Screening for prostate cancer: the roles of science, policy, and opinion in determining what is best for patients

Optimization of PSA screening policies: a comparison of the patient and societal perspectives

OBJECTIVE

To estimate the benefit of PSA-based screening for prostate cancer from the patient and societal perspectives.

METHOD

A partially observable Markov decision process model was used to optimize PSA screening decisions. Age-specific prostate cancer incidence rates and the mortality rates from prostate cancer and competing causes were considered. The model trades off the potential benefit of early detection with the cost of screening and loss of patient quality of life due to screening and treatment. PSA testing and biopsy decisions are made based on the patient's probability of having prostate cancer. Probabilities are inferred based on the patient's complete PSA history using Bayesian updating.

DATA SOURCES

The results of all PSA tests and biopsies done in Olmsted County, Minnesota, from 1993 to 2005 (11,872 men and 50,589 PSA test results).

OUTCOME MEASURES

Patients' perspective: to maximize expected quality-adjusted life years (QALYs); societal perspective: to maximize the expected monetary value based on societal willingness to pay for QALYs and the cost of PSA testing, prostate biopsies, and treatment.

RESULTS

From the patient perspective, the optimal policy recommends stopping PSA testing and biopsy at age 76. From the societal perspective, the stopping age is 71. The expected incremental benefit of optimal screening over the traditional guideline of annual PSA screening with threshold 4.0 ng/mL for biopsy is estimated to be 0.165 QALYs per person from the patient perspective and 0.161 QALYs per person from the societal perspective. PSA screening based on traditional guidelines is found to be worse than no screening at all.

CONCLUSIONS

PSA testing done with traditional guidelines underperforms and therefore underestimates the potential benefit of screening. Optimal screening guidelines differ significantly depending on the perspective of the decision maker.

A structured implicit abstraction method to evaluate whether content of counseling before prostate cancer screening is consistent with recommendations by experts

OBJECTIVE

To assess the content of counseling about prostate-specific antigen (PSA) screening. Guidelines recommend informed consent before screening because of concerns about benefits versus risks. As part of the professional practice standard for informed consent, clinicians should include content customarily provided by experts.

METHODS

40 transcripts of conversations between medicine residents and standardized patients were abstracted using an instrument derived from an expert Delphi panel that ranked 10 "facts that experts believe men ought to know."

RESULTS

Transcripts contained definite criteria for an average of 1.7 facts, and either definite or partial criteria for 5.1 facts. Second- and third-year residents presented more facts than interns (p=0.01). The most common facts were "false positive PSA tests can occur" and "use of the PSA test as a screening test is controversial." There was an r=0.88 correlation between inclusion by residents and the experts' ranking.

CONCLUSION

Counseling varied but most transcripts included some expert-recommended facts. The absence of other facts could be a quality deficit or an effort to prioritize messages and lessen cognitive demands on the patient.

PRACTICE IMPLICATIONS

Clinicians should adapt counseling for each patient, but our abstraction approach may help to assess the quality of informed consent over larger populations.

Educating African American men about the prostate cancer screening dilemma: a randomized intervention

BACKGROUND

Until there is a definitive demonstration that early diagnosis and treatment of prostate cancer reduces disease-related mortality, it is imperative to promote informed screening decisions by providing balanced information about the potential benefits and risks of prostate cancer screening. Within a community/academic collaboration, we conducted a randomized trial of a printed booklet and a videotape that were designed for African American (AA) men. The purpose of the trial was to determine the effect of the interventions on knowledge, decisional conflict, satisfaction with the screening decision, and self-reported screening.

METHODS

Participants were 238 AA men, ages 40 to 70 years, who were members of the Prince Hall Masons in Washington, DC. Men were randomly assigned to the (a) video-based information study arm, (b) print-based information study arm, or (c) wait list control study arm. Intervention materials were mailed to men at home. Assessments were conducted at baseline, 1 month, and 12 months postintervention. Multivariate analyses, including ANCOVA and logistic regression, were used to analyze group differences.

