Primary care physicians' use of an informed decision-making process for prostate cancer screening

Do health professionals know about overdiagnosis in screening, and how are they dealing with it? A mixed-methods systematic scoping review

INTRODUCTION

Medical screening is a major driver of overdiagnosis, which should be considered when making an informed screening decision. Health professionals (HPs) often initiate screening and are therefore responsible for informing eligible screening participants about the benefits and harms of screening. However, little is known about HPs' knowledge of overdiagnosis and whether they are prepared to inform screening candidates about this risk and enable people to make an informed screening decision.

METHODS

This is a systematic review of studies examining HPs' knowledge and perception of overdiagnosis, whether it affects their position on offering screening, and their willingness to inform screening candidates about overdiagnosis. We conducted systematic searches in MEDLINE, Embase, Web of Science, Scopus, CINAHL, and PsycArticles without language restrictions. Two authors analysed the qualitative and quantitative data separately. Confidence in the findings of the qualitative data was assessed using the GRADE-CERQual approach.

RESULTS

We included 23 publications after screening 9786 records. No studies directly examined HPs' knowledge of overdiagnosis. HPs' perceptions of overdiagnosis varied widely, from considering it a significant harm to seeing it as negligible. This seems linked to their overall beliefs about the benefits and harms of screening and to their position on offering screening, which varies from discouraging to actively promoting it. HPs also hold diverging approaches to informing screening candidates about overdiagnosis, from providing detailed explanations to limited or no information.

CONCLUSION

There is a lack of research on HPs' knowledge of overdiagnosis, however, HPs who do know about overdiagnosis attribute substantially different levels of harm to it. This seems intertwined with their overall beliefs about the benefits of screening, their position towards offering screening, and their willingness to inform screening candidates about overdiagnosis. This has important implications for the public's right to evidence-based information and compromises an individual's right to make an informed screening decision.

Shared medical decision in prostate cancer screening in primary care: a systematic literature review of current evidence

PURPOSE

Prostate cancer screening has not significantly reduced mortality. International guidelines strongly endorse shared decision-making to navigate risks, emphasizing its crucial role prior to prescribing a prostate-specific antigen test. This study aims to provide insight into the current role of shared decision-making in primary care for prostate cancer screening and suggest ways to improve the process.

METHODS

PubMed, Cochrane, and Lissa databases were searched for following terms: 'prostate-specific antigen' or 'prostate cancer screening' combined with 'shared decision making', 'informed decision making' or 'decision support' and 'primary care'. All studies were screened by two independent reviewers. This systematic review followed the PRISMA guidelines.

RESULTS

Of 85 articles screened, 34 were included. Key findings included heterogenous and poor quality implementation of shared decision-making in practice, patients with limited knowledge of shared decision-making, clinicians infrequently discussing patients' views, decision aids that could be better integrated into practice, and finally, changes in care systems to support the expansion of shared decision-making in prostate cancer screening.

CONCLUSION

Decision aids are essential tools in the informed decision-making process. Integrating these elements into practice would require training for doctors and adjustments to the healthcare system.

A Provider-Facing Decision Support Tool for Prostate Cancer Screening in Primary Care: A Pilot Study

OBJECTIVES

 Our objective was to pilot test an electronic health record-embedded decision support tool to facilitate prostate-specific antigen (PSA) screening discussions in the primary care setting.

METHODS

 We pilot-tested a novel decision support tool that was used by 10 primary care physicians (PCPs) for 6 months, followed by a survey. The tool comprised (1) a risk-stratified algorithm, (2) a tool for facilitating shared decision-making (Simple Schema), (3) three best practice advisories (BPAs: <45, 45-75, and >75 years), and (4) a health maintenance module for scheduling automated reminders about PSA rescreening.

RESULTS

 All PCPs found the tool feasible, acceptable, and clear to use. Eight out of ten PCPs reported that the tool made PSA screening conversations somewhat or much easier. Before using the tool, 70% of PCPs felt confident in their ability to discuss PSA screening with their patient, and this improved to 100% after the tool was used by PCPs for 6 months. PCPs found the BPAs for eligible (45-75 years) and older men (>75 years) more useful than the BPA for younger men (<45 years). Among the 10 PCPs, 60% found the Simple Schema to be very useful, and 50% found the health maintenance module to be extremely or very useful. Most PCPs reported the components of the tool to be at least somewhat useful, with 10% finding them to be very burdensome.

CONCLUSION

 We demonstrated the feasibility and acceptability of the tool, which is notable given the marked low acceptance of existing tools. All PCPs reported that they would consider continuing to use the tool in their clinic and were likely or very likely to recommend the tool to a colleague.

Provider Perceptions of an Electronic Health Record Prostate Cancer Screening Tool

OBJECTIVES

 We conducted a focus group to assess the attitudes of primary care physicians (PCPs) toward prostate-specific antigen (PSA)-screening algorithms, perceptions of using decision support tools, and features that would make such tools feasible to implement.

METHODS

 A multidisciplinary team (primary care, urology, behavioral sciences, bioinformatics) developed the decision support tool that was presented to a focus group of 10 PCPs who also filled out a survey. Notes and audio-recorded transcripts were analyzed using Thematic Content Analysis.

RESULTS

 The survey showed that PCPs followed different guidelines. In total, 7/10 PCPs agreed that engaging in shared decision-making about PSA screening was burdensome. The majority (9/10) had never used a decision aid for PSA screening. Although 70% of PCPs felt confident about their ability to discuss PSA screening, 90% still felt a need for a provider-facing platform to assist in these discussions. Three major themes emerged: (1) confirmatory reactions regarding the importance, innovation, and unmet need for a decision support tool embedded in the electronic health record; (2) issues around implementation and application of the tool in clinic workflow and PCPs' own clinical bias; and (3) attitudes/reflections regarding discrepant recommendations from various guideline groups that cause confusion.

CONCLUSION

 There was overwhelmingly positive support for the need for a provider-facing decision support tool to assist with PSA-screening decisions in the primary care setting. PCPs appreciated that the tool would allow flexibility for clinical judgment and documentation of shared decision-making. Incorporation of suggestions from this focus group into a second version of the tool will be used in subsequent pilot testing.

Urologists' and general practitioners' knowledge, beliefs and practice relevant for opportunistic prostate cancer screening: a PRISMA-compliant systematic review

Background

Recent guidelines on opportunistic prostate cancer screening conclude that the decision to screen with prostate-specific antigen should be made by each patient individually together with the clinician. However, there is evidence of a lack of clinicians' awareness of prostate cancer screening. This study sought to assess the recent evidence of clinicians' knowledge, beliefs, and practice regarding opportunistic prostate cancer screening comparing urologists and generals practitioners.

Methods

A systematic search was conducted in 3 online databases: MEDLINE, Web of Science and EMBASE (from January 1, 2015, to January 9th, 2023). Studies that explored clinicians' knowledge, beliefs, and practices regarding opportunistic prostate cancer screening were included. Studies were assessed for quality reporting according to the Strengthening the Reporting of Observational studies in Epidemiology guidelines.

