|Year : 2019 | Volume
| Issue : 3 | Page : 195-196
Shared decision making and cancer screening
Filipe Prazeres1, Elisa Martins2
1 Faculty of Health Sciences, University of Beira Interior, 6200-506 Covilhã; Family Health Unit, Beira Ria, Gafanha da Nazaré, Portugal
2 Family Health Unit, Beira Ria, Gafanha da Nazaré, Portugal
|Date of Web Publication||19-Jul-2019|
Faculty of Health Sciences, University of Beira Interior, 6200-506 Covilhã; Family Health Unit, Beira Ria, Gafanha da Nazaré
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Prazeres F, Martins E. Shared decision making and cancer screening. Indian J Cancer 2019;56:195-6
An overdiagnosed cancer is a cancer that would not present clinically during the person's lifetime, thus will not be the cause of the patient's death. When it is not clear if the potential benefits of cancer screening outweigh the potential harms, shared decision making (SDM) should be sought.
The first study on the quality of SDM regarding lung cancer screening (LCS) in clinical practice was recently published in JAMA Internal Medicine by Brenner and colleagues. Although there was a great disappointment in the results, also denoted in the corresponding editorial by Redberg, this paper can be used as a learning tool to stop repeating the ineffective SDM process observed in Brenner and colleagues' study—as of today, we need to start informing patients not only of the benefits but also of the harms of cancer screening (false positives, their sequelae, and overdiagnosis), only then can patients truly decide about screening. This is even more important after the publication of Heleno and colleagues' research in this same journal  that showed a significant percentage of overdiagnosis in patients subjected to LCS with computed tomography.
Another example is the “epidemic” of thyroid cancers in South Korea due to overdetection of harmless tumors that would not need to be treated. According to recent studies, in many countries, the incidence of thyroid cancer has markedly increased in the last decades. In 2009, the incidence of age-standardized thyroid cancer was 47.5 per 100,000 in South Korea—an increase by more than sevenfold in a 10-year period—making it the highest incidence worldwide., As such, in South Korea, a nationwide study—National Epidemiologic Survey of Thyroid cancer (NEST)—investigated the main reasons for the upraise in thyroid cancer incidence. The study observed that the thyroid cancer incidence increased due to superior detection of small tumors. The widespread use of ultrasonography as a screening tool for thyroid cancer is the main reason for this increase. Same authors concluded that to decrease the expected economic and treatment burdens of overdiagnosed thyroid cancer, ultrasound examination of the thyroid should not be recommended in the asymptomatic patient.
Involving patients in decision making is an intuitive process, is cost-free to provide, and is pro-patient, so why is it still unattainable or controversial? Some reasons were stated by Brenner and colleagues  and in Redberg's editorial: consultation time restraints, lack of education/training in SDM, and lack of awareness. Education and training of physicians regarding SDM may increase discussion of bidirectional options, but will this be enough?
SDM is traditionally implemented when dealing with “single event high-risk problems.” But, can cancer screening be considered one of these problems? Personally, we do not think so. In our society, cancer has a negative psychological burden like no other disease, and in a broad sense, it defined for many years human mortality. Modern health care struggles to fight diseases and save lives, and cancer screening was sold as a weapon of such fight; this may be why overdiagnosis is so difficult to accept.
To reduce overdiagnosis regarding cancer screening, we will probably need a multifactorial approach: (i) reduce cancer diagnosis related–anxiety or depression by increasing patients' health literacy or even change the nomenclature used for low risk cancer lesions, (ii) increase physicians' and patients' awareness that screening can lead to overdiagnosis, (iii) include measures of quality of life and not only mortality outcomes when talking about informed consent, and (iv) know the patient as a whole person, their “ideas, fears, expectations, preferences, values and needs,” through an effective physician–patient communication.
On the contrary, health checks are a common practice in many countries, with the aim of “finding disease early, preventing disease from developing, or providing reassurance.” Although their ultimate goal is to reduce morbidity and mortality, a 2012 Cochrane Systematic Review  found no reduction of morbidity or mortality by cancer. Physicians should also be aware that patients' psychological distress, loss of income, and insurance difficulties are some risks of abnormal screening results.
SDM should be increasingly encouraged as not only because of patients' benefit but also because it reduces the burden on the health care, especially in a resource limited setting like the Indian one. This should also be an important part of a choosing wise campaign which many heath care systems are increasingly adopting.
We would like to add some suggestions on how to implement SDM in our day-to-day practice. In cancer settings, some of the most known are Fagerlin et al. methods to better risk communication: “i) use plain language to make written and verbal materials more understandable; ii) present data using absolute risks; iii) present information in pictographs if you are going to include graphs; iv) present data using frequencies; v) use an incremental risk format to highlight how treatment changes risks from pre-existing baseline levels; vi) be aware that the order in which risks and benefits are presented can affect risk perceptions; vii) consider using summary tables that include all of the risks and benefits for each treatment option; viii) recognize that comparative risk information (e.g., what the average person's risk is) is persuasive and not just informative; ix) consider presenting only the information that is most critical to the patients' decision making, even at the expense of completeness; x) repeatedly draw patients' attention to the time interval over which a risk occurs.”
Nonetheless, we can also easily use online SDM visual aids, sample conversations, handouts, and videos regarding cancer screening from the World Wide Web (e.g. in our practice, we use SDM visual aids about lung, breast, and prostate cancer screenings available through “Less Is More Medicine”: http://www.lessismoremedicine.com/hands-on/. This website is curated by Dr. Otte, with no financial ties to drug or medical device manufacturers.).
Summing up, SDM must be a tool to optimize the benefit–harm ratio of cancer screening.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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