In accordance with national guidelines, physicians are discussing the pros and cons of lung cancer screenings with high-risk patients. They’re just doing it wrong.

That’s the conclusion reached by researchers at the University of North Carolina Lineberger Comprehensive Cancer Center in their new study, which found conversations on lung cancer screening to be "poor" in quality and discussions on the potential harms of screening to be "virtually nonexistent."

"Our payment system rewards procedures and infusions through high levels of reimbursement. Our system does not reimburse well for visits with patients having multiple chronic medical problems in the outpatient setting," senior author Daniel S. Reuland, director of the University of North Carolina Lineberger Comprehensive Cancer Center's Carolina Cancer Screening Initiative and a professor at the UNC School of Medicine, told HCB News. "As a result, visit times are very short, many issues need to be covered quickly, and a culture and practice of moving quickly through visits has developed. This environment is poorly conducive to educating and engaging patients more deeply, and having nuanced, evidence-informed discussions about the trade-offs inherent in many medical decisions."

More than 234,000 people are diagnosed annually with lung cancer, which takes the lives of more than 154,000 individuals each year, making it the leading cause of death throughout the U.S., according to the American Cancer Society.

Discussions on screenings are recommended to help prevent deaths from occurring, and are even required in some cases by national guidelines. In addition, organizations like the U.S. Centers for Medicare and Medicaid require these conversations to take place before funding such procedures, and to include in them the pros and cons of screening, as well as issues of overdiagnosis and false positives and the risk of total radiation exposure.

Researchers analyzed 14 transcripts of audio-recorded office visit discussions between age-eligible patients and their doctors, finding them to be brief and one-sided, with each physician failing to mention any word on the potential harms involved in screening, the chance for false positives, or the need for additional imaging or invasive diagnostic procedures. Complete conversations for screenings, on average, were found to last one minute.

Detection of lung cancer in its earliest stage reduces the risk of death by the disease, according to the National Lung Screening Trial (NLST), which found that low-dose spiral CT scan screenings resulted in 20 percent fewer lung cancer deaths among those with very high risks than patients who underwent chest X-rays.

The trial also identified the potential harms of screening, such as false positives, which lead to invasive follow-up procedures that do not find any cancer, wasting both physician and patient time and saddling patients with unnecessary costs. More than 95 percent of lung nodules found on screening CT scans are not cancerous.

Another issue was overdiagnosis, in which screenings lead to the diagnosis of cancers that would not affect a patient during his or her lifetime if left untreated.

Echoing these sentiments is the U.S. Preventive Services Task Force, which, since 2013, has recommended annual lung cancer screenings with low-dose CT for adults between 55 and 80 who have smoked a minimum of 30 pack-years, as in 20 cigarettes a day annually for 30 years. This advice also applies to those who are still smoking or have only quit in the last 15.

In addition, the USPSTF recommends that decisions to screen follow a "thorough discussion of the possible benefits, limitations and the known and uncertain terms," publishing just this month its final preparation plan for adjusting its research and evaluation protocols for CT lung cancer screening.

Reuland suggests that doing so requires the implementation of better systems and infrastructure to ensure screenings are properly discussed, and investing in more approaches, such as decision aids, to help clinical support staff educate patients.

"Providers should be forthright about the uncertainties inherent in screening and make authentic attempts to help patients understand these. They really should use a decision aid and plan to set aside time for a decision like this with patients. This may mean scheduling a separate visit, at least for the initial decision about initiating annual lung cancer screening," he said. "In addition, all physicians should advocate for a payment model that encourages the provision of patient education and decision support outside of face-to-face visits and incentivizes informed and shared decisions rather than a large volume of brief, face-to-face office visits."

Conversations were derived from a database of 5,300 recorded interactions provided by Verilogue, a private patient-physician dialogue research company. Of the 137 that meet keyword criteria for the study, fourteen specifically addressing lung cancer screenings were chosen.

In addition to Reuland, the study’s first author is Alison Brenner, a UNC Lineberger member and assistant professor at the UNC School of Medicine; Teri Malo of UNC Lineberger; Marjorie Margolis and Shynah James of UNC Gillings; Jennifer Elston Lafata of UNC Lineberger and UNC Eshelman School of Pharmacy; and Maihan B. Vu of UNC Gillings and UNC-Chapel Hill.

Partial funding was granted by the North Carolina Translational and Clinical Sciences (NC TraCS) Institute.

The findings were published in JAMA Internal Medicine.