NP Insights
Engaging patients in their healthcare: Cancer screening
By Tom Bartol, APRN
When a patient is “due” for screening, do we just order a screening test, or do we engage the patient in the process? Because a patient is 50 years old, do we simply order a colonoscopy, or do we discuss the pros and cons, the costs, and other measures that may improve health? Are we sharing information to help patients make decisions, or are we just following guidelines and checklists? Providing good care is not just about meeting the quality guidelines. Patient-centered care must focus on the patients, involving them in their healthcare decisions based on their goals, values, and perspectives. Guidelines and parameters are important, but what is needed is engagement, sharing information, and giving patients a perspective from which to make a decision. ■ Assessing baseline risk Healthcare providers are given many screening guidelines. In my earlier days as a nurse practitioner (NP), I presumed that since these guidelines were developed by expert panels and were “evidence-based,” the more I followed these guidelines, the better care my patients would receive. I never thought about risks, and I presumed the benefits would be great. These guidelines, though, are just that: guidelines—not mandates. They are a starting point, a place from which to share information and engage the patient. www.tnpj.com
To help patients make decisions, we must first determine and share with them the baseline risk for their condition or disease. This can be determined using family history, past medical history, and lifestyle assessment. For example, a 50-year-old male who exercises daily, is of normal weight, eats a high-fiber diet, and has no family history of colon cancer, has a very different risk for colon cancer than the 50-year-old male who is obese, a smoker, not physically active, and drinks five beers a day. Simply recommending a colon cancer screening for both of these men based solely on their age is missing the opportunity to take this to the level of patient engagement. ■ Screening: Making informed decisions Just because someone meets the criteria for the screen does not mean they should be screened. Sharing information about the screening test can help patients make an informed decision. A patient came to see me recently asking for “that lung cancer screening.” He recently attended the funerals of two friends, both who died of lung cancer. Fifty-five years old, he quit smoking 14 years ago and had a 30-pack year history of smoking, so he certainly met the guidelines for the low-dose computed tomography (CT) screen for lung cancer. He did not want to die of lung cancer and thought that screening and early detection of lung cancer would save his life.
■ Individualized care It would have been easy to just order the low-dose CT lung cancer screen, but without sharing information about the screen, his only perspective for choosing it is emotional. Are we not obliged to share with patients the potential risks and benefits of what we do to help them make an informed decision? It is easy to just follow guidelines and recommendations, but patients deserve to have information. We expect this kind of information when we bring our car in for repairs: what are the choices, the options, and the risks? Yet in healthcare, this discussion often does not take place. Would this patient choose lung cancer screening if he knew the risks and benefits of the screen? Sharing information and engaging patients in their healthcare decisions about medications, treatments, and diagnostics will help to provide the “right care” for each particular patient. In this case, I shared two simple statistics from the National Lung Cancer Screening Trial with this patient: First, I shared with him that the screening reduced mortality from 1.66% in the baseline screened to 1.33% in the CT screened group for an absolute risk reduction of 0.33%. The other statistic I shared was that 96% of the people who screened positive in this study did not have lung cancer (yet they all had additional procedures done to rule out lung cancer from repeat CT scans to surgical biopsy in some).1 The Nurse Practitioner • February 2015 17
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
NP Insights This figure alone, the fact that there are 96% false positives in this study, led my patient (despite his emotional factors of friends recently dying of lung cancer) to choose not to have lung cancer screening performed. ■ Reducing risks Patient engagement involves sharing information, not just about the screening, but about other ways to reduce risks. Simply screening the high-risk patient for colon cancer misses out on the opportunity to engage the patient, to motivate him, to talk about lifestyle changes, and other ways to reduce or prevent colon cancer. These changes might well have a benefit beyond colon cancer prevention and could extend to other chronic diseases. Overweight, smoking, physical inactivity, and alcohol consumption all pose
preventing these cancers. In our zeal to get the screening done, we must not fail to share such beneficial information. ■ Breast cancer screening Breast cancer screening provides another opportunity to engage patients and share information. The National Cancer Institute (NCI) states that “based on solid evidence from randomized controlled trials, screening mammography between the ages of 40 and 74 reduces breast cancer mortality by about 15% to 20% with an absolute reduction in mortality of about 1% over 10 years.”3 It is important to remember that exercise has been shown to reduce breast cancer mortality by 20% to 80%, as good or better than screening mammography. We must share with women ways they can reduce breast cancer risk rather than
We need to transform healthcare to be a “custom care” process where the patients are equal partners.
