393 - LUTS in Men, Lung CA Screening, Shared Decision-Making?
Take 3 – Practical Practice Pointers©
From the Literature
1) Self-Management for Men with Lower Urinary Tract Symptoms
Lower urinary tract symptoms (LUTS) – including urinary frequency, urgency, nocturia, incontinence, hesitancy, poor stream, incomplete emptying, and dribbling - are common in men and are associated with advancing age. These symptoms can impact quality of life considerably. Not all of them are due to bladder outlet obstruction by the prostate, and thus, not all of them will resolve with typical benign prostatic hypertrophy medications or surgery – even though we’re trained to think of these first. Other causes can include detrusor muscle instability and urethral conditions. Infrequently considered for LUTS are self-management (“behavioral”) interventions. An online American Urological Association (AUA) guideline barely mentions them.
A recent systematic review found eight studies (N = 1006) that looked at the effectiveness of these self-management interventions (SMI) on LUTS. The review was very well-done, but the included studies were only of fair quality overall.
The studied SMIs broke down into the following categories:
- education and reassurance,
- fluid management (timing and amount of fluids),
- reduction of caffeine and alcohol intake,
- use of concurrent medication (mainly rescheduling diuretics),
- toilet and bladder training (delayed voiding, double voiding, timed voiding, urethral milking, pelvic floor exercises, voiding diaries)
- miscellaneous (avoiding constipation, sleep hygiene, edema management)
These were compared to usual care/watchful waiting and to medications. Much of the outcome assessment examined improvement in validated prostate symptoms scores, and for most of this data, the authors defined the differences that were associated with clinically significant improvement.
Two studies compared SMIs vs. usual care:
- SMIs resulted in clinically significant reductions LUTS at 6 months (e.g., ~7.4 points on the 35 item International Prostate Symptom Score (IPSS)).
- SMIs improved quality of life by three times the minimum clinically significant difference at 6 months on a prostate-specific quality of life scale.
- SMIs reduced treatment failures (a rise of 3 points on the IPSS, or acute urinary retention, or need for medications or surgery) at 6 and 12 months by 48% (95% CI, 32% to 64%, NNT ~ 2).
Four studies compared SMIs to drug therapy:
- There were no differences in symptom scores at 6 and 12 weeks.
- SMIs reduced nocturia slightly, but not 24-hour voiding frequency.
- Drug therapy caused 26% more adverse events than SMIs
Two studies compared SMIs + drug therapy to drug therapy alone:
- Single study results showed small improvements in symptom score at 6 weeks, nocturia and 24-hour voiding frequency at 6 and 12 weeks.
- Adverse events were similar.
The authors attempted to analyze the specific components of SMIs for evidence of increased benefit but could not be conclusive. They suggest that combinations of SMIs focused on a patient’s specific symptoms would be the best approach.
I know I could do a better job with recommending these interventions rather than just typing “F-L-O-M…”. The data is compelling that these self-management interventions can work well, especially if we listen closely to our patients’ symptoms and tailor the SMIs to those symptoms. Remember, when you are reading a study with lots of data about improvement in symptom scores, make sure the authors define what constitutes a “clinically significant improvement.” The better-quality scales will have established this and statistical significance frequently does not mean a difference in patient-oriented outcomes.
- Albarqouni L, Sanders S, Clark J, Tikkinen KAO, Glasziou P. Self-Management for Men With Lower Urinary Tract Symptoms: A Systematic Review and Meta-Analysis. Ann Fam Med. 2021 Mar;19(2):157–67. Link
From the USPSTF
2) Screening for Lung Cancer – Updated Recommendations
Lung cancer is the second most common cancer and the leading cause of cancer death in the US. The most important risk factor for lung cancer is smoking, accounting for approximately 90% of all lung cancer cases. Increasing age is also a risk factor. Lung cancer has a generally poor prognosis, with an overall 5-year survival rate of 20%. However, early-stage lung cancer has a better prognosis and is more amenable to treatment. Despite screening being recommended by the USPSTF since 2013, available data indicate that uptake of lung cancer screening is low. One recent study using data from 10 states found that 14% of persons eligible for lung cancer screening (based on 2013 USPSTF criteria) had been screened in the prior 12 months.
