One Third of Men Undergo PSA Test Without Discussion, Survey Says

Nick Mulcahy

September 29, 2009

September 29, 2009 — Thirty percent of men underwent prostate-specific antigen (PSA) testing for prostate cancer without their doctor first discussing the test with them, according to data from a survey of American men 40 years and older.

The finding is "disconcerting," write the authors of a new paper on the survey published in the September 28 issue of the Archives of Internal Medicine.

The finding is not surprising, suggests an accompanying editorial.

"Today's practice environment presents few incentives or support tools for those clinicians and patients who prefer a discussion rather than simply marking a checkbox for PSA on a laboratory requisition form," write editorialists Steven H. Woolf, MD, MPH, and Alex Krist, MD, MPH, from Virginia Commonwealth University in Richmond.

Ideally, shared decision-making between a healthcare provider and patient should take place with PSA testing, the editorialists note.

For shared decision-making about PSA testing to take place broadly in the United States, write Drs. Woolf and Krist, many things would be needed: reimbursement for the time, tort reforms to protect clinicians who present informed choice, and a more balanced set of messages about prostate cancer screening from the public health community.

In the survey, only 20% of the respondents indicated that they had discussed the pros and cons of PSA testing with their healthcare provider and that they were asked if they wanted to have the test done. "This is what is needed — at a minimum," lead study author Richard M. Hoffman, MD, MPH, told Medscape Oncology. He is an internist at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico.

Dr. Hoffman also noted that the survey respondents "way overestimated" the risk of getting cancer and dying from cancer, and the accuracy of PSA.

What is the Alternative to Extensive Discussion?

The study is derived from a telephone survey of a national sample, known as the National Survey of Medical Decisions, which was conducted among 3010 adults, including 375 men who had either undergone a PSA test or discussed one with their doctor in the previous 2 years.

Recommendations and information from the healthcare provider strongly influenced testing decisions by the 240 men who went on to get the PSA test, write Dr. Hoffman and his coauthors.

A healthcare provider recommendation (odds ratio, 2.67; 95% confidence interval, 1.08 - 6.58) was the only "discussion characteristic" associated with testing, they write.

Notably, the healthcare providers "emphasized the pros of testing in 71.4% of discussions but infrequently addressed the cons (32%)" note Dr. Hoffman and his coauthors.

Inaccuracy and imbalance are 2 of the shortcomings in how these PSA discussions take place. That they sometimes take place at all — given all of the demands on primary care providers — is remarkable, suggested Dr. Hoffman.

"Shared decision-making isn't going to happen in primary care. There is no time for it," he said.

What can work instead? Decision aids, said Dr. Hoffman. They are written or audiovisual tools that help patients when "there is more than 1 reasonable strategy for clinical management." Interestingly, in other studies, the aids have "consistently shown that enhanced knowledge is associated with decreased interest in testing," note the authors.

Dr. Hoffman disclosed that he works with and receives partial salary support from the not-for-profit Foundation for Informed Medical Decision Making, in Boston, Massachusetts. Dr. Hoffman is the medical editor of the Foundation's aids for prostate cancer screening and treatment.

Currently, the state of Washington has funded a demonstration project using decision aids for prostate and colorectal cancer screenings, he noted.

As sensible as the aids seem, "there aren't many of them," Dr. Hoffman noted, saying that they are in their "infancy as a clinical tool."

Arch Intern Med. 2009;169:1557-1559, 1611-1618.

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