higher risks for morbidity and mortality than colon cancer screening would prevent. Engaging the patient—not accusing, threatening, or even educating—but building a relationship can make more of a difference than simply doing the screening test. Exercise has been well studied in the prevention of colon cancer, breast cancer, as well as many chronic diseases. Exercise reduces colon cancer mortality by 30% to 40% and breast cancer mortality by 20% to 80%.2 Knowing this, I question if it is even ethical to order colon cancer screening or screening mammography without also discussing the beneficial effects of exercise in
just recommending screening mammograms. What are the data about screening mammography? If 1,000 average-risk women are screened yearly starting at age 50, over 10 years, there will be between 0.3 and 3.2 deaths avoided. However, between 490 to 670 of those 1,000 women will have false-positive results, and 70 to 100 of these women will have biopsies, while 3 to 14 will be overdiagnosed and treated with surgery, chemotherapy, or radiation even though they do not have breast cancer.4 I am not opposed to screening mammography, but I do believe we must give women information about the risks
and benefits of the screen, a perspective from which to make a choice. This perspective should also be based on stratified risk, based on lifestyle, family history, and past history. It is only then that a patient can make an informed choice. ■ The power of information Sharing information means we must be familiar with it ourselves. The NCI has put together excellent Physician Data Queries, which have great information for NPs as well summarizing various types of cancers, including the data about screening often in a convenient chart form (cancer.gov/cancertopics/pdq). I condensed the data into a few bullet points that I placed in a PowerPoint slide, which I can easily share with patients on my computer during an office visit and print out if necessary. I put the reference in the slide so that the patient or I can easily refer to it. Success must not be measured as having the test done but in engaging the patient in an informed decision based on individual risks and benefits as well as on the patient’s individual values and desires. Our role is to share information so the patient can make an informed decision. In these days of meeting standards and guidelines as a way to give what is called “patient-centered” care, we are not being patient centered if we do not give the patients information and engage them in the decisionmaking process. If it were simply a “cookbook” full of guidelines to follow, we would not need the education, communication skills, or the compassion that NPs have to offer. ■ Patients leading their healthcare All of this takes a bit more time, but it is time well spent. The result may
18 The Nurse Practitioner • Vol. 40, No. 2
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
NP Insights be that some patients choose not to follow the guidelines. My experience has been that patients often choose lifestyle changes over screenings and they end up healthier. Is better health not the ultimate goal in the first place? I am not against cancer screenings. Someone always tells me how his or her life was saved by cancer screening. That may be the case, but there are many more people who are treated for falsepositive tests or for cancers that would never have killed them. What we do is an art, not a science: the choices are not black and white, right or wrong. We cannot predict which cancers will kill. We can, however, predict the potential benefit and harm from
the screening. The potential benefit from other measures, such as exercise, that will reduce the risk of mortality from cancer can be predicted. The key is to balance the emotional components of screening with information and data so each individual can make an informed choice about cancer screening. We must not become an assembly line and put everyone through screening without engaging the consumer, providing information about potential risk, benefit, and additional measures to prevent cancer. We need to transform healthcare to be a “custom care” process where the patients are equal partners, if not leaders, in their healthcare.
REFERENCES 1. The National Lung Screening Trial Research Team. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368:1980-91. 2. Physical Activity and Cancer. www.cancer.gov/ cancertopics/factsheet/prevention/ physicalactivity. 3. Breast Cancer Screening (PDQ). www.cancer.gov/ cancertopics/pdq/screening/breast/health professional/page1. 4. Welch, HG & Passow, HJ. Quantifying the benefits and harms of screening mammography. Intern Med. 2014;174(3):448-453.