Results

A total of 14 studies met the inclusion criteria: ten studies included primary care health professionals, three studies included urologists, and one study included both. Studies involving general practitioners showed a generally low level of awareness of the recommended uses of the test, and urologists showed a greater knowledge of clinical practice guidelines. General practitioners' opinion of prostate-specific antigen was generally unfavourable in contrast to urologists' who were more likely to be proactive in ordering the test. Less than half of the included studies evaluated shared-decision making in practice and 50% of clinicians surveyed implemented it.

Conclusion

General practitioners had less knowledge of prostate cancer risk factors and clinical practice guidelines in the use of PSA than urologists, which makes them less likely to follow available recommendations. A need to carry out education interventions with trusted resources based on the available evidence and the current guidelines was identified.

Barriers and facilitators of shared decision-making in prostate cancer screening in primary care: A systematic review

Objective

To identify barriers and facilitators of the implementation of shared decision-making (SDM) on PSA testing in primary care.

Design

Systematic review of articles.

Data sources

PubMed, Scopus, Embase and Web of Science.

Eligibility criteria

Original studies published in English or Spanish that assessed the barriers to and facilitators of SDM before PSA testing in primary care were included. No time restrictions were applied.

Data extraction and synthesis

Two review authors screened the titles, abstracts and full texts for inclusion, and assessed the quality of the included studies. A thematic synthesis of the results were performed and developed a framework. Quality assessment of the studies was based on three checklists: STROBE for quantitative cross-sectional studies, GUIDED for intervention studies and SRQR for qualitative studies.

Results

The search returned 431 articles, of which we included 13: five cross-sectional studies, two intervention studies, five qualitative studies and one mixed methods study. The identified barriers included lack of time (healthcare professionals), lack of knowledge (healthcare professionals and patients), and preestablished beliefs (patients). The identified facilitators included decision-making training for professionals, education for patients and healthcare professionals, and dissemination of information.

Conclusions

SDM implementation in primary care seems to be a recent field. Many of the barriers identified are modifiable, and the facilitators can be leveraged to strengthen the implementation of SDM.

Ethnic Differences Among Black Men in Prostate Cancer Knowledge and Screening: a Mixed-Methods Study

Black men are disproportionately affected by prostate cancer (PCa) incidence and mortality. Limited research has been reported on the ethnic differences among Black men in regard to family history, knowledge, and screening habits. Thus, this study was conducted to understand and compare knowledge levels and family history of the three main Black subgroups (African Americans, Caribbean immigrants, and African immigrants) in the USA and to assess the influence of knowledge on past screening behavior and intentionality for screening in the future for PCa. A concurrent mixed-methods design was used with participants (N = 396) recruited from different parts of the country. The grounded theory method of analysis was used for qualitative data and a logistic regression was used to explain the relationship between screening intentionality and PCa knowledge and family history. Qualitative results indicated that subjective PCa knowledge between the three subgroups was relatively similar but differed based on whether a person knew a family member or friend who had been affected by the disease. Themes focused on risk, PCa education, screening, and impact on sexuality. Quantitatively, result revealed that there are ethnic differences in knowledge across the three subgroups. Additionally, regression results revealed that family history is a stronger predictor of screening behavior and intentionality than knowledge. This study was able to unveil a deeper understanding on the role of family history and knowledge on PCa among Black subgroups.

How Much Information Do Icelandic Men Receive on Pros and Cons of Prostate-Specific Antigen Testing Prior to Undergoing Testing?

Prostate-specific antigen (PSA) testing for asymptomatic men is neither encouraged nor discouraged in most countries; however, shared decision-making is emphasized prior to PSA testing. The objective of this study was to examine to what extent Icelandic men receive information about the pros and cons of PSA testing. Furthermore, to explore if patient–provider communication about pros and cons of PSA testing has improved in the last decade during which time more emphasis has been placed on shared decision-making. All Icelandic men diagnosed with prostate cancer in the years 2015 to 2020 were invited to participate, and a total of 471 out of 1002 men participated (response rate 47.0%). Participants’ age ranged from 51 to 95 years (M = 71.9, SD = 7.3). Only half of the men received information about the pros and cons of PSA testing, a third did not receive any information prior to testing and, alarmingly, 22.2% of the men did not even know that they were being tested. A majority of the participants lacked knowledge about the testing with half of the men reporting that they had no knowledge about pros and cons of PSA testing prior to testing. The findings have major public health relevance as they indicate that information provided prior to PSA testing continue to be deficient and that there is a pressing need for interventions that educate men about the benefits and limitations of PSA testing before men undergo medical procedures that can seriously affect their quality of life.

Examination of prostate-specific antigen (PSA) screening in military and civilian men: analysis of the 2018 behavioral risk factor surveillance system

PURPOSE

To determine whether military men report different prostate-specific antigen (PSA) screening rates than civilian men and if shared decision-making (SDM) is associated with PSA screening.

METHODS

We used data from the 2018 Behavioral Risk Factor Surveillance System and included 101,901 men (26,363 military and 75,538 civilian men) in the analysis conducted in 2021. We conducted binomial logistic regression analyses to determine covariate-adjusted associations between military status and receiving a PSA test in the last 2 years. We then added patient reports of SDM to the model. Finally, we looked at the joint effects of military status and SDM on the receipt of a PSA test in the last 2 years.

RESULTS

Military men had 1.1 times the odds of PSA testing compared to civilian men (95% CI 1.1, 1.2) after adjusting for SDM and sociodemographic and health covariates. When examining the joint effect of military status and SDM, military and civilian men had over three times the odds of receiving a PSA test in the last 2 years if they had reported SDM (OR 3.5 and OR 3.4, respectively) compared to civilian men who did not experience SDM.

CONCLUSION

Military men are slightly more likely to report receiving a PSA test in the last 2 years compared to civilian men. Additionally, results show SDM plays a role in the receipt of a PSA test in both populations. These findings can serve as a foundation for tailored interventions to promote appropriate SDM for PSA screening in civilian, active duty, and veteran healthcare systems.

Healthcare professionals' behaviour regarding the implementation of shared decision-making in screening programmes: A systematic review

OBJECTIVE

To explore the barriers to and facilitators of healthcare professionals' implementation of SDM regarding screening programmes.

METHOD

A systematic review was conducted in PubMed, Cochrane Library, CINHAL, and PsyscInfo. The barriers and facilitators identified were classified into three factors based on their origin: patients, healthcare system performance, and healthcare professionals themselves.

RESULTS

Eight studies were selected: seven related to cancer screening. The most significant facilitators were literacy and interest in active participation, both of which have their origins in patients. The most significant barriers identified for the first time in a systematic review were legal conflict, lack of remuneration and lack of flexibility in clinical guidelines in screening programmes.

CONCLUSION

The results of this study show that there are differences between barriers and facilitators for SDM when it is applied in the context of healthy people who perform preventive activities, particularly screening, in contrast to general medical consultation contexts.

PRACTICAL IMPLICATIONS

The authors suggest that to advance in the practice of SDM, we need to develop and disseminate training documents. Further, SDM should be incorporated into clinical guidelines. There should be more studies focusing on healthcare professionals' behaviour within the context of the uncertainty of screening programmes.

