A Medicare policy requiring primary care providers (PCPs) to share in the decision-making with patients on whether to proceed with lung cancer screening is fraught with confusion and lack of evidence-based information, and may actually be undermining the purpose for which it was created, Mount Sinai researchers say.
In their study, published in Annals of Family Medicine, the team reported that the policy, enacted nearly 10 years ago to encourage the use of lung cancer screening, is in urgent need of new research, protocols, and guidelines to enable physicians to make more confident and informed decisions around which patients are suitable candidates for lung cancer testing.
The policy of shared decision-making was intended to take into account the patient’s full health history. It was prompted by the fact that smokers have an increased risk of not just lung cancer but complex comorbidities—including cardiovascular or cerebrovascular disease and chronic obstructive pulmonary disease—from their tobacco exposure. The policy required counseling on the importance of adherence to annual lung cancer screening, impact of comorbidities and ability or willingness to undergo diagnosis and treatment, but did not address the increasing prevalence of comorbidities, or give any guidance on how to assess the impact of comorbidities on screening, diagnosis, and treatment. That, the researchers said, is part of the problem.
“The policy was added in 2015 for a well-intentioned reason, but unfortunately it’s caused a great deal of confusion over patient eligibility and may contribute to ambivalence among primary care physicians when it comes to recommending lung cancer screening to patients with complex comorbidities,” says lead author Minal Kale, MD, MPH, Associate Professor of Medicine (General Internal Medicine) at the Icahn School of Medicine at Mount Sinai. “Our study found that primary care physicians’ approach reflects a dearth of evidence-based guidance for lung cancer screening shared decision-making in patients with complex comorbidities.”
The goal of the Mount Sinai study was to better understand how primary care physicians factor comorbidities into their evaluation of the risks and benefits of lung cancer screening, and into their shared decision-making conversations with patients. Researchers conducted interviews via videoconference with 15 PCPs from internal medicine practices affiliated with the Mount Sinai Health System. From these 45-minute sessions they learned that PCPs are predisposed to make subjective clinical judgments about whether a patent is a good candidate for lung cancer screening before approaching the patient, rather than basing that determination on a shared discussion.
“Patients perceived as likely to adhere to treatment recommendations and as having a high quality of life were more likely to be advised to undertake lung cancer screening, as opposed to those who had previously expressed frustration or dissatisfaction with their state of health and well-being,” notes Juan Wisnivesky, MD, DrPH, Drs. Richard and Mortimer Bader Professor of Medicine and Chief of the Division of Internal Medicine at Icahn Mount Sinai, and co-author of the study. “Other patient characteristics shown by the study to influence physician judgments include life expectancy, presence of a support system, and expectations of and attitudes toward medical care.”
To counter that selection bias, the study’s authors called for continued research to determine the impact of comorbidities on lung cancer screening risks and benefits, as well as its clinical applications. “Uncertainty by primary care physicians in referring patients for lung cancer screening likely reflects their confusion about its benefits due to complicated recommendations,” explains Dr. Kale. “Protocols should therefore be streamlined and guidelines made clearer for both physicians and patients if we’re going to increase adoption of lung cancer screening for this high-risk population.”
About the Mount Sinai Health System
Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 600 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time—discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes approximately 9,000 primary and specialty care physicians and 11 free-standing joint-venture centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida. Hospitals within the System are consistently ranked by Newsweek’s® “The World’s Best Smart Hospitals, Best in State Hospitals, World Best Hospitals and Best Specialty Hospitals” and by U.S. News & World Report‘s® “Best Hospitals” and “Best Children’s Hospitals.” The Mount Sinai Hospital is on the U.S. News & World Report® “Best Hospitals” Honor Roll for 2023-2024.For more information, visit https://www.mountsinai.org or find Mount Sinai on Facebook, Twitter and YouTube.
About the Icahn School of Medicine at Mount Sinai
The Icahn School of Medicine at Mount Sinai is internationally renowned for its outstanding research, educational, and clinical care programs. It is the sole academic partner for the eight- member hospitals* of the Mount Sinai Health System, one of the largest academic health systems in the United States, providing care to a large and diverse patient population.
Ranked 13th nationwide in National Institutes of Health (NIH) funding and among the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges, Icahn Mount Sinai has a talented, productive, and successful faculty. More than 3,000 full-time scientists, educators, and clinicians work within and across 44 academic departments and 36 multidisciplinary institutes, a structure that facilitates tremendous collaboration and synergy. Our emphasis on translational research and therapeutics is evident in such diverse areas as genomics/big data, virology, neuroscience, cardiology, geriatrics, as well as gastrointestinal and liver diseases.
Icahn Mount Sinai offers highly competitive MD, PhD, and Master’s degree programs, with current enrollment of approximately 1,300 students. It has the largest graduate medical education program in the country, with more than 2,000 clinical residents and fellows training throughout the Health System. In addition, more than 550 postdoctoral research fellows are in training within the Health System.
A culture of innovation and discovery permeates every Icahn Mount Sinai program. Mount Sinai’s technology transfer office, one of the largest in the country, partners with faculty and trainees to pursue optimal commercialization of intellectual property to ensure that Mount Sinai discoveries and innovations translate into healthcare products and services that benefit the public.
Icahn Mount Sinai’s commitment to breakthrough science and clinical care is enhanced by academic affiliations that supplement and complement the School’s programs.
Through the Mount Sinai Innovation Partners (MSIP), the Health System facilitates the real-world application and commercialization of medical breakthroughs made at Mount Sinai. Additionally, MSIP develops research partnerships with industry leaders such as Merck & Co., AstraZeneca, Novo Nordisk, and others.
The Icahn School of Medicine at Mount Sinai is located in New York City on the border between the Upper East Side and East Harlem, and classroom teaching takes place on a campus facing Central Park. Icahn Mount Sinai’s location offers many opportunities to interact with and care for diverse communities. Learning extends well beyond the borders of our physical campus, to the eight hospitals of the Mount Sinai Health System, our academic affiliates, and globally.
* Mount Sinai Health System member hospitals: The Mount Sinai Hospital; Mount Sinai Beth Israel; Mount Sinai Brooklyn; Mount Sinai Morningside; Mount Sinai Queens; Mount Sinai South Nassau; Mount Sinai West; and New York Eye and Ear Infirmary of Mount Sinai.
