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AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
Lung Cancer Screening Tools for Patients and Clinicians

FOR CLINICIANS

Lung Cancer Screening: A Clinician’s Checklist

This checklist was developed to help clinicians meet the Centers for Medicare & Medicaid Services (CMS) criteria for a lung cancer screening counseling and shared decisionmaking visit. All of the criteria listed below must be met for the screening to be covered as a preventive service benefit under Medicare.


Before the Clinical Encounter

Determine patient’s eligibility.

This checklist may be completed with the assistance of a nurse, physician assistant, or other medical assistant.

a Screening is not recommended. If the patient is a current smoker, encourage smoking cessation and provide resources. If the patient is a former smoker, encourage continued abstinence and provide additional support if needed.

b Symptomatic patients may need followup and diagnostic testing, but not screening. Patients with a history of lung cancer need surveillance, but not screening.

Is the patient 55 to 77 years old? (55 to 80 years old for patients with private insurance)
Is the patient a current smoker or former smoker who has quit within the past 15 years?
Does the patient have at least a 30 pack-year smoking history? (See the calculator below.)
Is the patient asymptomatic for lung cancer with no personal history of lung cancer?
Is the patient healthy enough to have lung surgery?
Is the patient willing to receive potentially curative treatment?

Calculate pack-years
(20 cigarettes = 1 pack)


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During the Clinical Encounter

Complete all of the following activities:

Documented all elements in the patient’s medical chart.

  • Used a decision aid

Discussed potential benefits of lung cancer screening:

  • Reduced mortality from lung cancer

Discussed potential harms of lung cancer screening, including:

  • False-positive results
  • Followup testing if an abnormality is found (and the possible complications of invasive testing)
  • Overdiagnosis
  • Total radiation exposure (screening and diagnostic testing, cumulative)

Discussed other issues:

  • The impact of comorbidities on screening (the benefit of screening is reduced in patients with poor health)
  • The patient’s ability or willingness to undergo invasive diagnostic procedures and treatment

Counseled about:

  • The importance of adherence to annual lung cancer screening
  • The importance of maintaining cigarette smoking abstinence or smoking cessation, as applicable
  • Tobacco cessation interventions (provided information, if appropriate)

After the Clinical Encounter

Establish the next steps.

If the patient would like screening, provide a written order for the lung cancer screening visit with the following elements:

  • Patient’s date of birth
  • Actual pack-year smoking history
  • Current smoking status; for former smokers, the number of years since quitting
  • Statement that the patient is asymptomatic
  • National Provider Identifier (NPI) of the ordering practitioner
  • If the patient declines screening, document the discussion and the patient’s decision in his or her medical record.
  • If the patient is unsure about screening or wants more time, consider scheduling a followup visit to discuss the patient’s screening decision.
  • For all patients, reinforce the importance of smoking cessation and abstinence.

The importance of shared decisionmaking

Lung cancer screening with low-dose computed tomography (LDCT) reduces mortality from lung cancer. There are also potential harms associated with lung cancer screening, including a high-false positive rate and the associated need for diagnostic followup, known and unknown risks of additional testing associated with incidental findings, cumulative radiation exposure, and overdiagnosis. Shared decisionmaking is a collaborative patient-centered process in which patients and clinicians make decisions together, within the context of the best evidence and recommendations and based on the patient’s values and preferences.

Tips To Promote a Shared Decision

Below is a five-step process for shared decisionmaking that includes exploring and comparing the possible benefits and harms of each option through meaningful dialogue about what matters most to the patient.

Step 1: Seek your patient’s participation in the decisionmaking process.

Step 2: Help your patient explore and compare the potential benefits and harms of lung cancer screening, and assess your patient’s level of understanding. (See the teach-back examples in the box to the far right.)

Step 3: Assess your patient’s values and preferences about lung cancer screening.

Step 4: Reach a decision about lung cancer screening with your patient.

Step 5: Evaluate your patient’s feelings about the decision by having a followup discussion.

Talking Points

Below are specific points to address during the clinical encounter.

  • Lung cancer screening can be effective if patients 1) follow the screening protocol, 2) undergo diagnostic followup procedures after a positive screening result, and 3) receive treatment, which has potential harms.
  • Screening does not mean that smoking is OK. Smoking still causes lung cancer, cardiovascular disease, and other lung disease.
  • Screening can lead to early treatment that can prevent some, but not all, lung cancer deaths.
  • False-positive results (“false alarms”) are common, and additional scans or invasive procedures may be needed. Less commonly, major complications of invasive procedures can occur, including bleeding, infection, or a collapsed lung.
  • Lung cancer screening may find lung cancer that would not have ever caused symptoms or harmed the patient in his or her lifetime if the cancer had not been found. This could lead to treatment of people who do not really need treatment.
  • Screening and followup testing exposes patients to radiation. The harms associated with cumulative radiation exposure are unknown.
  • Screening should stop if the patient 1) exceeds the upper age criterion, 2) no longer wants screening, 3) has a worsening health condition that limits their life expectancy or increases the risk of complications from lung surgery, or 4) has not smoked for 15 years.

Teach-Back Examples

“I know I have given you a lot of information. Tell me in your own words what you have heard.”

“What are your thoughts about lung cancer screening?”

“Let’s stop right there for a moment. What questions or comments do you have about the information I have given you?”

Referral Information

Visit the CMS.gov website for a list of CMS-approved lung cancer screening registries.

 

AHRQ Publication No. 16-EHC007-11
March 2016