Websites that promote low-dose CT lung cancer screening (LCS) tended to be big on hype and short on substance, researchers reported.
In a cross-sectional content analysis of 162 LCS program websites, 98% described the potential benefits of screening more often than they described any potential harms (48%, P<0.01), according to Stephen D. Clark, MD, of the University of North Carolina at Chapel Hill, and co-authors.
Additionally, 73% did not recommend that people consider the potential benefits and harms of LCS, while only 22% suggested that people discuss those pros and cons with a healthcare professional, they stated in JAMA Internal Medicine.
Finally, important issues, such as potential overdiagnosis, were often ignored in the sites evaluated, “and most of the centers did not explicitly guide individuals toward a guideline-recommended, shared decision-making discussion of harms and benefits,” they wrote.
The authors’ conclusion that online information for the U.S. public on LCS “appears to lack balance” was “disappointing,” but not a surprise, noted Steven Woloshin, MD, MS, of The Dartmouth Institute in Lebanon, N.H., and co-authors in an editorial accompanying the study.
They emphasized that “communication about screening, given the important inherent tradeoffs, should be transparent and balanced,” but that historically, “communications about medical tests, treatments and procedures are often imbalanced…with the expected consequence that people tend to overestimate benefit and underestimate harm.”
The editorialists referenced a 2004 study by Woloshin and colleagues that found “The public is enthusiastic about cancer screening. This commitment is not dampened by false-positive test results or the possibility that testing could lead to unnecessary treatment. This enthusiasm creates an environment ripe for the premature diffusion of technologies… placing the public at risk of overtesting and overtreatment.”
Websites that “are essentially advertisements for screening,” do a disservice to the informed decision-making process — which is required for LCS reimbursement per a Centers for Medicare and Medicaid Services decision memo — because “the format is confusing for both patients and health care professionals.”
“We agree with Clark et al that failing to highlight the importance of engaging in shared decision-making from the outset is a missed opportunity to promote wise decisions because website ads potentially shape individuals’ thinking,” Woloshin and co-authors wrote.
They referred physicians and patients to a 2012 National Cancer Institute (NCI) guide that covers the basics of LCS, such as offering context for screening and summarizing the evidence for LCS.
While Woloshin’s group, which helped create the NCI guidance, acknowledged that it could use an update, they pointed out that the guidance still has value as a “template for a simple communication that would help inform and guide shared screening decision-making conversations — and which could be posted by screening centers with their ads if they continue to run them through their websites.”
Low-dose CT LCS was green lit by CMS in 2015 for people, ages 55-74 years, who are current or former smokers who quit within the past 15 years, and had at least 30 pack-years of smoking. The U.S. Preventive Services Task Force has also recommended screening for those who meet CMS eligibility requirements.
Clark and co-authors noted that these recommendations are not without controversy, “in part because screening also frequently leads to false-positive findings… false-negative findings, [and] overdiagnosis…” although more recent research has indicated that the false discovery rate of LCS has been misreported as the false-positive rate (FP), and that the overdiagnosis rate is no more than 3% per extended follow-up from the National Lung Screening Trial (NLST).
Still, “little is known about the websites’ portrayal of benefits and harms or what next steps they recommend for individuals considering screening,” the authors stated. Their analysis included online LCS offerings from 81 academic medical centers and 81 state-matched, American College of Radiology-designated community medical centers. The study was done from December 2018 to January 2019.
The authors found that FP findings were the most frequently reported potential harm (44% of all websites). Also, community centers were less likely than academic centers to report:
- Any potential harm: 40% versus 57% (P=0.03).
- Advise consideration on personal harms and benefits: 19% versus 35% (P=0.02).
- Potential harm from radiation: 25% versus 43% (P=0.01).
- Overdiagnosis: 0% versus 14% (P<0.01).
- Quantitative benefits (relative risk reduction or absolute risk reduction): 32% versus 54% (P=0.01).
However, both types of centers were more likely to present the NLST relative risk reduction of 20% than the NLST absolute risk reduction of three lung cancer deaths prevented per 1,000 people screened (P<0.01).
Finally, 97% of the centers listed follow-up steps for screening, but few recommended that individuals discuss benefits and harms with a healthcare provider. Even if shared decision-making is not an issue for non-Medicare beneficiaries, having such talks “can create expectations in screening-eligible individuals and guide their considerations about next steps,” Clark and co-authors emphasized.
Study limitations included the exclusion of oncology centers or radiology-specific imaging centers and a lack of metrics on how or when the websites were accessed by people eligible for LCS.
The authors called for “policy efforts aimed at helping patients receive timely, balanced information about preference-sensitive cancer screening decisions, including lung cancer screening,” and better expert-based standardization, in the same vein as the International Patient Decision Aid Standards, of information disseminated on LCS websites.
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Potential benefits of low-dose CT lung cancer screening (LCS) were presented significantly more often than potential harms in a cross-sectional study of 162 LCS program websites.
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Less than a quarter of the LCS websites guided individuals to a shared decision-making visit with a healthcare professional.
Shalmali Pal, Contributing Writer, BreakingMED™
Clark and a co-author reported support the Health Resources & Services Administration-funded primary care research fellowship T32-HP14001 at the University of North Carolina at Chapel Hill.
Woloshin reported being a founding member of the board for the Scientific Committee of the University of Oxford Preventing Overdiagnosis conference and a member of the science committee. Co-authors reported serving on the Science Committee for the Preventing Overdiagnosis, the American College of Radiology Lung-RADS committee, and Lung Cancer Screening Registry committee.
Cat ID: 24
Topic ID: 78,24,730,24,192,65,925