Tom Bartol is an Advanced Practice Registered Nurse at Richmond Area Health Center, HealthReach Community Health Centers, Richmond, Me. The author has disclosed that he has no financial relationships related to this article. Questions or comments? E-mail bartolnp@gmail. com DOI-10.1097/01.NPR.0000459733.23146.bd
20 The Nurse Practitioner • Vol. 40, No. 2
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
Engaging patients in their healthcare: Cancer screening
By Tom Bartol, APRN
When a patient is “due” for screening, do we just order a screening test, or do we engage the patient in the process? Because a patient is 50 years old, do we simply order a colonoscopy, or do we discuss the pros and cons, the costs, and other measures that may improve health? Are we sharing information to help patients make decisions, or are we just following guidelines and checklists? Providing good care is not just about meeting the quality guidelines. Patient-centered care must focus on the patients, involving them in their healthcare decisions based on their goals, values, and perspectives. Guidelines and parameters are important, but what is needed is engagement, sharing information, and giving patients a perspective from which to make a decision. ■ Assessing baseline risk Healthcare providers are given many screening guidelines. In my earlier days as a nurse practitioner (NP), I presumed that since these guidelines were developed by expert panels and were “evidence-based,” the more I followed these guidelines, the better care my patients would receive. I never thought about risks, and I presumed the benefits would be great. These guidelines, though, are just that: guidelines—not mandates. They are a starting point, a place from which to share information and engage the patient. www.tnpj.com
To help patients make decisions, we must first determine and share with them the baseline risk for their condition or disease. This can be determined using family history, past medical history, and lifestyle assessment. For example, a 50-year-old male who exercises daily, is of normal weight, eats a high-fiber diet, and has no family history of colon cancer, has a very different risk for colon cancer than the 50-year-old male who is obese, a smoker, not physically active, and drinks five beers a day. Simply recommending a colon cancer screening for both of these men based solely on their age is missing the opportunity to take this to the level of patient engagement. ■ Screening: Making informed decisions Just because someone meets the criteria for the screen does not mean they should be screened. Sharing information about the screening test can help patients make an informed decision. A patient came to see me recently asking for “that lung cancer screening.” He recently attended the funerals of two friends, both who died of lung cancer. Fifty-five years old, he quit smoking 14 years ago and had a 30-pack year history of smoking, so he certainly met the guidelines for the low-dose computed tomography (CT) screen for lung cancer. He did not want to die of lung cancer and thought that screening and early detection of lung cancer would save his life.
■ Individualized care It would have been easy to just order the low-dose CT lung cancer screen, but without sharing information about the screen, his only perspective for choosing it is emotional. Are we not obliged to share with patients the potential risks and benefits of what we do to help them make an informed decision? It is easy to just follow guidelines and recommendations, but patients deserve to have information. We expect this kind of information when we bring our car in for repairs: what are the choices, the options, and the risks? Yet in healthcare, this discussion often does not take place. Would this patient choose lung cancer screening if he knew the risks and benefits of the screen? Sharing information and engaging patients in their healthcare decisions about medications, treatments, and diagnostics will help to provide the “right care” for each particular patient. In this case, I shared two simple statistics from the National Lung Cancer Screening Trial with this patient: First, I shared with him that the screening reduced mortality from 1.66% in the baseline screened to 1.33% in the CT screened group for an absolute risk reduction of 0.33%. The other statistic I shared was that 96% of the people who screened positive in this study did not have lung cancer (yet they all had additional procedures done to rule out lung cancer from repeat CT scans to surgical biopsy in some).1 The Nurse Practitioner • February 2015 17
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
NP Insights This figure alone, the fact that there are 96% false positives in this study, led my patient (despite his emotional factors of friends recently dying of lung cancer) to choose not to have lung cancer screening performed. ■ Reducing risks Patient engagement involves sharing information, not just about the screening, but about other ways to reduce risks. Simply screening the high-risk patient for colon cancer misses out on the opportunity to engage the patient, to motivate him, to talk about lifestyle changes, and other ways to reduce or prevent colon cancer. These changes might well have a benefit beyond colon cancer prevention and could extend to other chronic diseases. Overweight, smoking, physical inactivity, and alcohol consumption all pose
preventing these cancers. In our zeal to get the screening done, we must not fail to share such beneficial information. ■ Breast cancer screening Breast cancer screening provides another opportunity to engage patients and share information. The National Cancer Institute (NCI) states that “based on solid evidence from randomized controlled trials, screening mammography between the ages of 40 and 74 reduces breast cancer mortality by about 15% to 20% with an absolute reduction in mortality of about 1% over 10 years.”3 It is important to remember that exercise has been shown to reduce breast cancer mortality by 20% to 80%, as good or better than screening mammography. We must share with women ways they can reduce breast cancer risk rather than
We need to transform healthcare to be a “custom care” process where the patients are equal partners.
