Shared decision-making uncommon for PSA tests
Most men have not discussed the potential advantages and disadvantages of prostate cancer screening with their doctor, according to a new study.
Guidelines from groups including the American Urological Association and American College of Physicians call for shared decision-making when it comes to prostate specific antigen (PSA) testing, taking into account each man’s values regarding screening.
“There’s a lot of scientific uncertainty about its benefits and harms for any one person,” said Dr. Paul Han, from the Maine Medical Center in Portland, who led the new study.
The concern with screening is that PSA tests catch some cancers that never would have affected a man’s life because they are so small and slow-growing - yet treatment can cause side effects such as incontinence and impotence.
And there’s still controversy about whether regular screening saves a significant number of lives.
The U.S. Preventive Services Task Force (USPSTF), a government-backed panel, recommends against prostate cancer screening.
Han and his colleagues analyzed questionnaires completed by about 3,400 men in their 50s, 60s and early 70s as part of a 2010 national health survey.
They found 64 percent of those men had not discussed the pluses and minuses of PSA tests with their doctors, or the scientific uncertainty of their effect. Of the rest, about half had talked only about the advantages of screening.
About 44 percent of study participants hadn’t been screened for prostate cancer in the past five years. The majority of those - 88 percent - reported no discussions regarding that choice, according to findings published in the Annals of Family Medicine.
Prior studies have focused on men who were screened without a discussion of the potential benefits and harms - sometimes without their knowledge.
Beyond weighing the risks and benefits of screening for any individual man, the PSA test itself may not be that accurate or reliable an indicator of cancer.
But if the evidence on PSA tests is “truly uncertain,” Han told Reuters Health, failing to talk about the decision to not get screened could be concerning as well.
The PSA test is the “poster child for uncertainty,” said Dr. Michael Wilkes, from the University of California, Davis.
“The test is horrible, yet there are still reasonable men who still might opt to have the test because they feel that knowing the information, even though it’s not perfect, is better than not knowing it,” he told Reuters Health.
“In this situation, reasonable people can look at the data and because of their own values and their own preferences decide, ‘I want the test’ or, ‘I don’t want the test.’”
HAVING THE CONVERSATION
In two studies published in the same journal, Wilkes and his colleagues looked at whether educating doctors about prostate cancer screening and prompting patients to ask about it boosted rates of shared decision-making.
Their studies included about 120 doctors who either were given typical brochures about PSA tests or completed an interactive program that included video vignettes showing the possible benefits and harms of screening.
When faced with a test patient a few months later, doctors in the intervention group were a little better at leading shared decision-making discussions - but not much.
Audio recordings of the appointments showed those doctors incorporated an average of 14 out of 32 decision-making elements into the visit, versus 11 by doctors in the comparison group. Those elements included sharing information about different screening and treatment options and asking about the patient’s values in relation to screening.
In another analysis, doctors were more neutral about their screening recommendations when they’d completed the computer program and some of their patients had been educated and primed to ask about screening.
“What we found was, educating the doctor is necessary but not sufficient,” Wilkes told Reuters Health.
He recommends men do their homework on prostate cancer screening - by looking at the U.S. Centers for Disease Control and Prevention and USPSTF websites, for example - before going in to see their doctor.
Better training and resources for doctors might also help, according to Han.
“Studies are converging to the same conclusion, that (shared decision-making) really doesn’t happen very often in PSA screening,” he said.
“It’s one of these things like world peace. Everyone agrees with it as an ideal, but how to actually achieve it, we don’t know.”
SOURCES: Annals of Family Medicine, July/August 2013.