Exploring Prostate Cancer Patients' Interest and Preferences for Receiving Genetic Risk Information About Cancer Aggressiveness

The number of cases of aggressive prostate cancer is increasing. Differentiating between aggressive and indolent cases has resulted in increased difficulty for the physician and patient to decide on the best treatment option. Due to this challenge, efforts are underway to profile genetic risk for prostate cancer aggressiveness, which may help physicians and patients at risk for developing aggressive prostate cancer to select an appropriate treatment option. This study explores patients’ interest in receiving genetic results, preference for how genetic risk information should be communicated, and willingness to share results with adult male first-degree relatives (FDRs). A nine-item survey was adapted to assess their beliefs and attitudes about genetic testing for prostate cancer aggressiveness. In addition, participants (n = 50) responded to hypothetical scenarios and questions associated with perceived importance of risk disclosure, preferences for receiving genetic risk information, and sharing of results with FDRs. As the hypothetical risk estimate for aggressive prostate cancer increased, patients’ willingness to receive genetic risk information increased. This study found that most patients preferred receiving genetic risk education in the form of a DVD (76%), one-page informational sheet (75%), or educational booklet (70%). Almost all patients (98%) reported that they would be willing to share their test results with FDRs. The results of this study highlight prostate cancer patients’ desire to receive and share genetic risk information. Future research should focus on assessing the long-term benefits of receiving genetic information for prostate cancer patients and implications of sharing this information with FDRs.

Does shared decision making increase prostate screening uptake in countries with a low prevalence of prostate cancer?

BACKGROUND

Men over 50 should discuss the benefits and harms of prostate-specific antigen (PSA) testing with their doctors.

OBJECTIVES

To investigate whether shared decision making (SDM) increases the uptake of prostate cancer screening practices among Saudi men.

METHODS

This community-based study recruited men aged ≥ 50 years between January and April 2019. Sociodemographic characteristics, history, and current medical condition information were collected. SDM information with regards to prostate cancer screening was discussed.

RESULTS

In total, 2034 Saudi men, aged between 50 and 88 years, agreed to participate in the current study. Prostate examination for early detection of cancer was recommended for 35.4% (720) of subjects. Of the subjects, 23.3% (473) reported that the physicians discussed the advantages and benefits of PSA testing, whereas only 5.6% (114) stated that the physicians explained the disadvantages and drawbacks of PSA testing.

CONCLUSION

Our findings suggest that less than one fourth discussed the advantages and disadvantages of PSA testing with their physicians; of these, less than one third underwent PSA blood tests. Improvements are needed in SDM for and against PSA screening. SDM does not affect the intensity of PSA testing. Primary health care physicians should be actively involved in the SDM process.

Associations of Prostate-Specific Antigen (PSA) Testing in the US Population: Results from a National Cross-Sectional Survey

Prostate-specific antigen (PSA) testing is one of the standard screening methods for prostate cancer (PC); however, a high proportion of men with abnormal PSA findings lack evidence for PC and may undergo unnecessary treatment. Furthermore, little is known about the prevalence of PSA testing for US men, after the US Preventive Services Task Force (USPSTF) recommended against routine PSA screening in 2012. Our objectives were to: (1) examine the self-reported patterns of PSA testing following a change in the USPSTF prostate cancer screening recommendations and (2) to determine the associated socio-demographic factors. Data were from the 2010 and 2015 National Health Interview Surveys. Men were ages ≥ 40 years and responded to the question "Ever had a PSA test?". Multivariable logistic regression was used to examine PSA testing prevalence in 2010 and 2015, and their associated socio-demographic factors. The analytic sample contained 15,372 men. A majority (75.2%) identified as non-Hispanic (NHW) and 14.2% were foreign-born. Those surveyed in 2015 were less likely to report ever having had a PSA test when compared to those in 2010. Compared to US-born and older NHW men, PSA testing was statistically significantly lower among foreign-born men and men belonging to all other racial categories. Fewer men reported PSA testing following the USPSTF 2012 recommendations. Associated socio-demographic factors included nativity, age, race/ethnicity, educational attainment and type of health insurance. Further studies are required to elucidate our findings and their health implications for the US native and foreign-born population.

Exnovation of Low Value Care: A Decade of Prostate-Specific Antigen Screening Practices

OBJECTIVES

To examine prostate-specific antigen (PSA) screening practice change in subgroups of men defined in guidelines and in various regions and to identify factors associated with change in screening practices.

DESIGN

Observational study using serial cross-sections, 2003 to 2013.

SETTING

National fee-for-service Medicare.

PARTICIPANTS

Men aged 68 and older eligible for prostate cancer screening.

MEASUREMENTS

National PSA screening practices in men aged 68 and older from 2003 to 2013 and change in regional screening rates in men aged 75 and older.

RESULTS

The PSA screening rate in men aged 68 and older was 17.2% in 2003, 22.3% in 2008, and 18.6% in 2013 (p < .001 for all differences); rates ended slightly lower than rates in 2003 only in men 80 and older. Racial disparities in screening became less pronounced over this period. In men aged 75 and older, change in regional screening rates varied widely, with absolute rates growing by 15 per 100 enrollees in some areas and declining by the same amount in others. Areas with high social capital, a measure associated with diffusion of new ideas, were more likely to decline; malpractice intensity and managed care penetration had no effect.

CONCLUSION

Studying Medicare enrollees over time, we found little reduction in PSA screening and even increases according to race and in some regions. The heterogeneous changes across regions suggest that consistent reduction in the use of low-value care may require change strategies that go beyond evidence and guidelines to include monitoring and feedback on performance. J Am Geriatr Soc 67:29-36, 2019.

Talking About Your Prostate: Perspectives from Providers and Community Members

Prostate cancer (PrCA) screening is controversial, especially for African-American (AA) men who have higher PrCA incidence and mortality than other racial/ethnic groups. Patient-provider communication is important for the PrCA screening decision process. The study purpose was to better understand the current dialogue between primary care providers (PCPs-physicians and nurse practitioners) and AA men about PrCA prevention and screening. An online survey with 46 PCPs, education sessions (including pre/post surveys) with 56 AA men, and a forum with 5 panelists and 38 AA men for open dialogue were held to examine both provider and community perspectives on PrCA communication needs and practices. PCPs' perceptions of PrCA screening were varied and they used different PrCA screening guidelines in their practices. PCPs and AA men had different experiences with PrCA communication. PCPs reported that they have discussions about PrCA screening and prostate health with AA patients; few AA men reported these same experiences. About 38.0% of PCPs reported that they remain neutral about PSA testing during discussions; however, only 10.7% of AA men reported that their doctor remained neutral. Prostate health knowledge among AA men increased significantly following participation in the education sessions (p < 0.001). AA community members reported high satisfaction regarding the education session and forum. Different recommendations from PCPs may hinder AA men's decisions about PrCA screening. The forum used in this study could be a model for others to help improve patient-provider communication and increase engagement in dialogue about this common cancer.

Primary care perspective and implementation of a multidisciplinary, institutional prostate cancer screening algorithm embedded in the electronic health record

PURPOSE

In response to controversy regarding prostate cancer (CaP) screening recommendations, a consolidated Duke Cancer Institute (DCI) multidisciplinary algorithm for CaP screening was developed and implemented. We conducted an online survey within the year following its implementation to assess primary care provider (PCP) attitudes and adoption as well as to evaluate how this program affects screening rates.