RESULTS

The booklet and video resulted in a significant improvement in knowledge and a reduction in decisional conflict about prostate cancer screening, relative to the wait list control. Satisfaction with the screening decision was not affected by the interventions. Self-reported screening rates increased between the baseline and the 1-year assessment, although screening was not differentially associated with either of the interventions. In exploratory analyses, prostate-specific antigen testing at 1 year was more likely among previously screened men and was associated with having low baseline decisional conflict.

CONCLUSIONS

This study represents one of the first randomized intervention trials specifically designed to address AA men's informed decision making about prostate cancer screening. We have developed and evaluated culturally sensitive, balanced, and disseminable materials that improved knowledge and reduced decisional conflict about prostate cancer screening among AA men. Due to the high incidence and mortality rates among AA men, there is a need for targeted educational materials, particularly materials that are balanced in terms of the benefits and risks of screening.

Men's reactions to disclosed and undisclosed opportunistic PSA screening for prostate cancer

OBJECTIVE

To assess the degree to which men considered it appropriate for general practitioners to order prostate-specific antigen (PSA) testing if the testing was either "disclosed" or "undisclosed" to the patient.

DESIGN

Telephone-administered survey conducted in June to October 2000.

PARTICIPANTS

514 men aged 50-70 years, identified by random selection of households from the Sydney Electronic White Pages phone directory.

METHODS

We developed two hypothetical scenarios. Each scenario described a GP ordering a PSA test for a male patient at the same time as other pathology tests were ordered. In Scenario 1, the GP's intention to order a PSA test was disclosed to the patient ("disclosed"). In Scenario 2, the GP did not tell the patient a PSA test was being ordered ("undisclosed"). For each scenario, men reported the degree to which they perceived screening to be "appropriate". We also recorded demographic characteristics, health status and health locus of control, and administered a 14-question knowledge test about prostate cancer and PSA screening.

RESULTS

Over 90% of men stated that "disclosed" PSA screening was either "appropriate" or "very appropriate". Significantly fewer (44.9%) rated "undisclosed" screening as appropriate/very appropriate (P < 0.001). While the skewed distribution of responses to Scenario 1 precluded multivariate analysis to determine predictors, men rejecting "undisclosed" PSA screening (Scenario 2) were more likely to be younger (adjusted odds ratio [AOR], 0.97; 95% CI, 0.94-1.00; P = 0.03); to have better knowledge of the issues (AOR, 1.01; 95% CI, 1.00-1.03; P = 0.02); and to be single (AOR, 0.62; 95% CI, 0.41-0.94; P = 0.02).

CONCLUSIONS

Many men consider that inclusion of PSA screening within a battery of pathology tests without disclosure to the patient is unacceptable. Educating men about the pros and cons of screening may alter their support of opportunistic screening and thus enhance community expectations of "informed participation".

Is screening for abdominal aortic aneurysm bad for your health and well-being?

BACKGROUND

The purpose of the present paper was to investigate whether screening for abdominal aortic aneurysm (AAA) causes health-related quality of life to change in men or their partners.

METHODS

A cross-sectional case-control comparison was undertaken of men aged 65-83 years living in Perth, Western Australia, using questionnaires incorporating three validated instruments (Medical Outcomes Study Short Form-36, EuroQol EQ-5D and Hospital Anxiety and Depression Scale) as well as several independent questions about quality of life. The 2009 men who attended for ultrasound scans of the abdominal aorta completed a short prescreening questionnaire about their perception of their general health. Four hundred and ninety-eight men (157 with an AAA and 341 with a normal aorta) were sent two questionnaires for completion 12 months after screening, one for themselves and one for their partner, each being about the quality of life of the respondent.

RESULTS

Men with an AAA were more limited in performing physical activities than those with a normal aorta (t-test of means P = 0.04). After screening, men with an AAA were significantly less likely to have current pain or discomfort than those with a normal aorta (multivariate odds ratio: 0.5; 95% confidence interval (CI): 0.3-0.9) and reported fewer visits to their doctor. The mean level of self-perceived general health increased for all men from before to after screening (from 63.4 to 65.4).

