Websites Paint Rosy Picture of Lung Cancer Screening

Nearly all lung cancer screening programs in the U.S. touted the benefits of low-dose computed tomography (LDCT) as a means of reducing cancer-related deaths, but fewer than half mentioned any potential harms, a new study found.

On examining the websites of over 150 academic and community screening programs, 98% cited potential benefits while just 48% detailed possible harms (P<0.01), reported Stephen Clark, MD, of the University of North Carolina at Chapel Hill, and colleagues.

"The lung cancer screening program websites of academic and community medical centers evaluated in this study rarely included a balanced message of potential benefits and harms that aligns with current recommendations," the authors wrote in JAMA Internal Medicine. "The imbalance is consistent with historical approaches to cancer screening advertising, which ignore or minimize potential harms and costs."

Academic programs were just as likely as community programs to mention screening benefits on their websites (99% vs 98%, respectively), but more often mentioned harms as well:

• Any harm: 57% vs 40% (P=0.03)
• Radiation exposure: 43% vs 25% (P=0.01)
• Overdiagnosis: 14% vs 0% (P<0.01)

And academic centers were more likely to quantitatively describe the relative or absolute benefits of screening -- the reduction in lung cancer-related mortality seen in the National Lung Screening Trial -- than community programs (54% vs 32%, P=0.01). In all, 41% of centers described the benefit as a 20% reduction in risk of lung cancer-related mortality, while just 1% described how for every 1,000 individuals undergoing screening, three deaths from lung cancer would be averted (P<0.01).

Across all centers' websites, a false-positive scan (44%) was the possible harm most frequently mentioned, while overdiagnosis was the harm cited least often (7%).

"Although screening program websites are not responsible for full delivery of guideline-recommended shared decision-making, they can create expectations in screening-eligible individuals," Clark's group wrote.

Though in practice, a lack of meaningful evidence exists for how shared decision-making talks play out, with reports describing cursory discussions on the subject or what often amounts to a straight referral.

Per requirements from the Centers for Medicare & Medicaid Services, the physician ordering LDCT screening is responsible for the single shared decision-making discussion, but the authors noted that patients exposed to information prior to the visit could be "susceptible to anchoring bias" tilting them one way or the other.

In the study, just a quarter of websites (26%) had explicit recommendations that individuals consider the possible harms and benefits when weighing screening, with academic sites more likely to have such a recommendation (35% vs 19%, P=0.02).

"Our findings suggest the need for policy efforts aimed at helping patients receive timely, balanced information about preference-sensitive cancer screening decisions, including lung cancer screening," Clark and colleagues wrote. "In the near term, development of expert consensus and specific standards about what information to publish on websites may help encourage the provision of balanced information across screening centers."

In an accompanying editorial, Steven Woloshin, MD, of the Dartmouth Institute in Lebanon, New Hampshire, and colleagues, called the findings disappointing, yet not surprising.

"Disappointing because communication about screening, given the important inherent tradeoffs, should be transparent and balanced," they wrote. "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."

Woloshin's group said a proper patient-physician guide should promote smoking cessation and "acknowledge uncertainty and variability" of screening, but include the following: who should consider LDCT screening, the risk of death from the lung cancer, the benefits of screening, and the harms and their frequency.

For their study, Clark's team analyzed the lung cancer screening websites of 81 academic centers and 81 state-matched community centers, from December 2018 to the end of January 2019, with sites selected at random from the list of American College of Radiology lung cancer screening-designated centers. Screening benefit was defined as any mention of the lung cancer mortality risk reduction, and potential harm was defined as mention of incidental findings, false positives or negatives, overdiagnosis, and exposure to radiation.

A secondary outcome was what institutions recommended as next steps for screening. Here, 30% of the websites offered information on contacting a screening center, and only 22% said individuals should discuss the benefits and harms with either their primary provider or at the screening visit.

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