Study Says Men are Not Adequately Involved in
Prostate Cancer Screening Discussions
Another new study finds screened men up to four times
more likely to be diagnosed with prostate cancer than unscreened men
Sept.
28, 2009 - Men largely make decisions about prostate cancer screening
based on conversations with their clinicians, but these discussions
often do not include information about the risks of testing in addition
to the benefits, according to a report in the September 28 issue of
Archives of Internal Medicine, one of the JAMA/Archives journals.
A second report in the same issue uses statistical
modeling to estimate the benefits and risks of prostate-specific antigen
(PSA) screening in men of various ages and risk levels.
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The majority of American men older than 50 have
been screened with the PSA blood test. This practice, however, is
controversial because there is no convincing evidence that screening
prevents deaths from the disease, and treating early-stage cancers
detected by screenings may lead to important complications.
"Given the uncertain benefit for screening and
known treatment risks, prostate cancer screening decisions should be
guided by patient preferences," the authors write.
"Indeed, most professional organizations recommend
that the first step in screening should be a discussion between health
care providers and patients about the risks and benefits of early
detection and treatment so that patients can make informed decisions
about whether to be screened."
Richard M. Hoffman, M.D., M.P.H., of New Mexico VA
Health Care System and University of New Mexico School of Medicine,
Albuquerque, and colleagues conducted a telephone survey of 3,010
randomly selected English-speaking adults age 40 and older in 2006 and
2007.
The sample included 375 men who had either
undergone or discussed PSA testing with their clinicians in the previous
two years. These men were asked what they knew about prostate cancer,
what their discussions with clinicians were like and what factors and
sources of information influenced their screening decisions.
Overall, 69.9 percent of the men had discussed
screening with their clinician before making a decision, including 14.4
percent who chose not to undergo testing.
Most often, clinicians raised the idea of screening
(64.6 percent), and 73.4 percent recommended it. Recommendation from a
clinician was the only characteristic of the discussion associated with
testing.
"Although respondents generally endorsed shared
decision-making process and felt informed, only 69.9 percent actually
discussed screening before making a testing decision, few subjects (32%)
reported having discussed the cons of screening, 45.2 percent said they
were not asked for their preference about PSA testing and performance on
knowledge testing was poor." Only 47.8 percent of men correctly answered
any of three questions about prostate cancer risk and screening
accuracy, the authors write.
"Therefore, these discussions - when held - did not
meet criteria for shared decision making. Our findings suggest that
patients need a greater level of involvement in screening discussions
and to be better informed about prostate cancer screening issues."
Another Study Looks at PSA Screening
Effectiveness
In a second study, Kirsten Howard, B.Sc.,
M.App.Sc., M.P.H., M.Health.Econ., Ph.D., of the University of Sydney,
Australia, and colleagues constructed a statistical model to provide
information for men age 40, 50, 60 and 70 years at low, moderate and
high risk for prostate cancer based on family history.
Using Australian prostate cancer incidence rates
before PSA screening began in 1989 and cancer death rates in 2005, along
with data from the European Randomized Study of Screening for Prostate
Cancer and the Australian Bureau of Statistics, the authors examined two
hypothetical cohorts of men who either participated in or declined
annual PSA screening.
The model predicts that benefits and harms of
annual PSA screening vary with age and risk level.
For example, for every 1,000 60-year-old men at low
risk, 53 of those who were screened yearly would be diagnosed with
prostate cancer and 3.5 would die of the disease during a 10-year
period, compared with 23 diagnoses and 4.4 deaths in unscreened men.
"For 1,000 men screened from 40 to 69 years of age,
there will be 27.9 prostate cancer deaths and 639.5 deaths overall by
age 85 years compared with 29.9 prostate cancer deaths and 640.4 deaths
overall in unscreened men," the study says.
"Higher-risk men have more prostate cancer deaths
averted but also more prostate cancers diagnosed and related harms."
In the model, screened men are two to four times
more likely to be diagnosed with prostate cancer than unscreened men,
but death rates from prostate cancer and from all causes are not
significantly different.
This implies that many men whose cancer is detected
by PSA screening may be undergoing treatment for clinically
insignificant cancers, the authors note.
"In conclusion, before undergoing PSA screening,
men should be aware of the possible benefits and harms and of their
chances of these benefits and harms occurring," they write.
"Even under optimistic assumptions, the net
mortality benefit is small, even when prostate cancer deaths are
cumulated to 85 years of age. These quantitative estimates can be used
to support the goal of individual informed choices about PSA screening."
Editorial: Study Helps Highlight Difficulties of
Shared Decision Making
Virtually every professional organizations' PSA
screening guidelines urge clinicians to engage patients in shared
decision making before performing PSA testing, write Steven H. Woolf,
M.D., M.P.H., of Virginia Commonwealth University, Richmond, and Alex
Krist, M.D., M.P.H., in an accompanying editorial.
"Definitions of shared decision making vary, but
the term generally refers to the effort to help patients understand the
benefits, harms and uncertainties of available options and to apply
personal preferences to determine the best choice. Both parties share
information, jointly participate in decision making and agree on a
course of action that incorporates personal preferences."
"Today's practice environment presents few
incentives or support tools for those clinicians and patients who prefer
a discussion rather than simply marking a checkbox for PSA on a
laboratory requisition form," they continue.
"In the United States, where medical technologies
are often adopted long before their effectiveness and safety are
confirmed, the difficulties of implementing shared decision making for
prostate cancer screening will likely recur with other modalities of
care. What is ultimately required is a deeper change in culture among
providers and consumers of health care to delay dissemination, resist
the assumption that newer is better, wait for evidence, tolerate
observation over intervention and accept uncertainty."
Editorial: Information Can Aid Discussion of PSA
Screening
"Data from the National Survey of Medical Decisions
reported in this issue of the Archives suggest that many patients have
not had an opportunity to discuss the full range of issues related to
the PSA screening decision," writes Michael Pignone, M.D., M.P.H., of
University of North Carolina-Chapel Hill, in an accompanying editorial.
"Because of the complexity of factors that need to
be considered in such discussions, tools have been developed to help
guide providers and patients in considering the benefits and downsides
of screening and in reaching a value-concordant decision," he continues.
"One type of tool, patient decision aids, has been
shown to increase patient knowledge, participation and confidence."
"To inform the development of future decision aids,
Howard and colleagues present a balance sheet of the consequences of PSA
screening in Australian men from different age groups and with different
levels of underlying risk," Dr. Pignone continues. "The work by Howard
and colleagues is an important step in providing information to patients
and providers to facilitate discussion about this trade-off."
Editor's Note: Dr. Pignone is supported by an
Established Investigator Award from the National Cancer Institute and by
the Foundation for Informed Medical Decision Making.
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