METHODS

A web-based 18-item survey was programmed and was electronically mailed to practicing PCPs at clinics affiliated with the Duke Primary Care system. The survey assessed provider practices and attitudes regarding CaP screening, factors that influenced their general screening recommendations and the confidence related to communicating with patients about screening. The rate of PSA screening before and after implementation of the algorithm was reported across age and race categories.

RESULTS

In sum, 94 of 106 respondents (88.6%) reported discussing the benefits and harms of screening and let their patients decide (52.8%) or recommended for (31.1%) or against (4.7%) screening. Three-fourths of respondents followed a specific panel recommendation such as the United States Preventative Services Task Force (USPSTF) (48.1%), DCI (20%), or the American Urological Association (AUA) (7.4%) guidelines. After integrating this algorithm into the electronic health record, the rate of prostate screening increased between 11% and 20.4% and 15.6% and 16.4% among different age and race categories, respectively. Overall, 79.2% of PCPs felt very confident regarding their ability to communicate the topic of CaP screening with patients.

CONCLUSION

The DCI multidisciplinary CaP screening algorithm was well adopted among PCPs shortly after its implementation. The rate of screening increased among all age and race categories thereafter. The majority of PCPs involved in this survey felt confident regarding their CaP screening knowledge and most discuss this topic with patients in a shared decision-making model.

Primary Care Physicians Beliefs about Prostate-Specific Antigen Evidence Uncertainty, Screening Efficacy, and Test Use

BACKGROUND/PURPOSE

Little is known about primary care physicians' (PCPs) beliefs about prostate cancer screening efficacy, evidence uncertainty, and their actual screening behaviors. We examined factors associated with PCP beliefs about screening efficacy and uncertainty and whether beliefs were associated with prostate specific-antigen (PSA) test use.

METHODS

The 2008 National Survey of Primary Care Physicians' Practices Regarding Prostate Cancer Screening collected information on physicians' attitudes, beliefs, and practices related to prostate cancer and screening (n=1,256). Two factors were constructed that measured belief in certainty of evidence for PSA testing and belief in screening efficacy. These factors, along with PCP sociodemographic and practice-related factors, were used to examine associations with offering the PSA test.

RESULTS

Most PCPs were male (70%), Caucasian (76%), under age 50 (56%), and practiced in communities with more than 50,000 residents (54%). In bivariate analysis, variables associated with PCP belief in evidence uncertainty included female gender, younger age, and lower patient volume. Variables associated with belief in screening efficacy included older age and general and family practice specialty. After adjustment, PCPs with high belief in evidence uncertainty were less likely (OR=0.19, 95% CI=0.06, 0.62) to offer PSA and more likely to practice shared decision making (OR=1.80, 95% CI=1.22-2.67). PCPs with high belief in screening efficacy were more likely (OR=2.99, 95% CI=1.15, 7.77) to offer PSA and less likely to practice shared decision making (OR=0.47, 95% CI=0.32-0.70).

CONCLUSION

Our data indicate that belief patterns about evidence uncertainty and the efficacy of using PSA may play a role in whether PCPs offer PSA.

Perceptions about screening for prostate cancer using genetic lifetime risk assessment: a qualitative study

Background

Most health authorities do not recommend screening for prostate cancer with PSA tests in asymptomatic patients who are not at increased risk. However, opportunistic screening for prostate cancer is still wanted by many patients and it is widely used in primary care clinics, with potential for overdiagnosis and overtreatment. Better tools for risk assessment have been called for, to better target such opportunistic screening. Our aim was to explore perceptions about prostate cancer risk and subsequent opportunistic screening among patients who were not at increased risk of prostate cancer after a first PSA test plus a genetic lifetime risk assessment.

Methods

We undertook semi-structured patient interviews with recording and verbatim transcription of interviews. Data were analysed thematically.

Results

Three themes were identified: uncertainty of the nature of prostate cancer; perceived benefits of testing; and conflicting public health recommendations. Prostate cancer was spoken of as an inescapable risk in older age. The aphorism “you die with it, not from it” was prominent in the interviews but patients focused on the benefits of testing now rather than the future risks associated with treatment relating to potential overdiagnosis. Many expressed frustration with perceived mixed messages about early detection of cancer, in which on one side men feel that they are encouraged to seek medical testing to act responsibly regarding the most common cancer disease in men, and on the other side they are asked to refrain from opportunistic testing for prostate cancer. Taken together, personal risks of prostate cancer were perceived as high in spite of a normal PSA test and a genetic lifetime risk assessment showing no increased risk.

Conclusion

Patients saw prostate cancer risk as high and increasing with age. They focused on the perceived benefit of early detection using PSA testing. It was also commonly acknowledged that most cases are indolent causing no symptoms and not shortening life expectancy. There was a frustration with mixed messages about the benefit of early detection and risk of overdiagnosis. These men’s genetic lifetime risk assessment showing no increased risk did not appear to influence current intentions to get PSA testing in the future.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0717-6) contains supplementary material, which is available to authorized users.

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.

Prostate cancer screening among family physicians in Ontario: An update on attitudes and current practice

INTRODUCTION

This study serves as an update of prostate cancer screening practices among family physicians in Ontario, Canada. Since this population was first surveyed in 2010, the Canadian Task Force on Preventive Health Care (CTFPHC) and the United States Preventive Services Task Force (USPSTF) released recommendations against prostate cancer screening.

METHODS

An online survey was developed through input from urologists and family practitioners. It was distributed via email to all members of the Ontario Medical Association's Section on General and Family practice (11 657 family physicians). A reminder email was sent at two weeks and the survey remained active for one month.

RESULTS

A total of 1880 family physicians completed surveys (response rate 16.1%). Overall, 80.4% offered prostate cancer screening compared to 91.7% when surveyed in 2010. Physicians new to practice (two years or less) were the most likely to not offer screening (24.6%). A combination of digital rectal exam (DRE) and prostate-specific antigen (PSA) remained the most common form of screening (58.3%). Following the release of the CTFPHC recommendations, 45.6% of respondents said they now screen fewer patients. Participants were less familiar with national urological society guidelines compared to task force recommendations. The majority (72.6%) of respondents feel PSA screening leads to overdiagnosis and treatment. Those surveyed remained split with respect to PSA utility.

CONCLUSIONS

Data suggest a decline in screening practices since 2010, with newer graduates less likely to offer screening. CFTPHC and USPSTF recommendations had the greatest impact on clinical practice. Those surveyed were divided with respect to PSA utility. Some additional considerations to PSA screening in the primary care setting, including patient-driven factors, were not captured by our concise survey.

Patient and provider perspectives on shared decision making: a systematic review of the peer-reviewed literature

For comparative effectiveness research to be effective, patients and providers must collaborate in shared decision making (SDM) to make evidence-based clinical decisions that align with patient preferences. We conducted a systematic review to examine patient and provider attitudes toward and engagement in SDM in the USA. Searches in PubMed and PsycINFO identified 1585 articles published between July 2006 and December 2016, of which 290 were screened in for coding and analysis. We found that patients and providers have generally positive attitudes toward SDM, but actual engagement in SDM behavior is lagging. Translation of positive attitudes into behavior could be achieved through policies that support key SDM processes of sharing evidence, considering patient preferences and discussing the relative advantages of different clinical options.

