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

Paul K. J. Han, MD, MA, MPH; Sarah Kobrin, PhD; Nancy Breen, PhD; Djenaba A. Joseph, MD, MPH; Jun Li, MD, PhD; Dominick L. Frosch, PhD; Carrie N. Klabunde, PhD

Disclosures

Ann Fam Med. 2013;11(4):306-314. 

In This Article

Abstract and Introduction

Abstract

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.

Introduction

Screening for prostate cancer using the prostate-specific antigen test (PSA screening) is a common practice in the United States. Each year approximately 40% to 50% of men aged 50 years and older undergo PSA screening,[1] often without their knowledge.[2–6] The test has become so routine that in one highly publicized case a physician was sued for malpractice for not ordering it.[7] Yet PSA screening remains controversial.[8,9] The PSA test has limited accuracy, and evidence for its effectiveness in reducing mortality is conflicting.[10] Prostate cancer has a heterogeneous natural history; although fatal in some men, it is indolent in most, and outcomes for individuals are difficult to predict. PSA screening can thus lead to overdiagnosis and unnecessary diagnostic evaluation and treatment. For these reasons, professional organizations, including the US Preventive Services Task Force (USPSTF), American Cancer Society (ACS), and American Urologic Association (AUA), have issued clinical practice guidelines recommending that clinicians inform patients about the pros, cons, and uncertainties of PSA screening, and that screening decisions be based on patient preferences.[11–13] These elements are essential for informed decision making[14,15] and for shared decision making.[14–16]

PSA screening decisions in the United States, however, fall short of these ideals. National surveys have shown that many men who undergo PSA screening are poorly informed, and screening decisions are typically made by clinicians alone.[17–21] PSA screening in the absence of shared decision making exposes men to its potential harms without their knowledge and has been a dominant focus of policy debates.[4,17,19,22] The USPSTF's revised guidelines address this problem by not only discouraging routine screening, but recommending that physicians "should not offer or order PSA screening unless they are prepared to engage in shared decision making."[10,22,23]

A problem that has attracted less attention is nonscreening, or test nonuptake,[24] in the absence of shared decision making. This problem is equally important if one believes that existing evidence remains insufficient to recommend for or against screening, as critics of the revised USPSTF guidelines have argued,[25–27] yet empirical data on its extent are lacking. National surveys have measured shared decision making in PSA screening rather than nonscreening—focusing on men who have undergone screening[18]or considered it during some recent time interval.[19] They have also used either brief measures of shared decision making[18,19] or smaller, nonrepresentative sample populations.[28] We thus have an incomplete understanding of the extent of shared decision making in PSA screening and the implications of alternative policy approaches to this problem.

The objective of the current study was to provide population-level evidence on the prevalence of shared decision making in both PSA screening and nonscreening. Using a large nationally representative health survey of the US public, we ascertained the extent of physician-patient discussions of the advantages, disadvantages, and uncertainties associated with PSA screening among screened and unscreened men aged 50 to 74 years. We then conducted analyses to (1) estimate the US population prevalence of both PSA screening and nonscreening in both the presence and absence of shared decision making; (2) examine the association between critical elements of shared decision making and PSA screening uptake and intensity of use; and (3) identify patient characteristics associated with shared decision making.

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