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The Need For Discussion About Prostate Cancer Screening Choices, Optimizing Shared Decision Making

Three research studies and an accompanying editorial address the importance of shared decision making around prostate cancer screening. Although prostate cancer is among the most common cancers among men in the United States, the value of screening for prostate cancer by measuring prostate-specific antigen levels remains highly controversial because screening can lead to invasive procedures and treatments that in turn can cause substantial harm. Because such harms may outweigh any population-level benefit, the U.S. Preventive Services Task Force in 2012 downgraded its PSA screening recommendation to recommend against screening for average-risk men and recommended clinicians inform patients of the pros, cons and uncertainties of PSA screening before offering the test. Shared decision making, in which clinicians collaboratively help patients understand medical information to reach value-congruent medical decisions, can be effective, especially in cases of such medical uncertainty. This cluster of articles explores the prevalence, mediators, mutability and meaning of shared decision making around prostate cancer screening.

Shared Decision Making Is an Uncommon Occurrence in PSA Screening, Especially in Men Who Do Not Receive Screening

Most U.S. men report little shared decision making in PSA screening, and a lack of shared decision making is more prevalent in nonscreened than in screened men. Analyzing data from a nationally representative survey of 3,427 men aged 50 to 74 years, researchers examined the prevalence of three key elements of shared decision making: physician-patient discussion of the advantages, disadvantages, and scientific uncertainty of PSA screening. Nearly two-thirds (64 percent) of men reported no past physician-patient discussion of any of the three elements (no shared decision making); 28 percent reported discussion of one to two elements only (partial shared decision making); and 8 percent reported discussion of all three elements (full shared decision making). Forty-four percent of participants reported no PSA screening, 28 percent reported less-than-annual screening and 25 percent reported nearly annual screening. Notably, the absence of shared decision making was more prevalent in men who were not screened – 88 percent of nonscreened men reported no shared decision making compared with 39 percent of men undergoing nearly annual screening. These findings, the authors assert, provide justification for a broader focus in the current policy debate about PSA screening. While much of this debate has historically focused on PSA screening in the absence of shared decision making and the potential harm of undesired and unnecessary treatment, these findings suggest the more prevalent problem is nonscreening in the absence of shared decision making – the harm of which is the failure to allow individuals to decide for themselves if screening is beneficial. The authors also found the 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 shared decision making.

National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening

By Paul K. J. Han, MD, MA, MPH, et al

Maine Medical Center Research Institute, Portland

Pairing Physician Education with Patient Activation Improves Rates of Shared Decision Making and Affects Physician Attitudes About Prostate Cancer Screening

Pairing a brief 20- to 30-minute Web-based educational intervention for physicians with a companion intervention for patients about counseling for prostate cancer screening appears to improve shared decision making rates and influence physicians’ attitudes about screening. Analyzing data on 120 physicians and 712 male patients aged 50 to 75 years, researchers compared usual education (control) with physician education alone (MD-Ed) and paired physician education and patient activation (MD-Ed+A). They found MD-Ed+A patients had higher prostate cancer screening discussion rates (65 percent) than MD-Ed (41 percent) or control (38 percent). Standardized patients – actors trained to simulate real patient cases and later report on the encounter – also reported that physicians seeing MD-Ed+A patients were more likely to be neutral in their final recommendations about whether the patient should obtain a PSA blood test (MD-Ed+A=50 percent, MD-Ed=33 percent, control=33 percent). (Further reporting on this secondary measure can be found in an accompanying study by Feng and colleagues. Please see the full summary below.) The shift in the physicians’ attitudes toward screening from a pro screening bias toward neutral counseling persisted three months after participating in the intervention. Notably, the researchers found no difference in patients’ ratings of shared decision making between the groups. Coupling physician education with patient activation, the authors conclude, has the potential to improve the appropriate utilization of medical services by encouraging shared decision making around issues of medical uncertainty such as prostate cancer screening.

Pairing Physician Education With Patient Activation to Improve Shared Decisions in Prostate Cancer

Screening: A Cluster-Randomized Controlled Trial

By Michael S. Wilkes, MD, PhD, et al

University of California, Davis

Analysis of Unannounced Standardized Patient Visits Shows Educational Intervention Can Improve Shared Decision Making and Change Physician Attitudes About Prostate Cancer Screening

In a more detailed discussion and analysis of the standardized patient visit data reported as a secondary measure in the previous study by Wilkes, et al, researchers discuss how the Web-based educational intervention appears to improve shared decision making, encourage neutrality in recommendation and reduce PSA test ordering. Analyzing transcripts from unannounced standardized patient encounters with the 118 participating primary care physicians in which trained actors prompted physicians to address prostate cancer screening, researchers found intervention physicians showed more shared decision making behaviors (intervention 14 items vs. control 11 items), were more likely to mention no screening as an option (intervention 63 percent vs. control 26 percent), to encourage patients to consider different screening options (intervention 62 percent vs. control 39 percent) and seek input from others (intervention 25 percent vs. control 7 percent). The authors conclude that by analyzing standardized patient transcripts of the actual conversations between physicians and patients, this study offers unique and important insights into how physicians actually behaved when prompted to discuss the risk and uncertainty of prostate cancer screening. They assert that in light of the USPSTF’s recent recommendation against screening, interventions such as this one may be important adjuvants to help influence physicians’ behaviors regarding controversial medical topics with public health implications and may potentially decrease utilization of tests with uncertain value.

Physician Communication Regarding Prostate Cancer Screening: Analysis of Unannounced Standardized Patient Visits

By Bo Feng, PhD, et al

University of California, Davis

Editorial: Shared Decision Making Should be Approached as a Learned Skill Cultivated Within the Context of an Ongoing Relationship

An accompanying editorial explores the importance of viewing shared decision making not as an episodic event but as a learned skill and ongoing process that is cultivated through repeated application within the context of meaningful physician-patient relationships. The authors assert the research in the current issue is consistent with previously published literature that shared decision making remains poorly integrated into primary care practices largely because it is considered in isolation. They encourage clinicians to reframe their approach to shared decision making, viewing it in a broader context and giving attention to unanswered questions, conflicting demands and systems implications.

Shared Decision Making, Contextualized

By Robert L. Ferrer, MD, MPH, and James M. Gill, MD, MPH

Annals of Family Medicine


News From The Annals Of Family Medicine: July/August 2013

American Academy of Family Physicians