Prostate-specific antigen screening: An update of physician beliefs and practices

PSA testing for early detection of prostate cancer decreased dramatically following the 2012 PSA screening recommendation against routine screening of asymptomatic men. In an assessment of the screening behaviors of primary care providers, the majority (61%) of family medicine and internal medicine practitioners who responded to a 2016 DocStyles online survey (608 of 1003) recommended prostate-specific antigen (PSA) testing based on individual risk or other factors, rather than routinely screening all men for prostate cancer.

The effect of the USPSTF PSA screening recommendation on prostate cancer incidence patterns in the USA

Guidelines regarding recommendations for PSA screening for early detection of prostate cancer are conflicting. In 2012, the United States Preventive Services Task Force (USPSTF) assigned a grade of D (recommending against screening) for men aged ≥75 years in 2008 and for men of all ages in 2012. Understanding temporal trends in rates of screening before and after the 2012 recommendation in terms of usage patterns in PSA screening, changes in prostate cancer incidence and biopsy patterns, and how the recommendation has influenced physician's and men's attitudes about PSA screening and subsequent ordering of other screening tests is essential within the scope of prostate cancer screening policy. Since the 2012 recommendation, rates of PSA screening decreased by 3-10% in all age groups and across most geographical regions of the USA. Rates of prostate biopsy and prostate cancer incidence have declined in unison, with a shift towards tumours being of higher grade and stage upon detection. Despite the recommendation, some physicians report ongoing willingness to screen appropriately selected men, and many men report intending to continue to ask for the PSA test from their physician. In the coming years, we expect to have an improved understanding of whether these decreased rates of screening will affect prostate cancer metastasis and mortality.

Patient-Provider Communication About Prostate Cancer Screening and Treatment: New Evidence From the Health Information National Trends Survey

The American Urological Association, American Cancer Society, and American College of Physicians recommend that patients and providers make a shared decision with respect to prostate-specific antigen (PSA) testing for prostate cancer (PCa). The goal of this study is to determine the extent of patient-provider communication for PSA testing and treatment of PCa and to examine the patient specific factors associated with this communication. Using recent data from the Health Information National Trends Survey, this study examined the association of patient characteristics with four domains of patient-provider communication regarding PSA test and PCa treatment: (1) expert opinion of PSA test, (2) accuracy of PSA test, (3) side effects of PCa treatment, and (4) treatment need of PCa. The current results suggested low level of communication for PSA testing and treatment of PCa across four domains. Less than 10% of the respondents report having communication about all four domains. Patient characteristics like recent medical check-up, regular healthcare provider, global health status, age group, marital status, race, annual household income, and already having undergone a PSA test are associated with patient-provider communication. There are few discussions about PSA testing and PCa treatment options between healthcare providers and their patients, which limits the shared decision-making process for PCa screening and treatment as recommended by the current best practice guidelines. This study helps identify implications for changes in physician practice to adhere with the PSA screening guidelines.

Do Men Receive Information Required for Shared Decision Making About PSA Testing? Results from a National Survey

Most professional organizations, including the American College of Physicians and U.S. Preventive Services Task Force, emphasize that screening for prostate cancer with the prostate-specific antigen (PSA) test should only occur after a detailed discussion between the health-care provider and patient about the known risks and potential benefits of the test. In fact, guidelines strongly advise health-care providers to involve patients, particularly those at elevated risk of prostate cancer, in a "shared decision making" (SDM) process about PSA testing. We analyzed data from the National Cancer Institute's Health Information National Trends Survey 2011-2012-a nationally representative, cross-sectional survey-to examine the extent to which health professionals provided men with information critical to SDM prior to PSA testing, including (1) that patients had a choice about whether or not to undergo PSA testing, (2) that not all doctors recommend PSA testing, and (3) that no one is sure if PSA testing saves lives. Over half (55 %) of men between the ages of 50 and 74 reported ever having had a PSA test. However, only 10 % of men, regardless of screening status, reported receiving all three pieces of information: 55 % reported being informed that they could choose whether or not to undergo testing, 22 % reported being informed that some doctors recommend PSA testing and others do not, and 14 % reported being informed that no one is sure if PSA testing actually saves lives. Black men and men with lower levels of education were less likely to be provided this information. There is a need to improve patient-provider communication about the uncertainties associated with the PSA test. Interventions directed at patients, providers, and practice settings should be considered.

Testing and referral patterns in the years surrounding the US Preventive Services Task Force recommendation against prostate-specific antigen screening

BACKGROUND

Since the US Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA) screening, there have been conflicting reports regarding the impact on the behavior of providers. This study analyzed real-world data on PSA ordering and referral practices in the years surrounding the recommendation.

METHODS

A whole-institution sample of entered PSA orders and urology referrals was obtained from the electronic medical record. The study was performed at a tertiary referral center with a catchment in the southern United States. PSA examinations were defined as screening when they were ordered by providers with appointments in internal medicine, family medicine, or general internal medicine. Linear and quadratic regression analyses were performed, and joinpoint regression was used to assess for trend inflection points.

RESULTS

Between January 2010 and July 2015, there were 275,784 unique ambulatory visits for men. There were 63,722 raw PSA orders, and 54,684 were evaluable. Primary care providers ordered 17,315 PSA tests and 858 urology referrals. The number of PSA tests per ambulatory visit, the number of referrals per ambulatory visit, the age at the time of the urology referral, and the proportion of PSA tests performed outside the recommended age range did not significantly change. The PSA value at the time of referral increased significantly (P = .022). Joinpoint analysis revealed no joinpoints in the analysis of total PSA orders, screening PSA tests, or examinations per 100 visits.

CONCLUSIONS

In the years surrounding the USPSTF recommendation, PSA behavior did not change significantly. Patients were referred at progressively higher average PSA levels. The implications for prostate cancer outcomes from these trends warrant further research into provider variables associated with actual PSA utilization. Cancer 2016;122:3785-3793. © 2016 American Cancer Society.

All care, but whose responsibility? Community juries reason about expert and patient responsibilities in prostate-specific antigen screening for prostate cancer

General practitioners have implicitly been given responsibility for guiding men's decisions about prostate-specific antigen-based screening for prostate cancer, but patients' expectations of the bounds of this responsibility remain unclear. We sought to explore how well-informed members of the public allocate responsibilities in prostate-specific antigen screening decision-making. In 2014, we convened two Community juries in Sydney, Australia, to address questions related to the content and timing of information provision and respective roles of patients and general practitioners in screening decisions. Participants in the first jury were of mixed gender and of all ages (n = 15); the participants in the second jury were all male and of screening age (n = 12). Both juries were presented with balanced factual evidence on the harms and benefits of prostate-specific antigen screening and expert perspectives on ethico-legal aspects of consent in medical practice. In their deliberations, jurors agreed that general practitioners should take responsibility for informing men of the options, risks and benefits of prostate-specific antigen testing, but arrived at different positions on whether or not general practitioners should also guide screening decisions. Jurors also disagreed on how much and when general practitioners should provide detailed information about biopsies and treatments. These responses suggest that for prostate-specific antigen testing, there is a public expectation that both the allocation of responsibility between general practitioners and their male patients, and the level of information provided will be tailored to individual men. In the presence of expert uncertainty, a well-informed public may have reason to embrace or resist shared decision-making processes.

