PSA disadvantages discussed with minority of men

San Francisco-A minority of patients are involved in shared decision-making about prostate cancer screening with PSA, but new strategies to incorporate shared decision-making into practice are being investigated, suggest separate studies presented at the Genitourinary Cancers Symposium in San Francisco.

At the meeting, investigators at Brigham and Women’s Hospital, Boston reported that less than one-third of patients are advised of both the advantages and disadvantages of prostate cancer screening.

Dr. Pucheril“This study identifies a gap,” lead investigator Daniel Pucheril, MD, a urology/oncology fellow at Brigham and Women’s, told Urology Times. “It doesn’t propose a solution and so as a community we need to work together to identify the appropriate decision aids that we can implement, certainly at institutional levels, if not at national levels.”

No specific decision aid has been universally endorsed by the AUA or cancer screening bodies, noted Dr. Pucheril, who worked on the study with Quoc-Dien Trinh, MD, and colleagues.

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For the analysis, data were abstracted from the 2012-2016 Behavioral Risk Factor Surveillance System for men 55 to 69 years of age without a personal history of prostate cancer and who answered all questions within the prostate cancer screening module. This demographic represented the population for whom the U.S. Preventive Services Task Force (USPTF) recommended against PSA-based screening for prostate cancer, assigning it a grade of “D,” or discouraging its use, in 2012. The recommendation was subsequently revised in 2017 to a grade of “C” for men 55-69 years of age, meaning the USPSTF recommends that clinicians inform patients about the potential benefits and harms of PSA-based screening.

The survey is telephone-based and is conducted every other year. Screening was defined as a man having a PSA test within the past 2 years for reasons other than “a prostate problem” or “prostate cancer.” For shared decision-making to occur, the respondent had to be informed about both the advantages and disadvantages of prostate cancer screening by a health professional.

Among the 138,492 men who met the inclusion criteria, rates of screening declined from 56.7% in 2012 to 52.6% in 2014 and to 49.1% in 2016. The rate of shared decision-making, however, was unchanged over the three surveys, and in all three surveys, less than one-third of the men reported shared decision-making.

The strongest predictor of undergoing PSA screening, after controlling for known confounders, was physician recommendation to undergo screening, with an odds ratio (OR) of 7.78.

“Historically, physicians tend to talk about the advantages of screening but don’t really talk about the disadvantages of screening,” said Dr. Pucheril. “That’s what drives a low rate of shared decision-making. It’s important that we give patients a full presentation of the evidence and help them make that decision, rather than giving them a bias.”

Other predictors of undergoing screening were having a personal physician (OR: 2.24) and receipt of information regarding the advantages of prostate cancer screening (OR: 3.93).

Odds of reporting participation in shared decision-making were highest among African-American respondents (OR: 2.09) and those who received a physician recommendation to undergo prostate cancer screening (OR: 4.64).

Next: Practices adopting decision aids

Practices adopting decision aids

Various approaches have been adopted by primary care practices to facilitate shared decision-making in prostate cancer screening, including the use of handouts and the development of scripts for staff, reported Cara Litvin, MD, and colleagues in a separate study.

Her finding comes as part of the ongoing HIT-OVERUSE study, which is a 2-year group randomized study in 20 primary care practices to test a practice-based intervention to reduce overuse of unnecessary preventive services, including avoidance of routine PSA screening without shared decision-making.

Dr. Litvin“The interesting thing is it’s a practice-based approach, so it’s not just relying on what the doctor does but on what the whole practice does,” said Dr. Litvin, associate professor of general internal medicine at the Medical University of South Carolina, Charleston. “Our ongoing hypothesis for the whole project is that use of a combination of practice-based strategies can reduce unnecessary services, not only changing the conversation that a doctor has with their patient but also doing other things in the practice.”

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From on-site visits and emails to 11 intervention practices in 10 states, the investigators found that four practices eliminated the routine standing orders for PSA screening, after which the use of PSA screening decreased in the practice. Six practices started using patient education handouts, three developed scripts for staff to use when asked about the PSA test, one practice showed a YouTube video to patients, and one used a slide show to view in the waiting room.

“We’re trying to get at other ways to educate your patients and inform them about the risks and benefits of prostate cancer screening besides the patient-provider conversation,” she said. “We’ve worked with these practices over the past year and a half to come up with these approaches.”

Dr. Litvin noted that even for providers who disagreed with the USPSTF recommendation, her group’s intervention led to “at least some discussion about the harms” with patients.

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