Do Physicians Believe in Shared Decision Making for Prostate Cancer Screening?
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP, Assistant Professor, Department of Medicine, Meharry Medical College, Nashville, TN; Assistant Clinical Professor, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN. Dr. Gupta reports no financial relationship to this field of study.
Synopsis: Although health care providers have a major influence on their patients when they decide to undergo screening for prostate cancer, shared decision making often does not occur despite recommendations.
Source: Hoffman RM, et al. Prostate cancer screening decisions: Results from the National Survey of Medical Decisions. Arch Intern Med 2009;168:1611-1618.
Screening recommendations for prostate cancer remain controversial although the disease is clearly both common and serious. Although screening with prostate-specific antigen (PSA) may detect early cases of prostate cancer, it is not clear whether there is more than negligible benefit from this strategy.1,2 Additionally, PSA screening for prostate cancer causes several harms related to over-diagnosis including excessive testing, pain, and suffering, as well as excess resource utilization.
Therefore, it is no surprise that in an era of evolving comparative effectiveness research, the United States Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years and recommends against screening for prostate cancer in men age 75 years or older.3 Specifically, the task force recommends that ".in men younger than age 75 years, a clinician should not order the PSA test without first discussing with the patient the potential but uncertain benefits and the known harms of prostate cancer screening and treatment. Men should be informed of the gaps in the evidence and should be assisted in considering their personal preferences before deciding whether to be tested."
In the study by Hoffman and colleagues, the authors utilize a survey methodology to assess this shared decision making (SDM) process for PSA testing. A telephone survey of a randomly selected sample of 3010 English-speaking U.S. adults age 40 years and older was conducted and included 375 men who had either undergone or discussed PSA testing in the previous 2 years with health care providers (HCPs). The HCPs most often raised the idea of screening and recommended testing. However, only about 70% of subjects reported having discussed screening with an HCP before making a decision about PSA testing, including about 14% who did not subsequently get tested. Only one in every five discussions presented both the pros and cons of screening by the HCPs and elicited the patient's preferences for testing. While the HCPs emphasized the pros of testing in more than 70% of discussions, they addressed the cons much less frequently (32%). Patients reported that HCPs often offered their personal opinions about screening, with the majority recommending PSA testing. HCPs' recommendations were strongly associated with having PSA testing done. Among the patients participating in screening discussions, most were satisfied with the SDM process. More than 80% believed that their level of involvement in the decision was appropriate, although only 55% reported that the clinician inquired about their preferences. However, there was poor performance of these subjects on the knowledge questions at the time of completing the survey module, characterized by substantially overestimating the lifetime risks for prostate cancer diagnosis and mortality. The explanation could be as simple as the diminution of knowledge retention of these subjects over time or as significant as potentially inadequate understanding of the clinical issues.
Commentary
Over the years, I have often scoffed at physicians who tend to have a paternalistic style toward the practice of medicine. Many of these have been my former chiefs of staff, mentors, and colleagues. These friends of mine cannot wait to be asked the question: "What would you do, Doc?" They are quick to offer their opinion, which most of the patients follow in the belief that "Doc knows what's best." Most patients remain satisfied and appreciative even though they rarely participate meaningfully in their own care. Their participation is most often limited to being informed of the intended treatment/procedure and providing consent. I have tended to be much more interactive. I encourage active discussion and debates, and often provide a balanced view of both sides to the argument along with my personal experiences. However, I try very hard not to offer my opinionated view. Obviously then the most difficult question for me to answer is: "What would you do, Doc?" I believe that my patients are also equally satisfied and appreciative of my style of practice of medicine.
However, what I find most unacceptable is when we lead our patients to believe a certain set of facts that does not exist. That is what Hoffman et al seem to have uncovered. The majority of the subjects interviewed believed that their level of involvement in the SDM leading to PSA testing for prostate cancer screening was appropriate. However, in many cases, the accurate information on which they should have based their decision seems to be missing. This was supplemented by the fact that while more than 70% of the HCPs discussed the pros of PSA testing, only a minority addressed the cons. Perhaps the most significant issue raised by this study is an urgent call for developing a good understanding of the concept of SDM. Shared decision making should mean those efforts by HCPs to help patients understand the benefits, harms, and uncertainties of available options and to help patients apply their personal preferences to determine the best choice.
References
1. Andriole GL, et al; PLCO Project Team. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009;360:1310-1319; Erratum in N Engl J Med 2009;360:1797.
2. Schröder FH, et al; ERSPC Investigators. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360:1320-1328.
3. U.S. Preventive Services Task Force. Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. AHRQ Publication No. 08-05121-EF-2. Available at: www.ahrq.gov/CLINIC/uspstf08/prostate/prostaters.htm. Accessed Oct. 20, 2009.
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