CONCLUSIONS

Apart from physical functioning, screening was not associated with decreases in health and well-being. A high proportion of men rated their health over the year after screening as being either the same or improved, regardless of whether or not they were found to have an AAA.

Effects of False-Positive Prostate Cancer Screening Results on Subsequent Prostate Cancer Screening Behavior

Objectives: Little is known about screening behavior following a false-positive prostate cancer screening result, which we have defined as a screening result with “abnormal/suspicious” labeling that did not result in a prostate cancer diagnosis within 14 months. The purpose of this analysis was to examine whether age, race, education, or previous false-positive prostate cancer screening results via prostate-specific antigen or digital rectal exam predict decision to obtain subsequent prostate cancer screening.

Methods: Data were drawn from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. The study sample consisted of 2,290 older men (mean age, 62.8 years; range, 55-75 years) who had false-positive (n = 318) or negative (n = 1,972) prostate-specific antigen or digital rectal exam baseline prostate cancer screening results. Multivariable logistic regression was used to assess the effect of false-positive results on subsequent prostate cancer screening behavior, adjusting for all covariates.

Results: The multivariable model showed that being African American (P = 0.016), and having a high school education or less (P = 0.007), having a previous false-positive prostate cancer screening result (P &lt; 0.001), were predictive of not returning for prostate cancer screening in the following screening trial year.

Conclusion: The study results highlight the importance of shared decision making between patients and their providers regarding the risks and benefits of prostate cancer screening, and follow-up options for abnormal prostate cancer screening results. Shared decision making may be especially important for African American men, whom prostate cancer disproportionately affects.

The Economic Impact of False-Positive Cancer Screens

Objective: Despite the promotion and widespread use of routine cancer screening, little is known about the economic consequences of false-positive screening results. We evaluated the medical and nonmedical costs associated with false-positive prostate, lung, colorectal, and ovarian cancer screens.

Method: We identified 1,087 Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial participants enrolled in a large managed care organization. Medical care use and costs were compiled from automated sources and trial data. Nonmedical care costs to patients with a false-positive lung cancer screen were obtained by telephone interview (n = 98).

Results: Forty-three percent of the study sample incurred at least one false-positive cancer screen. The majority of these patients (83%) received follow-up care. Prior to and after controlling for participant characteristics, significantly higher medical care expenditures in the year following screening were found among those with a false-positive screen. The adjusted mean difference was $1,024 for women and $1,171 for men. Among lung cancer screening patients, few nonmedical care costs were identified beyond the time (mean, 1.5 hours) spent receiving care.

Conclusion: The results here indicate that false-positive results among some available cancer screening tests are relatively common, that patients incurring a false-positive screen tend to receive follow-up testing, and that such follow-up is not without associated medical costs. Along with trials evaluating the health benefits of available cancer screening modalities, investigations into potential undesirable consequences of cancer screening are also warranted.

Knowledge of the Limitations Associated With Prostate Cancer Screening Among Low-income Men

This correlational pilot study measured limitations of prostate cancer screening, using a revised Knowledge of Prostate Cancer Questionnaire. Knowledge in 81 low-income men is reported. The Knowledge About Prostate Cancer Screening Questionnaire consists of 12 questions, with scores ranging from 0 to 12. Concepts measured include limitations, symptoms, risk factors, and screening age guidelines. The Total Knowledge Score had a mean of 6.60, with a standard deviation of 3.00, indicating that knowledge was low. Half of the men knew that "some treatments for prostate cancer can make it harder for men to control their urine." More than half of the men knew that, "some treatments for prostate cancer can cause problems with a man's ability to have sex." Married men, low-income men, and Caucasian men had significantly lower Total Knowledge Scores than unmarried, higher income, and African American men. Implications for practice and research are discussed.