Prostate Cancer Education in African American Barbershops: Baseline Client Survey Results and Differences in Decisional Conflict and Stage of Decision Making

There have been very few studies to rigorously evaluate the potential of African American barbers to educate men about prostate cancer in the barbershop setting. This research brief presents baseline data from a cross-sectional survey identifying differences in decisional conflict and stage of decision making by screening status from an efficacy trial to educate African American men about informed decision making for prostate cancer screening. Those men who had already received the prostate-specific antigen (PSA) test were more advanced in their stage of decision making and had less decisional conflict about the PSA test than those men who had never received a PSA test. Educational interventions to increase informed decision making with prostate cancer screening must consider previous PSA test history as a mediating variable affecting decision self-efficacy.

Feasibility Study of Engaging Barbershops for Prostate Cancer Education in Rural African-American Communities

The barbershop is a promising setting where African-American men might receive information and education about prostate cancer. In this study, we assessed the feasibility of engaging rural barbershops as venues for barbers to deliver a prostate cancer education intervention to increase informed decision-making for prostate cancer screening among customers. Twelve barbershops were recruited from two separate micropolitan areas in Georgia as intervention and control sites. Structured interviews were conducted with 11 barbers in both sites about customer characteristics as well as their willingness to participate in the study. The interviews were audio recorded and transcribed for analysis. In the intervention site, six barbers completed a survey and a pre-/posttest prostate cancer knowledge instrument following training classes. Barbers reported a wide average range of customers served per week (50 to 300). African-American men made up an average of 87% of customers. Barbers thought prostate cancer was an important discussion topic, felt they would be comfortable discussing it, and supported the participation of their barbershop in the study. For intervention group barbers, there was a statistically significant difference between the average pretest knowledge score of 72% (mean 12.2, SD=3.2) and the posttest knowledge score of 89% (mean 15.2, SD=1.1) (P=0.03) on the 17-item prostate cancer knowledge instrument. Based on the multiple interactions with the barbers, there was high receptivity to the topic and consensus about the importance of addressing prostate cancer with their customers. Rural barbershops represent feasible venues for delivering a prostate cancer education intervention.

Adult Patients' Perspectives on the Benefits and Harms of Overused Screening Tests: a Qualitative Study

BACKGROUND

In recent years, there has been a growing interest in reducing the overuse of healthcare services. However, little is known about how patients conceptualize the benefits and harms of overused screening tests or how patients make decisions regarding these tests.

OBJECTIVE

To determine how patients think about the harms and benefits of overused screening tests and how they consider these and other factors when making decisions.

DESIGN

Semi-structured, qualitative interviews.

PARTICIPANTS

The study comprised 50 patients, ages 50-84, who had previously received or not received any of four overused screening services: 1) prostate cancer screening (men ages 50-69), 2) colon cancer screening (men and women ages 76-85), 3) osteoporosis screening (low-risk women ages 50-64), or 4) cardiovascular disease screening (low-risk men and women ages 50-85).

APPROACH

We conducted a thematic analysis, using a hybrid inductive-deductive approach. Two independent coders analyzed interview transcriptions to identify themes and exemplifying quotes.

KEY RESULTS

Many patients could not name a harm of screening. When they did name harms, patients often focused on only the harms of the screening test itself and rarely mentioned harms further along the screening cascade (e.g., from follow-up testing and treatment). In contrast, patients could easily name benefits of screening, although many seemed to misunderstand or overestimate the magnitude of the benefits. Furthermore, patients described many additional factors they considered when making screening decisions, including their clinicians' recommendations, their age, family or friends' experiences with disease, and insurance coverage.

CONCLUSIONS

This study highlights the need to help adults recognize and understand the benefits and harms of screening and make appropriate decisions about overused screening tests.

Clinical Consultation Guide: How to Optimize the Use of Prostate-specific Antigen in the Current Era

Optimizing the benefits versus harms of prostate-specific antigen screening can be achieved through stratifying screening and biopsy. This clinical consultation guide provides the scientific background and evidence-based recommendations.

Perceptions of Prostate Cancer Screening Controversy and Informed Decision Making: Implications for Development of a Targeted Decision Aid for Unaffected Male First-Degree Relatives

PURPOSE

First-degree relatives (FDRs) of prostate cancer (PC) patients should consider multiple concurrent personal risk factors when engaging in informed decision making (IDM) about PC screening. This study assessed perceptions of IDM recommendations and risk-appropriate strategies for IDM among FDRs of varied race/ethnicity.

DESIGN

A cross-sectional, qualitative study design was used.

SETTING

Study setting was a cancer center in southwest Florida.

PARTICIPANTS

The study comprised 44 participants (24 PC patients and 20 unaffected FDRs).

METHOD

Focus groups and individual interviews were conducted and analyzed using content analysis and constant comparison methods.

RESULTS

Patients and FDRs found the PC screening debate and IDM recommendations to be complex and counterintuitive. They overwhelmingly believed screening saves lives and does not have associated harms. There was a strongly expressed need to improve communication between patients and FDRs. A single decision aid that addresses the needs of all FDRs, rather than one separating by race/ethnicity, was recommended as sufficient by study participants. These perspectives guided the development of an innovative decision aid that deconstructs the screening controversy and IDM processes into simpler concepts and provides step-by-step strategies for FDRs to engage in IDM.

CONCLUSION

Implementing IDM among FDRs is challenging because the IDM paradigm departs from historical messages promoting routine screening. These contradictions should be recognized and addressed for men to participate effectively in IDM. A randomized pilot study evaluating outcomes of the resulting decision aid is underway.

[Rates of prostate-specific antigen testing for early detection of prostate cancer: a first comparison of German results with current international data]

OBJECTIVE

Measurement of prostate-specific antigen (PSA) is not only used as a screening instrument by urologists, but also by general practitioners and internal specialists (GP-IS). Until now, there are neither data on the approach of German GP-IS in practicing this nor have data been classified in the context of available international literature on this topic.

MATERIALS AND METHODS

Between May and December 2012, a questionnaire containing 16 items was sent to 600 GP-IS in Brandenburg and Berlin. The response rate was 65% (392/600). Six indicator questions (IQ1-6) were selected and results were set in the context of available international data. The quality of present studies was evaluated by the Harden criteria.

RESULTS

Of the 392 responding physicians, 317 (81%) declared that they would use PSA testing for early detection of PCA (IQ1) and, thus, formed the study group. Of these GP-IS, 38% consider an age between 41 and 50 years as suitable for testing begin (IQ2), while 53% and 14% of the GP-IS perform early detection until the age of 80 and 90 years, respectively (IQ3). A rigid PSA cut-off of 4 ng/ml is considered to be reasonable by 47% of the involved GP-IS, whereas 16% prefer an age-adjusted PSA cut-off (IQ4). Patients with pathological PSA levels were immediately referred to a board-certified urologist by 69% of the GP-IS. On the other hand, 10% first would independently control elevated PSA levels themselves after 3-12 months (IQ5). Furthermore, 14% of the interviewed physicians consider a decrease of PCA-specific mortality by PSA screening as being proven (IQ6). Knowledge regarding PCA diagnostics is mainly based on continuous medical education for GP-IS (33%), personal contact with urologists (6%), and guideline studies (4%). While 53% indicated more than one education source, 4% did not obtain any PCA-specific training. The results provided by this questionnaire evaluating response of German GP-IS to six selected indicator questions fit well into the international context; however, further studies with sufficient methodical quality are required.

