Doctors' perspectives on PSA testing illuminate established differences in prostate cancer screening rates between Australia and the UK: a qualitative study

Diagnostic testing in children: A qualitative study of pediatricians' considerations

AIMS AND OBJECTIVES

Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation.

METHOD

We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes.

RESULTS

Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes.

CONCLUSION

We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.

Spatial patterns of prostate-specific antigen testing in asymptomatic men across Australia: a population-based cohort study, 2017-2018

OBJECTIVES

In Australia, while prostate-specific antigen (PSA) testing rates vary by broad area-based categories of remoteness and socio-economic status, little is known about the extent of variation within them. This study aims to describe the small-area variation in PSA testing across Australia.

STUDY DESIGN

This was a retrospective population-based cohort study.

METHODS

We received data for PSA testing from the Australian Medicare Benefits Schedule. The cohort included men (n = 925,079) aged 50-79 years who had at least one PSA test during 2017-2018. A probability-based concordance was applied across multiple iterations (n = 50) to map each postcode to small areas (Statistical Areas 2; n = 2,129). For each iteration, a Bayesian spatial Leroux model was used to generate smoothed indirectly standardized incidence ratios across each small area, with estimates combined using model averaging.

RESULTS

About a quarter (26%) of the male population aged 50-79 years had a PSA test during 2017-2018. Testing rates among small areas varied 20-fold. Rates were higher (exceedance probability>0.8) compared with the Australian average in the majority of small areas in southern Victoria and South Australia, south-west Queensland, and some coastal regions of Western Australia but lower (exceedance probability<0.2) in Tasmania and Northern Territory.

CONCLUSIONS

The substantial geographical variation in PSA testing rates across small areas of Australia may be influenced by differences in access to and guidance provided by clinicians and attitudes and preferences of men. Greater understanding of PSA testing patterns by subregions and how these patterns relate to health outcomes could inform evidence-based approaches to identifying and managing prostate cancer risk.

Low-Value Care: Convergence and Challenges Comment on "Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands"

Interest has increased in the topic of de-implementation, ie, reducing so-called low-value care (LVC). The article "Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands" by Verkerk and colleagues identifies national-level factors affecting LVC use in those three countries. This commentary raises three critical points regarding the study. First, the study does not clearly define the national level. Secondly, national-level factors might not be relevant for all types of LVCs and thirdly, the study's rather limited sample makes it difficult to draw firm conclusions. We also include some critical comments related to some of the study's findings in relation to results of our recently published scoping review of the international literature on de-implementation and use of LVC and an interview study with primary care physicians on LVC use. Finally, we provide some suggestions for further research that we believe is needed to improve understanding of LVC use and facilitate its de-implementation.

PSMA PET-CT in the Diagnosis and Staging of Prostate Cancer

Prostate cancer is the most common cancer and the second leading cause of cancer death in men. The imaging assessment and treatment of prostate cancer has vastly improved over the past decade. The introduction of PSMA PET-CT has improved the detection of loco-regional and metastatic disease. PSMA PET-CT also has a role in the primary diagnosis and staging, in detecting biochemical recurrence after curative treatment and in metastasis-directed therapy. In this paper we review the role of PSMA PET-CT in prostate cancer.

General practitioners' reflections on using PSA for diagnosis of prostate cancer. A qualitative study

OBJECTIVE

To investigate how GPs use the PSA test as a diagnostic tool in daily practice.

DESIGN

Qualitative study using focus group interviews, the transcripts being analyzed by systemic text condensation.

SUBJECTS

A total of 17 Norwegian GPs in three CME groups.

MAIN OUTCOME MEASURES

Exploring GPs' attitudes to national guidelines and the practical use of the PSA test.

RESULTS

Detecting prostate cancer in general practice is a common and important, but difficult diagnostic issue. Our participants experienced uncertainty regarding the test when to use it, how to interpret the results and when to refer to specialist health services.

CONCLUSION

The study revealed a general ambivalence to the use of PSA. Many patients present urological problems, and many are afraid of having cancer. PSA is commonly used, but sometimes generates problems rather than solving them.

IMPLICATIONS

The use of the PSA test should be based on a thorough clinical assessment and in close collaboration with the patient.Key pointsMany patients in general practice present urological problems, and many are afraid of having cancer.GPs have a general ambivalence to the use of PSA when to use it, how to interpret the results and when to refer to specialist health services.The use of PSA sometimes generates problems rather than solving them.

Acceptability of risk-stratified population screening across cancer types: Qualitative interviews with the Australian public

BACKGROUND

There is mounting evidence of the benefit of risk-stratified (risk-tailored) cancer population screening, when compared to standard approaches. However, shifting towards this approach involves changes to practice that may give rise to implementation challenges.

