A Sea of Silence Between Doctors and Patients About Prostate Testing

Despite fairly broad coverage on the subject, a recent report shows that men and their doctors aren’t talking about the risks and benefits of prostate cancer screening.

A couple of years ago, as we wrote, the U.S. Preventive Services Task Force (USPSTF) recommended against routine testing for most men, and guidelines compiled by the American Urological Association and American College of Physicians promote the practice of doctors and patients sharing the decision about undergoing prostate specific antigen (PSA) tests.

As noted in a story by Reuters, it’s not happening.

The problem with the overuse of PSA screening is that the tests catch some cancers that never would become a health threat because they are small and grow slowly, and treating them aggressively can create serious problems, such as incontinence, impotence, unnecessary worry and infection. And it’s far from certain that regular screening of most men saves a significant number of lives.

And sometimes, the PSA test isn’t a very accurate or reliable an indicator of cancer.

The new study, published in the Annals of Family Medicine, involved questionnaires completed by about 3,400 men in their 50s to early 70s. More than 6 in 10 of the respondents had not discussed the benefits and risks of PSA tests with their doctors, or the scientific uncertainty of their effect. About half of the others had discussed only the advantages of screening.

More than 4 in 10 of the study participants had not been screened for prostate cancer in the preceding five years. Most of them, nearly 9 in 10, had not discussed that choice with their doctors.

Before the scientific community began to spread the word about the wisdom of routine PSA screening, studies focused on men who had been screened without any discussion of potential side effects versus potential benefits and harms, many of whom underwent the test without their knowledge.

Dr. Michael Wilkes, of the University of California, Davis, told Reuters that the PSA test is the “poster child for uncertainty.”

“The test is horrible, yet there are still reasonable men who still might opt to have the test because they feel that knowing the information, even though it’s not perfect, is better than not knowing it,” he said.

“In this situation, reasonable people can look at the data and because of their own values and their own preferences decide, ‘I want the test’ or, ‘I don’t want the test.'”

But no one can make that decision if the topic isn’t given a full review by the doctor and the patient.

Wilkes and his colleagues also published two studies in the same journal (here and here) that examined whether educating doctors about prostate cancer screening and prompting patients to ask about it boosted rates of shared decision-making.

Those studies involved about 120 doctors who were given either typical brochures about PSA tests or completed an interactive program that included video showing the possible benefits and harms of screening. A few months later when faced with a test patient, doctors in the intervention group were somewhat more likely to lead shared decision-making discussions … but not much.

The intervention docs incorporated an average of 14 of 32 decision-making elements into the visit; the typical treatment docs incorporated 11. Those elements included sharing information about different screening and treatment options and asking about the patient’s values in relation to screening.

Doctors in another analysis were more neutral about their screening recommendations if they had completed a computer program and some of their patients had been educated and prompted to ask about screening.

“What we found was, educating the doctor is necessary but not sufficient,” Wilkes told Reuters.

Wilkes reinforces what this blog has recommended: Before seeing your doctor, inform yourself about prostate cancer screening by reviewing information from the U.S. Centers for Disease Control and Prevention (CDC) and the USPSTF.

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