CONCLUSIONS

Despite current findings and controversial recommendations of the two large PCA screening studies on this issue, German GP-IS still frequently use PCA screening by PSA measurement. Primary strategies of early detection as well as follow-up after assessment of pathologically elevated PSA levels poorly follow international recommendations. Thus, an intensification of specific education is justified.

Deliberative democracy and cancer screening consent: a randomised control trial of the effect of a community jury on men's knowledge about and intentions to participate in PSA screening

OBJECTIVE

Prostate-specific antigen (PSA) screening is controversial. A community jury allows presentation of complex information and may clarify how participants view screening after being well-informed. We examined whether participating in a community jury had an effect on men's knowledge about and their intention to participate in PSA screening.

DESIGN

Random allocation to either a 2-day community jury or a control group, with preassessment, postassessment and 3-month follow-up assessment.

SETTING

Participants from the Gold Coast (Australia) recruited via radio, newspaper and community meetings.

PARTICIPANTS

Twenty-six men aged 50-70 years with no previous diagnosis of prostate cancer.

INTERVENTION

The control group (n=14) received factsheets on PSA screening. Community jury participants (n=12) received the same factsheets and further information about screening for prostate cancer. In addition, three experts presented information on PSA screening: a neutral scientific advisor provided background information, one expert emphasised the potential benefits of screening and another expert emphasised the potential harms. Participants discussed information, asked questions to the experts and deliberated on personal and policy decisions.

MAIN OUTCOME AND MEASURES

Our primary outcome was change in individual intention to have a PSA screening test. We also assessed knowledge about screening for prostate cancer.

RESULTS

Analyses were conducted using intention-to-treat. Immediately after the jury, the community jury group had less intention-to-screen for prostate cancer than men in the control group (effect size=-0.6 SD, p=0.05). This was sustained at 3-month follow-up. Community jury men also correctly identified PSA test accuracy and considered themselves more informed (effect size=1.2 SD, p<0.001).

CONCLUSIONS

Evidence-informed deliberation of the harms and benefits of PSA screening effects men's individual choice to be screened for prostate cancer. Community juries may be a valid method for eliciting target group input to policy decisions.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry (ACTRN12612001079831).

Informed decision making among first-degree relatives of prostate cancer survivors: a pilot randomized trial

BACKGROUND

First degree relatives (FDRs) of men diagnosed with prostate cancer (PCa) are at increased risk for developing the disease, due in part to multiple concurrent risk factors. There is a lack of innovative targeted decision aids to help FDRs make an informed decision about whether or not to undergo PCa screening.

PURPOSE

This randomized pilot trial evaluated the efficacy of a targeted PCa screening decision aid in unaffected FDRs of PCa survivors.

METHODS

Seventy-eight Black and White FDRs were randomized to one of two decision aid groups; 39 to a FDR-targeted decision aid and 39 to a general decision aid. The targeted decision aid group received a general PCa decision aid booklet plus a newly developed decision aid DVD targeted specifically for FDRs. PCa screening decision outcomes included knowledge, decisional conflict, distress, and satisfaction with screening decision. Outcomes were assessed at baseline and 4 weeks after baseline.

RESULTS

There were no differences by intervention group for knowledge, decisional conflict, distress, or satisfaction with screening decision (p>0.05). However, men in both groups had significant increases in knowledge and decreases in decisional conflict (p<0.001). These changes were most pronounced (p<0.05) for younger men compared to older men.

CONCLUSION

Results suggest that general and targeted information can play an important role in increasing knowledge and decreasing decisional conflict among FDRs. Additional research is needed to identify subgroups of men who benefit the most and better understand the outcomes of a screening decision aid among diverse samples of FDRs.

Development and pilot testing of an online case-based approach to shared decision making skills training for clinicians

Background

Although research suggests that patients prefer a shared decision making (SDM) experience when making healthcare decisions, clinicians do not routinely implement SDM into their practice and training programs are needed. Using a novel case-based strategy, we developed and pilot tested an online educational program to promote shared decision making (SDM) by primary care clinicians.

Methods

A three-phased approach was used: 1) development of a conceptual model of the SDM process; 2) development of an online teaching case utilizing the Design A Case (DAC) authoring template, a well-tested process used to create peer-reviewed web-based clinical cases across all levels of healthcare training; and 3) pilot testing of the case. Participants were clinician members affiliated with several primary care research networks across the United States who answered an invitation email. The case used prostate cancer screening as the clinical context and was delivered online. Post-intervention ratings of clinicians’ general knowledge of SDM, knowledge of specific SDM steps, confidence in and intention to perform SDM steps were also collected online.

Results

Seventy-nine clinicians initially volunteered to participate in the study, of which 49 completed the case and provided evaluations. Forty-three clinicians (87.8%) reported the case met all the learning objectives, and 47 (95.9%) indicated the case was relevant for other equipoise decisions. Thirty-one clinicians (63.3%) accessed supplementary information via links provided in the case. After viewing the case, knowledge of SDM was high (over 90% correctly identified the steps in a SDM process). Determining a patient’s preferred role in making the decision (62.5% very confident) and exploring a patient’s values (65.3% very confident) about the decisions were areas where clinician confidence was lowest. More than 70% of the clinicians intended to perform SDM in the future.

Conclusions

A comprehensive model of the SDM process was used to design a case-based approach to teaching SDM skills to primary care clinicians. The case was favorably rated in this pilot study. Clinician skills training for helping patients clarify their values and for assessing patients’ desire for involvement in decision making remain significant challenges and should be a focus of future comparative studies.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6947-14-95) contains supplementary material, which is available to authorized users.

Physician behaviors to promote informed decisions for prostate cancer screening: a National Research Network study

Clinical guidelines for prostate cancer screening (PCS) advise physicians to discuss the potential harms and benefits of screening. However, there is a lack of training programs for informed decision-making (IDM), and it is unknown which IDM behaviors physicians have the most difficulty performing. Identifying difficult behaviors can help tailor training programs. In the context of developing a physician-IDM program for PCS, we aimed to describe physicians' use of nine key IDM behaviors for the PCS discussion and to examine the relation between the behaviors and physician characteristics. A cross-sectional sample of The American Academy of Family Physicians National Research Network completed surveys about their behavior regarding PCS (N = 246; response rate = 58%). The surveys included nine physician key IDM behaviors for PCS and a single-item question describing their general practice style for PCS. The most common IDM behavior was to invite men to ask questions. The two least common reported behaviors concerned patients uncertain about screening (i.e., arrange follow-up and provide additional information for undecided men). Physicians reported difficulty with these two behaviors regardless whether they reported to discuss or not to discuss PCS with patients. Reported use of key IDM behaviors was associated with a general practice style for PCS and being affiliated with a residency-training program. Physician training programs for IDM should include physician skills to address the needs of patients uncertain about screening. Future research should determine if actual behavior is associated with self-reported behavior for the PCS discussion.