OBJECTIVES

To explore the public's potential acceptance of risk-stratified screening across different cancer types, including reducing screening frequency if at low risk and the use of personal risk information, to inform implementation strategies.

METHOD

Semi-structured interviews were conducted with 40 public participants; half had received personal genomic risk information and half had not. Participants were prompted to consider different cancers. Data were analysed thematically as one dataset.

RESULTS

Themes included the following: (a) a sense of security; (b) tailored screening is common sense; (c) risk and the need to take action; (d) not every cancer is the same; and (e) trust and belief in health messages. Both groups expressed similar views. Participants were broadly supportive of risk-stratified screening across different cancer types, with strong support for increased screening frequency for high-risk groups. They were less supportive of reduced screening frequency or no screening for low-risk groups. Findings suggest the public will be amenable to reducing screening when the test is invasive and uncomfortable; be less opposed to forgo screening if offered the opportunity to screen at some stage; and view visible cancers such as melanoma differently.

CONCLUSIONS

Approaching distinct cancer types differently, tailoring messages for different audiences and understanding reasons for participating in screening may assist with designing future implementation strategies for risk-stratified cancer screening.

Why Does Cancer Screening Persist Despite the Potential to Harm?

Population screening for early-stage cancer or cancer precursors began in the mid-twentieth century, with the goal of reducing suffering from cancer illness and lengthening average life by preventing cancer deaths. Since the establishment of cancer screening, concerns have emerged that it may be doing considerable harm; despite this, screening practices have remained relatively intractable. This intractability in the face of harm is the central problematic of my analysis. I reinterpret a large study of breast, cervical and prostate cancer screening completed recently by our Australian research group, working across empirical bioethics, public health and social science. I suggest three reasons why cancer screening might persist as it does, and thus reach conclusions about what might be required to make cancer screening systems more responsive to the potential for harm.

Determinants for the use and de-implementation of low-value care in health care: a scoping review

BACKGROUND

A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC.

AIM

The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care.

METHODS

A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group.

RESULTS

In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research.

CONCLUSION

The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC.

REGISTRATION

The review has not been registered.

Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998-2017

Background

Prostate cancer is a leading cause of cancer- related death. Interpreting the results from trials of screening with prostate-specific antigen (PSA) is complex in terms of defining optimal prostate cancer screening policy.

Aim

To assess the rates of, and factors associated with, the uptake of PSA testing and opportunistic screening (that is, a PSA test in the absence of any symptoms) in England between 1998 and 2017, and to estimate the likely rates of pre-randomisation screening and contamination (that is, unscheduled screening in the ‘control’ arm) of the UK-based Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP).

Design and setting

Open cohort study of men in England aged 40–75 years at cohort entry (1998–2017), undertaken using the QResearch database.

Method

Eligible men were followed for up to 19 years. Rates of PSA testing and opportunistic PSA screening were calculated; Cox regression was used to estimate associations.

Results

The cohort comprised 2 808 477 men, of whom 631 426 had a total of 1 720 855 PSA tests. The authors identified that 410 724 men had opportunistic PSA screening. Cumulative proportions of uptake of opportunistic screening in the cohort were 9.96% at 5 years’, 22.71% at 10 years’, and 44.13% at 19 years’ follow-up. The potential rate of contamination in the CAP control arm was estimated at 24.50%.

Conclusion

A substantial number of men in England opt in to opportunistic prostate cancer screening, despite uncertainty regarding its efficacy and harms. The rate of opportunistic prostate cancer screening in the population is likely to have contaminated the CAP trial, making it difficult to interpret the results.

General practitioners' approaches to prostate-specific antigen testing in the north-east of the Netherlands

BACKGROUND

There is wide variation in clinical practice for the early detection of prostate cancer, not least because of the ongoing debate about the benefits of prostate-specific antigen (PSA) testing. In this study, we aimed to assess the approaches, attitudes, and knowledge of general practitioners (GPs) regarding PSA testing in primary care in the Netherlands, particularly regarding recommendations for prostate cancer.

METHODS

Questionnaire surveys were sent to 179 GPs in the north-east of the Netherlands, of which 65 (36%) were completed and returned. We also surveyed 23 GPs attending a postgraduate train-the-trainer day (100%). In addition to demographic data and practice characteristics, the 31-item questionnaire covered the attitudes, clinical practice, adherence to PSA screening recommendations, and knowledge concerning the recommendations for prostate cancer early detection. Statistical analysis was limited to the descriptive level.