The USPTF recently updated their 2013 recommendation for lung cancer screening in present and former smokers. The new recommendation includes:
Annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50-80 who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. (B recommendation)
Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
Compared with the 2013 recommendation, this lowers the time to initiate screening by 5 years and reduces the definition of “heavy smoker” by 10 pack-years.
The USPSTF notes that the moderate net benefit of screening depends on limiting screening to persons at high risk, the accuracy of image interpretation being similar to or better than that found in clinical trials, and the resolution of most false-positive results with serial imaging rather than invasive procedures. Beyond false-positive results, lung cancer screening has the potential to cause harm through incidental findings that can lead to subsequent testing and treatment, including the anxiety of living with a lung lesion that may be cancer. Overdiagnosis of lung cancer and the risks of radiation exposure are harms, although their exact magnitude is uncertain. The recommendation notes that the decision to undertake screening should involve a thorough discussion of the potential benefits, limitations, and harms of screening through shared decision-making. According to a statement from the USPSTF, this new recommendation will double the number of people eligible for lung cancer screening.
The process of “Shared Decision-Making” continues to be used as a “catch-all
phrase” that both the literature and the practicalities of clinical medicine would
indicate is more aspirational than based in clinical reality. I thought the USPSTF did a good job helping guide this process with the shared decision-making guide for prostate cancer screening, which helped explain the probabilities in ways many would be able to understand (not necessarily comprehend, but at least understand). In the case of this recommendation, reference is made to the National Cancer Institute lung cancer screening patient information (2nd reference), which is mostly text with one picture of the lung anatomy. Reading and reviewing this document would not even closely approximate the intricacies of shared decision-making, let alone thinking this would also be happening for colon, breast or prostate cancer screening during the same patient visit. We know how those conversations usually go. “You’re due for your ….” See Pointer 3 for additional thoughts.
From the Art of Medicine
3) Engaging in “Shared Decision-Making”
As is pointed out in Pointer 2, I continue to be concerned about how the term “shared decision-making” is being utilized by all groups, as they appear to imply this is a globally understood and easily accomplished process. It is not.
Shared decision-making (between clinician and patient and, in some cases, family members) appears to be an excellent strategy for making health care decisions when there is more than one medically reasonable option. The purpose of shared decision making is to ensure patients:
- understand their diagnosis,
- understand that they have a choice about their care,
- understand the risk/benefit tradeoffs involved in each of the choices, and
- come to a decision that is in keeping with their values and preferences.
Framed in this way, theoretically “shared decision-making” should be used for the majority of medical decisions, since, except in emergencies, there is usually more than one reasonable path. Understood in this way, however, there are many challenges to this process. What does it mean for a patient to “understand” a diagnosis? Can most patients truly understand the nuances of possible benefits and risks of different paths when these are often hard to quantify for a population, let alone for an individual patient, and where we in medicine often can’t even agree (e.g.: HTN guidelines, PCa screening, T2D goals, breast cancer screening, cancer treatment, etc.)? What if their values are in conflict with sound medical practice or societal values (opioids, antibiotics, etc.)?
Additionally, true “academically-defined” shared decision-making takes time – sometimes a lot of time depending on the decision. See the referenced “Ottawa Personal Decision Guide Aid” to appreciate just how detailed “true” shared decision-making could be! And what about all the data indicating that most people (and many clinicians) do not truly grasp statistical probabilities, often greatly overestimating potential benefit and underestimating potential harm, and the influence we clinicians can have on how patients make their decisions?
Finally, though understandable, there is great danger in carving out a process of “shared decision-making” to a few more highly controversial or emotionally charged diagnoses or interventions (when was the last time you performed shared decision-making prior to performing cervical cancer screening?), as many healthcare decisions are potentially “life-altering” over time.
Instead, acknowledging the limitations and uncertainty involved in patient care, let’s use the 4 steps above as an “aspirational” general guide rather than a hard-and-fast but realistically impractical rule for all patients in most circumstances, doing our best to ensure that they are routinely informed about and included in decisions about their care. That just seems like the right thing to do.
- AHRQ – The SHARE Approach to Shared Decision-Making: SHARE Approach
- Ottawa Personal Decision Guide Aid: https://decisionaid.ohri.ca/docs/das/OPDG.pdf
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.