Multicriteria decision analysis in oncology

BACKGROUND

There has been a growing interest in the development and application of alternative decision-making frameworks within health care, including multicriteria decision analysis (MCDA). Even though the literature includes several reviews on MCDA methods, applications of MCDA in oncology are lacking.

AIM

The aim of this paper is to discuss a rationale for the use of MCDA in oncology. In this context, the following research question emerged: How can MCDA be used to develop a clinical decision support tool in oncology?

METHODS

In this paper, a brief background on decision making is presented, followed by an overview of MCDA methods and process. The paper discusses some applications of MCDA, proposes research opportunities in the context of oncology and presents an illustrative example of how MCDA can be applied to oncology.

FINDINGS

Decisions in oncology involve trade-offs between possible benefits and harms. MCDA can help analyse trade-off preferences. A wide range of MCDA methods exist. Each method has its strengths and weaknesses. Choosing the appropriate method varies depending on the source and nature of information used to inform decision making. The literature review identified eight studies. The analytical hierarchy process (AHP) was the most often used method in the identified studies.

CONCLUSION

Overall, MCDA appears to be a promising tool that can be used to assist clinical decision making in oncology. Nonetheless, field testing is desirable before MCDA becomes an established decision-making tool in this field.

Evaluating the use of prostate-specific antigen as an instrument for early detection of prostate cancer beyond urologists: results of a representative cross-sectional questionnaire study of general practitioners and internal specialists

OBJECTIVES

The aim of this cross-sectional study was to evaluate the value of prostate-specific antigen (PSA) testing as a tool for early detection of prostate cancer (PCa) applied by general practitioners (GPs) and internal specialists (ISs) as well as to assess criteria leading to the application of PSA-based early PCa detection.

METHODS

Between May and December 2012, a questionnaire containing 16 items was sent to 600 GPs and ISs in the federal state Brandenburg and in Berlin (Germany). The independent influence of several criteria on the decision of GPs and ISs to apply PSA-based early PCa detection was assessed by multivariate logistic regression analysis (MLRA).

RESULTS

392 evaluable questionnaires were collected (return rate 65%). 81% of the physicians declared that they apply PSA testing for early PCa detection; of these, 58 and 15% would screen patients until the age of 80 and 90 years, respectively. In case of a pathological PSA level, 77% would immediately refer the patient to a urologist, while 13% would re-assess elevated PSA levels after 3-12 months. Based on MLRA, the following criteria were independently associated with a positive attitude towards PSA-based early PCa detection: specialisation (application of early detection more frequent for GPs and hospital-based ISs) (OR 3.12; p < 0.001), physicians who use exclusively GP or IS education (OR 3.95; p = 0.002), and physicians who recommend yearly PSA assessment after the age of 50 (OR 6.85; p < 0.001).

CONCLUSIONS

GPs and ISs frequently apply PSA-based early PCa detection. In doing so, 13% would initiate specific referral to a urologist in case of pathological PSA values too late. Improvement of this situation could possibly result from specific educational activities for non-urological physicians active in fields of urological core capabilities, which should be guided by joint boards of the national associations of urology and general medicine.

Response to the U.S. Preventative Services Task Force decision on prostate cancer screening

The population-level data demonstrate that the inception of prostate-specific antigen (PSA) screening has lowered mortality for prostate cancer over the past 2 decades. However, more recent evidence from randomized trials has presented conflicting results regarding the benefit of PSA screening for prostate cancer mortality. Using available data, the U.S. Preventative Services Task Force recently recommended against PSA screening for prostate cancer. However, prostate cancer continues to kill over 30,000 men annually, and as such, completely abandoning screening for this disease is a disservice to many patients. Rather, the emphasis should be on utilizing evidence-based medicine to reduce overdiagnosis and overtreatment through less frequent screening for low-risk individuals or those unlikely to benefit from screening, halting further screening when appropriate, and utilizing observational strategies in patients unlikely to suffer clinically significant effects of prostate cancer over their anticipated life expectancy.

Primary care physician PSA screening practices before and after the final U.S. Preventive Services Task Force recommendation

OBJECTIVES

In May 2012, United States Preventive Services Task Force (USPSTF) finalized its recommendation against prostate-specific antigen (PSA) screening in all men. We aimed to assess trends in PSA screening frequency amongst primary care physicians (PCPs) surrounding the May 2012 USPSTF recommendation.

METHODS AND MATERIALS

The electronic data warehouse was used to identify men aged between 40 and 79 years with no history of prostate cancer or urology visit who were evaluated by an internal medicine or family practice physician between 2007 and 2012. Analyses were directed toward PSA testing within 6-month time period from June to November, with particular focus on the 2011 (pre-USPSTF recommendation) and 2012 (post-USPSTF recommendation) cohorts. The primary outcome measure was proportion of men with at least 1 PSA test during the 6-month pre- and post-USPSTF recommendation periods.

RESULTS

A total of 112,221 men met inclusion criteria. There was a significant decrease in screening frequency between the 2011 and 2012 cohorts (8.6% vs. 7.6%, P = 0.0001; adjusted odds ratio 0.89, 95% confidence interval 0.83-0.95). This decrease was most evident amongst patients aged 40 to 49 years (5.6% vs. 4.6%, P = 0.004) and 70 to 79 years (7.9% vs. 6.2%, P = 0.01). A significant decrease was also observed in patients with highest previous PSA value<1.0 (P<0.0001) and 1.0 to 2.49 ng/ml (P = 0.0074).

CONCLUSIONS

Since the USPSTF recommendation was finalized, there is evidence of continuing decreases in PSA testing by PCPs. PCPs may be shifting toward more selective screening practices, as decreases in screening are most pronounced in the youngest and oldest patients and in those with history of PSA values<2.5 ng/ml.

National evidence on the use of shared decision making in prostate-specific antigen screening

PURPOSE

Recent clinical practice guidelines on prostate cancer screening using the prostate-specific antigen (PSA) test (PSA screening) have recommended that clinicians practice shared decision making-a process involving clinician-patient discussion of the pros, cons, and uncertainties of screening. We undertook a study to determine the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making.

METHODS

A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past 5 years), and sociodemographic and health-related characteristics.

RESULTS

Nearly two-thirds (64.3%) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (no shared decision making); 27.8% reported discussion of 1 to 2 elements only (partial shared decision making); 8.0% reported discussion of all 3 elements (full shared decision making). Nearly one-half (44.2%) reported no PSA screening, 27.8% reported low-intensity (less-than-annual) screening, and 25.1% reported high-intensity (nearly annual) screening. Absence of shared decision making was more prevalent in men who were not screened; 88% (95% CI, 86.2%-90.1%) of nonscreened men reported no shared decision making compared with 39% (95% CI, 35.0%-43.3%) of men undergoing high-intensity screening. Extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial vs no or full shared decision making.

CONCLUSIONS

Most US men report little shared decision making in PSA screening, and the lack of shared decision making is more prevalent in nonscreened than in screened men. Screening intensity is greatest with partial shared decision making, and different elements of shared decision making are associated with distinct patient characteristics. Shared decision making needs to be improved in decisions for and against PSA screening.