RESULTS

Most GPs (95%; n = 82) stated that they had at least read the Dutch GP guideline, but just half (50%; n = 43) also stated that they knew the content. Almost half (46%; n = 39) stated they would offer detailed counseling before ordering a PSA test to an asymptomatic man requesting a test. Overall, prostate cancer screening was reported to be of minor importance compared to other types of cancer screening.

CONCLUSIONS

Clinical PSA testing in primary care in this region of the Netherlands seems generally to be consistent with the relevant guideline for Dutch GPs that is restrictive to PSA testing. The next step will be to further evaluate the effects of the several PSA testing strategies.

Why clinicians overtest: development of a thematic framework

BACKGROUND

Medical tests provide important information to guide clinical management. Overtesting, however, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are ultimately responsible for test requests, and are therefore ideally positioned to prevent overtesting and its unintended consequences. Through this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference (Sydney, 2019), we aimed to identify and establish a thematic framework of factors that influence clinicians to request non-recommended and unnecessary tests.

METHODS

Articles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development.

RESULTS

The MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed: "Intrapersonal" - fear of malpractice and litigation; clinician knowledge and understanding; intolerance of uncertainty and risk aversion; cognitive biases and experiences; sense of medical obligation "Interpersonal" - pressure from patients and doctor-patient relationship; pressure from colleagues and medical culture; "Environment/context" - guidelines, protocols and policies; financial incentives and ownership of tests; time constraints, physical vulnerabilities and language barriers; availability and ease of access to tests; pre-emptive testing to facilitate subsequent care; contemporary medical practice and new technology CONCLUSION: This thematic framework may raise awareness of overtesting and prompt clinicians to change their test request behaviour. The development of a scale to assess clinician knowledge, attitudes and practices is planned to allow evaluation of clinician-targeted interventions to reduce overtesting.

Colorectal, cervical and prostate cancer screening in Australians with severe mental illness: Retrospective nation-wide cohort study

OBJECTIVE

People with severe mental illness have similar cancer incidence, but higher mortality than the general population. Participation in cancer screening may be a contributing factor but existing studies are conflicting. The aim of this study was to investigate the frequency of colorectal, prostate and cervical cancer screening among people with and without severe mental illness in Australia, who have access to universal health care.

METHODS

We followed three cohorts using de-identified data from a random 10% sample of people registered for Australia's universal health care system: those aged 50-69 years ( n = 760,058) for colorectal cancer screening; women aged 18-69 years ( n = 918,140) for cervical cancer screening and men aged 50-69 years ( n = 380,238) for prostate cancer screening. We used Poisson regression to estimate incidence rate ratios and 95% confidence intervals for the association between severe mental illness and rates of faecal occult blood testing, pap smears and prostate-specific antigen testing.

RESULTS

Having severe mental illness was associated with a 17% reduction in rates of pap smear (incidence rate ratio = 0.83, 95% confidence interval: 0.82-0.84) and prostate-specific antigen testing (incidence rate ratio = 0.83, 95% confidence interval: 0.81-0.85), compared to the general population. By contrast, incidence rates of faecal occult blood testing were only lower in people with severe mental illness among the participants who visited their general practitioner less than an average of five times per year (incidence rate ratio = 0.83, 95% confidence interval = [0.73, 0.94]).

CONCLUSION

Our results suggest that differences in screening frequency may explain some of the mismatch between cancer incidence and mortality in people with severe mental illness and indicate that action is required to improve preventive screening in this very disadvantaged group.

Valuing Healthcare Improvement: Implicit Norms, Explicit Normativity, and Human Agency

I argue that greater attention to human agency and normativity in both researching and practicing service improvement may be one strategy for enhancing improvement science, illustrating with examples from cancer screening. Improvement science tends to deliberately avoid explicit normativity, for paradigmatically coherent reasons. But there are good reasons to consider including explicit normativity in thinking about improvement. Values and moral judgements are central to social life, so an adequate account of social life must include these elements. And improvement itself is unavoidably normative: it assumes that things could and should be better than they are. I seek to show that normativity will always be implicated in the creation of evidence, the design of programs, the practice of healthcare, and in citizens' judgements about that care, and to make a case that engaging with this normativity is worthwhile.

