1) they met the U.S. Preventive Services Task Force's age and smoking criteria for LCS eligibility but had not previously undergone VA LCS; (2) were offered VA LCS in the prior six months based on clinician completion of an LCS clinical reminder in the electronic health record; and (3) had marginal anticipated LCS benefit, based on a high care assessment score, suggesting greater health concerns and decreased life expectancy. Interview questions explored LCS decision making within the broader contexts of the participant's life and their patient-clinician relationship, their perceptions of their own health, their beliefs about screening, and how they perceived the benefits and harms of LCS. Twenty-six participants had agreed to undergo VA LCS after discussing it with their clinician. While 14 Veterans initially declined LCS, several were screened later, either within the VA system or elsewhere.
Study participants largely held positive beliefs about LCS and perceived screening as non-invasive. Thematic analysis of the interviews revealed factors that influenced participants to choose LCS included personal health goals, trust in their clinician and the VA system, and anticipated regret over not getting screened. Factors that did not influence their decisions included their perception of their own health and their perception (or lack of knowledge) of the potential harms. Many participants did not recall discussing potential harms with their clinician, but when informed by the researchers of such risks, many said it would be unlikely that they would pursue further screening. This underscores the importance of patient-clinician discussions and shared decision making to ensure that patients understand the potential harms and benefits of undergoing LCS.
What We Know: Overscreening for various types of cancer occurs frequently. It can be challenging for clinicians and patients to balance benefits and harms when deciding whether to pursue screening. LCS offers less benefit and has a greater potential for causing harm to people with multiple comorbidities and limited life expectancy. However, such individuals are more likely to undergo screening than healthier LCS-eligible people, often without being aware of the possible consequences.
What This Study Adds: This study suggests that patients with multimorbidity and limited life expectancy may be unaware of their risk of harm when accepting LCS. It identifies several motivating factors explaining why people with marginal anticipated LCS benefits are receptive to LCS. It also suggests that, if they had been aware of the potential harms, they may have been less likely to undergo LCS. It appears that neither the electronic health record (EHR) -generated prompt algorithm nor the clinician took into account the potential harms of screening for those with limited life expectancy. Discussions of relative benefits and risks between patients and their clinicians are necessary in order to make informed, shared decisions on whether to pursue screening.
"It Can't Hurt!": Why Many Patients Withimited Life Expectancy Decide to Accept Lung Cancer Screening
Eduardo R. Núñez, MD, et al
Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts VA Bedford Healthcare System, Bedford, Massachusetts; The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts; Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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