The report is a product of the VA/HSR Evidence Synthesis Program.

Shared Decision Making for Lung Cancer Screening: A Systematic Review

Takeaway: Lung cancer screening (LCS) with annual low-dose CT scans is recommended for eligible individuals. However, prior to LCS, shared decision making (SDM) is required by the Centers for Medicare and Medicaid Services for reimbursement. This review summarizes the evidence regarding LCS SDM strategies and tools. The review found a decision aid may be superior to an educational tool, and the choice of decision aid may not impact LCS. While most studies reported on knowledge, few evaluated prioritized outcomes such as receipt of initial or subsequent LCS, adherence to follow-up for abnormal findings, concordance of LCS decisions with values, decisional conflict/regret, distress/anxiety, or information quality. There was little evidence on whether effects varied by patient or clinic characteristics. Implementation barriers and facilitators were present at the patient, clinician, and health system level. Studies conducted in VHA identified ways to facilitate LCS SDM.

More than 230,000 new cases of lung and bronchus cancer will be diagnosed in the United States in 2024. An estimated 125,070 lung cancer deaths will occur during the same year. Lung cancer screening (LCS) reduces lung cancer mortality through early detection and treatment but requires repeated screenings and follow-up evaluations, which come with potential harms including false-positive results, distress, and additional diagnostic testing and burden. Shared decision making (SDM) — a Centers for Medicare and Medicaid Services (CMS) prerequisite for LCS reimbursement — involves the patient and clinician in decisions and is meant to help patients understand LCS benefits and harms, incorporate their preferences and values, and make an informed decision as to whether LCS is right for them.

To support VA’s National Center for Lung Cancer Screening (NCLCS), HSR’s Minneapolis Evidence Synthesis Program (ESP) Center conducted an evidence review on the effects of SDM practices and strategies. Investigators identified 39 eligible randomized trials and observational studies in MEDLINE, Embase, and CINAHL published from January 2010 through December 6, 2023.

Summary of Findings

Variation in, and methodological limitations of, studies, interventions, comparators, and outcomes precluded quantitative evidence synthesis or conclusive statements on most interventions and outcomes, resulting in low to very low certainty of evidence. However, the report concluded that:

• A decision aid may be superior to an educational tool, and the choice of decision aid may not affect LCS uptake.
• SDM (which at times included care coordinators or patient navigators) does not increase decisional conflict/regret and may increase LCS with acceptable information quality.
• There was little to no evidence on whether effects varied by patient (age, sex, race/ethnicity, smoking status, comorbidities, education) or clinic characteristics (primary care, prevention, smoking cessation clinics, or public forums).
• Studies did not report on smoking behaviors, harms, resource allocation/usage, or cost.
• The most studied tool (k=7) was a 5- to 15-minute web- or print-based decision aid available in English, Spanish, and
• Most studies reported on knowledge. Few addressed clinically relevant/partner prioritized outcomes of receipt of initial or subsequent LCS, adherence to follow-up for abnormal findings, decisional conflict/regret, distress/anxiety, information quality, concordance of screening decision with values, sustainability, harms, or cost.
• Implementation barriers included healthcare professionals’ time constraints and patients’ lack of engagement with, and negative response to, SDM. Facilitators included use of a decision aid during the SDM encounter. In VHA, facilitators included a culture receptive to SDM, available resources including time and tools, prioritization among other clinic demands, and innovation among deliverers and recipients.

Implications

Qualitative research suggested that while Veterans and healthcare providers believed that VA culture was receptive to LCS SDM, competing demands, primarily time, were barriers that needed to be addressed to enhance SDM implementation.

Limitations

• Studies varied in methodology, and often had limitations in rigor, replicability, and clinical applicability. Small sample sizes and short duration, as well as inconsistency in interventions, delivery modes and timing, comparators, and outcomes present challenges to systematic reviewers, researchers, clinicians, policymakers, and patients.
• Few studies described whether interventions met CMS criteria for SDM.

Future Research

Research is needed to enhance SDM for LCS, including identifying accurate, efficient, and effective SDM tools adaptable to settings and patients; reducing barriers to appropriate LCS and follow-up; promoting tobacco abstinence; and more accurately assessing adherence and competing mortality risk in individuals otherwise considered LCS eligible.

Citation: Landsteiner A, Zerzan N, Ullman KE, Anthony M, Claussen A, Bayer R, Do T, Gustavson A, Melzer A, Wilt TJ. Shared Decision Making for Lung Cancer Screening: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project 09-009; 2024.

To view the full report, go to https://vaww.hsrd.research.va.gov/publications/esp/sdm-lung-cancer.cfm. (This report is available via Intranet only.)

How can VA leadership work with the ESP? Nominations for systematic review topics may be submitted to the program at any time. When you submit a topic nomination form, ESP Coordinating Center staff will work with you to determine the appropriate research approach and ESP product to address your questions of interest. Topics are selected and assigned to an ESP Center based on program capacity and alignment with VA national goals

This Management Brief is provided to inform you about recent HSR findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR Resource Center charged with disseminating important HSR findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers; and to disseminate these reports throughout VA.

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