Medical centers tout benefits of lung cancer screening, but rarely address potential harms
Authors: Mike Fillon
Journal: CA A Cancer Journal for Clinicians (2020)

“These guidelines call for patients to understand the benefits and harms of screening prior to pursuing it…By presenting an imbalanced message, it seems that many of these websites do not promote this informed decision making for individuals.”–Stephen Clark, MD, MPH A new study examining the websites of lung cancer screening programs finds that although nearly all explain the benefits of screening with low-dose computed tomography scans, fewer than one-half mention the potential harms. The research appears in JAMA Internal Medicine (published online April 13, 2020. doi:10.1001/jamainternmed.2020.0111). In 2011, the National Lung Screening Trial reported a 20% reduction in lung cancer–specific mortality among high-risk individuals who were screened annually using low-dose computed tomography scans (compared with the control group that was screened using ordinary chest x-rays). However, the scans are not without risks, including false-positive and false-negative findings, radiation exposure, and overdiagnosis. As a result, guidelines from many organizations, including the United States Preventive Services Task Force, American Cancer Society, National Comprehensive Cancer Network, American Thoracic Society, and American College of Chest Physicians, emphasize the need for individuals to understand the possible benefits and risks of screening. They also urge health care professionals to consult with potential patients to aid in their decisions regarding whether to be screened. According to lead author Stephen Clark, MD, MPH, a clinical instructor and National Research Service Award in Primary Care research fellow at the University of North Carolina at Chapel Hill, investigators evaluated the presentation of benefits and harms on the websites of 162 lung cancer screening programs. “We did not find similar previous studies on this topic in the literature,” he says. Dr. Clark says the research team suspected, and ultimately confirmed, that many of the websites have an imbalanced presentation that does not align with the recommended guidelines for individuals considering screening. “These guidelines call for patients to understand the benefits and harms of screening prior to pursuing it,” he says. “By presenting an imbalanced message, it seems that many of these websites do not promote this informed decision making for individuals.” Dr. Clark and his colleagues scoured the internet from December 31, 2018, to January 31, 2019, searching for information regarding lung cancer screening on the websites of academic and community medical centers. They identified 162 lung cancer screening websites, which included 81 academic medical centers and an equal number of randomly selected state-matched community medical centers to control for possible geographical differences. They then evaluated whether each of the websites provided information regarding benefits, harms, and follow-up recommendations. Robert A. Smith, PhD, the senior vice president of Cancer Screening at the American Cancer Society in Atlanta, Georgia, says he is not surprised by the study's findings. “Unfortunately, this is about what we should expect where the ‘system' isn't really set up to ensure that these discussions take place or make it clear where they are supposed to take place, what content should be delivered, and how to make sure patients understand the differences between relative and absolute risk of death from lung cancer and the expected changes in these risks associated with screening,” he says. In an accompanying editorial, Steven Woloshin, MD, MS; William C. Black, MD; and Barnett S. Kramer, MD, MPH wrote that the conclusions that can be drawn from the results of this “well-done study are disappointing but not surprising. Disappointing because communication about screening, given the important inherent tradeoffs, should be transparent and balanced; not surprising because communications about medical tests, treatments, and procedures are often imbalanced in these same ways, with the expected consequence that people tend to overestimate benefit and underestimate harm.” Dr. Woloshin and his colleagues expressed concern regarding “the propriety of websites which are essentially advertisements for screening.” Moreover, they emphasize that the goal of screening is “not to detect the most cancers, but to detect the ones in which screening makes a difference. Similarly, the goal of lung cancer screening websites should not be to screen the most people, but to screen informed eligible people.” The study, they concluded, demonstrates that much work is needed to achieve more balanced presentations to benefit the public. Dr. Clark is optimistic that the study may spark much-needed dialogue regarding the content included on medical center websites. “Hopefully, this will lead to standards from within the medical community for information presented on the websites, similar to The International Patient Decision Aid Standards (IPDAS) Collaboration guidelines for patient decision aids,” he says. “Legislation could come in the future to regulate the presentation of online information to ensure balance and/or accuracy for individuals consuming the information, but hopefully we can improve online content within the medical community without such a step being necessary.” Furthermore, he and his fellow researchers hope the study will motivate clinicians to further engage individuals who are eligible for screening in shared decision making to facilitate screening decisions that are in keeping with their own values. “They can also look at their own institution's website and pursue editing within the institution if needed,” he says. “Additionally, and also importantly, clinicians should continue to engage patients in conversations of smoking cessation, which is the best way to prevent lung cancer.”