COMMENTARY

Should We Even Talk About a PSA?

Stranding Men on the Shores of 'Shared Decision-Making'

Kenneth W. Lin, MD, MPH

Disclosures

October 22, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University Medical Center, and I blog at Common Sense Family Doctor. I'm speaking to you from Philadelphia, where I am attending the American Academy of Family Physicians (AAFP) Family Medicine Experience.

Last year, the AAFP diverged slightly from the US Preventive Services Task Force's (USPSTF's) updated recommendation on prostate-specific antigen (PSA)-based screening for prostate cancer. Although the AAFP agreed with the USPSTF's "C" grade, they also stated that there is no obligation for a clinician to routinely discuss PSA screening if the patient does not bring it up. In response, the writer of a recent letter to the editor of American Family Physician  asked, "How do physicians discern a patient's desire to engage in shared decision-making without first introducing the concept of choice?" In other words, how would a man in the 55- to 69-year-old age group eligible for screening know that there was a decision to be made about the test without being informed?

Around the same time, the New York Times Magazine published a letter from a puzzled patient who had been diagnosed with localized prostate cancer. The patient complained that when he asked his urologist if he should receive surgical or radiation treatment, the doctor repeatedly declined to recommend either course, saying that the patient had to make the decision for himself.

The high value that modern medicine places on patient autonomy, when the benefits of testing or therapy are uncertain, is reflected by the increasing number of guidelines that suggest shared decision-making (SDM). But as a JAMA commentary, "Realizing Shared Decision-Making in Practice" noted, what seems like a good idea in theory is often much harder to carry out in practice, due to time pressure and a lack of clinician awareness that even routine decisions can be difficult for patients. The authors faulted the lack of specificity in some guidelines. "To be meaningful," they observed, "a specific recommendation for SDM should clearly outline the particular values, as well as the risks, benefits, and consequences, of different decisions for patients." They also recommended the use of decision aids to supplement physicians' verbal presentation of benefits and harms.

I sometimes use a printed or online decision aid when I discuss prostate cancer screening with patients, but a recent systematic review and meta-analysis of decision aids for prostate screening choice suggests that this may not make much difference. Reviewing 19 randomized trials that compared decision aids with usual care, the analysis concluded that decision aids slightly improved men's short-term knowledge regarding prostate cancer screening but had no effects on the likelihood of an SDM discussion or on the decision to undergo screening.

I argued in a previous Medscape commentary that SDM around PSA screening often distracts patients and physicians from preventive services with a greater likelihood of benefit. In an era of "too much medicine" resulting from diagnostic cascades, expanding disease definitions, and screening tests with disputed benefits, Minna Johansson and colleagues suggest re-examining the proposition that pushing patients to make an "informed choice" will resolve this ethical problem. They wrote:

Before feeling satisfied for navigating someone through an "informed choice," perhaps doctors should start with some more humble reflections. Did we, the patient, or some other force, initiate the process leading to an informed choice being necessary? Is it likely the person will benefit from having to make an informed choice? Can she or he be harmed?

Although the PSA test was not developed to screen asymptomatic men for prostate cancer, primary care physicians were persuaded by expert opinion to use it for nearly two decades in this way before the publication of the only US trial testing its efficacy. That study, and its subsequent reports, found that the test did not decrease prostate cancer deaths and there was clear evidence of harm to the screening group. It has appropriately led to less PSA screening being performed in the United States, ensuring that fewer patients suffer from a needless test.

In contrast to the USPSTF's current recommendation to discuss the pros and cons of PSA-based screening, the best evidence indicates that routine use of a decision aid does not improve clinical outcomes. My practice, therefore, follows the lead of the AAFP. I do not recommend prostate cancer screening. If patients ask me about it, I tell them, "The PSA test is unlikely to help you and is much more likely to cause harm." If they still want the test, I will order it. These patients, at least, know what they are getting themselves into rather than being stranded with millions of other men on the shores of SDM.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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