HOXD-AS1 Exerts Oncogenic Functions and Promotes Chemoresistance in Cisplatin-Resistant Cervical Cancer Cells

Long noncoding RNAs (lncRNAs) are important regulators in various human diseases. The lncRNA HOXD-AS1 is a tumor promoter in ovarian cancer, glioma, and lung cancer, but the specific effects of HOXD-AS1 on cervical cancer (CC) chemoresistance remain unclear. Here, the level of HOXD-AS1 in nonmalignant and CC tissues as well as in CC cells and cisplatin-resistant CC cells was determined. qRT-PCR indicated that HOXD-AS1 was overexpressed in CC tissues and cisplatin-resistant CC cells. Loss-of-function assays showed that downregulation of HOXD-AS1 expression suppressed chemoresistance of cisplatin-resistant CC cells. HOXD-AS1 targeted miR-130a-3p, and in gain-of-function assays miR-130a-3p could reverse cisplatin resistance of CC cells. miR-130a-3p in turn targeted zinc finger E-box homeobox 1 (ZEB1). These results collectively show that HOXD-AS1 can act as a competing endogenous RNA to upregulate ZEB1 expression via miR-130a-3p. The effects of the HOXD-AS1-miR-130a-3p-ZEB1 axis on cisplatin resistance of cisplatin-resistant CC cells were supported by rescue assay results. In summary, HOXD-AS1 enhanced chemoresistance of cisplatin-resistant CC cells by modulating miR-130a-3p/ZEB1 axis expression.

The attitudes and beliefs of general practitioners towards clinical practice guidelines: a qualitative study in Al Ain, United Arab Emirates

BACKGROUND

The efficacy of implementing practices based on the best evidence is determined by the limitations and preparedness of the structure and processes of the healthcare system as well as healthcare professionals' (HCP) levels of knowledge and acceptance. Facilitating implementation of such practices also partly depends on HCPs' attitudes.

METHOD

We investigate the attitudes and beliefs of four groups of physicians in the United Arab Emirates on clinical practice guidelines (CPGs), with a focus on applying revisions to these CPGs in a different setting than the one in which they were developed, and where no locally developed guidelines exist.

RESULTS

CPGs were the main source of information for revisions. We identified a rising concern in the applicability of the recommendations, which persists due to a lack of locally developed revisions. Other concerns include the pressures of practice management changes and of coping with the rapid development in resources and the growing demand on its use. Some international and government-endorsed CPGs were still accepted as being the best candidates for adoption.

CONCLUSIONS

This group welcomes evidence-based practice and is supported by electronic medical records, structured care programmes, and ongoing quality monitoring. Barriers and facilitators of clinical practice guidelines are discussed and thoughts on effective implementation strategies are considered.

Primary goals, information-giving and men's understanding: a qualitative study of Australian and UK doctors' varied communication about PSA screening

OBJECTIVES

(1) To characterise variation in general practitioners' (GPs') accounts of communicating with men about prostate cancer screening using the prostate-specific antigen (PSA) test, (2) to characterise GPs' reasons for communicating as they do and (3) to explain why and under what conditions GP communication approaches vary.

STUDY DESIGN AND SETTING

A grounded theory study. We interviewed 69 GPs consulting in primary care practices in Australia (n=40) and the UK (n=29).

RESULTS

GPs explained their communication practices in relation to their primary goals. In Australia, three different communication goals were reported: to encourage asymptomatic men to either have a PSA test, or not test, or alternatively, to support men to make their own decision. As well as having different primary goals, GPs aimed to provide different information (from comprehensive to strongly filtered) and to support men to develop different kinds of understanding, from population-level to 'gist' understanding. Taking into account these three dimensions (goals, information, understanding) and building on Entwistle et al's Consider an Offer framework, we derived four overarching approaches to communication: Be screened, Do not be screened, Analyse and choose, and As you wish. We also describe ways in which situational and relational factors influenced GPs' preferred communication approach.

CONCLUSION

GPs' reported approach to communicating about prostate cancer screening varies according to three dimensions-their primary goal, information provision preference and understanding sought-and in response to specific practice situations. If GP communication about PSA screening is to become more standardised in Australia, it is likely that each of these dimensions will require attention in policy and practice support interventions.

Avoiding harm and supporting autonomy are under-prioritised in cancer-screening policies and practices

The ethical principles of avoiding harm and supporting autonomy are relevant to cancer-screening policy. We argue that more attention needs to be given to implementing them. Cancer screening may deliver excessive harms due to low-value or outdated screening programs and from poorly communicated screening options that leave people with heavy burdens of decision-making. Autonomy is inadequately supported due to limited opportunities for people to understand downsides of screening and because of institutional and societal pressures in favour of screening. Members of screening policy committees may have differing ideas about the goals of screening or have conflicts of interest that prevent them from addressing policy questions in a neutral way. We recommend the following: 1. Committees should be required to discern and discuss the values of individual members and the wider public; 2. Committee membership and voting procedures should be more carefully constructed to reduce the likelihood that committee members' interests are placed above public interests; 3. Committees should explain their policy decisions with reference to values as well as evidence, so that values considered in decision-making can be interrogated and challenged if necessary. These changes would increase the likelihood that cancer-screening policy decisions are in keeping with public views about what is important.