higher risks for morbidity and mortality than colon cancer screening would prevent. Engaging the patient—not accusing, threatening, or even educating—but building a relationship can make more of a difference than simply doing the screening test. Exercise has been well studied in the prevention of colon cancer, breast cancer, as well as many chronic diseases. Exercise reduces colon cancer mortality by 30% to 40% and breast cancer mortality by 20% to 80%.2 Knowing this, I question if it is even ethical to order colon cancer screening or screening mammography without also discussing the beneficial effects of exercise in
just recommending screening mammograms. What are the data about screening mammography? If 1,000 average-risk women are screened yearly starting at age 50, over 10 years, there will be between 0.3 and 3.2 deaths avoided. However, between 490 to 670 of those 1,000 women will have false-positive results, and 70 to 100 of these women will have biopsies, while 3 to 14 will be overdiagnosed and treated with surgery, chemotherapy, or radiation even though they do not have breast cancer.4 I am not opposed to screening mammography, but I do believe we must give women information about the risks
and benefits of the screen, a perspective from which to make a choice. This perspective should also be based on stratified risk, based on lifestyle, family history, and past history. It is only then that a patient can make an informed choice. ■ The power of information Sharing information means we must be familiar with it ourselves. The NCI has put together excellent Physician Data Queries, which have great information for NPs as well summarizing various types of cancers, including the data about screening often in a convenient chart form (cancer.gov/cancertopics/pdq). I condensed the data into a few bullet points that I placed in a PowerPoint slide, which I can easily share with patients on my computer during an office visit and print out if necessary. I put the reference in the slide so that the patient or I can easily refer to it. Success must not be measured as having the test done but in engaging the patient in an informed decision based on individual risks and benefits as well as on the patient’s individual values and desires. Our role is to share information so the patient can make an informed decision. In these days of meeting standards and guidelines as a way to give what is called “patient-centered” care, we are not being patient centered if we do not give the patients information and engage them in the decisionmaking process. If it were simply a “cookbook” full of guidelines to follow, we would not need the education, communication skills, or the compassion that NPs have to offer. ■ Patients leading their healthcare All of this takes a bit more time, but it is time well spent. The result may
18 The Nurse Practitioner • Vol. 40, No. 2
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
NP Insights be that some patients choose not to follow the guidelines. My experience has been that patients often choose lifestyle changes over screenings and they end up healthier. Is better health not the ultimate goal in the first place? I am not against cancer screenings. Someone always tells me how his or her life was saved by cancer screening. That may be the case, but there are many more people who are treated for falsepositive tests or for cancers that would never have killed them. What we do is an art, not a science: the choices are not black and white, right or wrong. We cannot predict which cancers will kill. We can, however, predict the potential benefit and harm from
the screening. The potential benefit from other measures, such as exercise, that will reduce the risk of mortality from cancer can be predicted. The key is to balance the emotional components of screening with information and data so each individual can make an informed choice about cancer screening. We must not become an assembly line and put everyone through screening without engaging the consumer, providing information about potential risk, benefit, and additional measures to prevent cancer. We need to transform healthcare to be a “custom care” process where the patients are equal partners, if not leaders, in their healthcare.
REFERENCES 1. The National Lung Screening Trial Research Team. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368:1980-91. 2. Physical Activity and Cancer. www.cancer.gov/ cancertopics/factsheet/prevention/ physicalactivity. 3. Breast Cancer Screening (PDQ). www.cancer.gov/ cancertopics/pdq/screening/breast/health professional/page1. 4. Welch, HG & Passow, HJ. Quantifying the benefits and harms of screening mammography. Intern Med. 2014;174(3):448-453.
Tom Bartol is an Advanced Practice Registered Nurse at Richmond Area Health Center, HealthReach Community Health Centers, Richmond, Me. The author has disclosed that he has no financial relationships related to this article. Questions or comments? E-mail bartolnp@gmail. com DOI-10.1097/01.NPR.0000459733.23146.bd
20 The Nurse Practitioner • Vol. 40, No. 2
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
