American Medical News
By — Posted July 22, 2013
Many professional guidelines encourage shared decision-making for prostate cancer screening, but finding the time for such discussions is tough for busy primary care physicians, medical experts say.
“On the surface, [the recommendations] sound wonderful,” said New York urologist Michael A. Palese, MD. “But in practice, we're kidding ourselves that every patient who walks in [to see a primary care doctor] is going to get a 20- or 30-minute conversation on the pluses and minuses of the PSA screen.”
Sixty-four percent of men ages 50 to 74 said a doctor never spoke with them about the advantages, disadvantages or scientific uncertainty of the prostate-specific antigen test, a recent study said. Only 8% reported discussing all three of those elements with a doctor. The findings were published in one of three reports on shared decision-making in the July/August issue of Annals of Family Medicine.
Shared decision-making is essential for helping patients make informed decisions about the PSA screen, medical experts say. The responsibility for such discussions frequently falls to primary care doctors, in part, because they have regular contact with patients.
To make the conversations more practical in primary care, physicians could extend the discussion over several appointments rather than trying to squeeze all the information into a single visit, said internist Paul K.J. Han, MD, MPH, lead author of one of the studies.
He recommends that physicians introduce the topic of the PSA test and then direct the individual to a decision aid or support tool. Such tools can be found free on the websites of health organizations such as the American Cancer Society and the American Society of Clinical Oncology.
“The doctor can tell the patient, 'Look over this information, and then let's talk about it at your next visit,' ” said Dr. Han, director of the Center for Outcomes Research and Evaluation at Maine Medical Center Research Institute in Portland. The discussion “doesn't have to be so burdensome over one visit.”
Key factors that deter physicians from shared decision-making for the PSA test are lack of time and payment for the conversation, as well as controversy about the efficacy and impact of the PSA test, medical experts said.
“PSA testing has become so controversial and the guidelines have changed so much that [some] primary care physicians are really getting confused” about whether or not they should screen patients, said Dr. Palese, associate professor of urology at the Icahn School of Medicine at Mount Sinai in New York.
The latest update to prostate cancer screening guidance was issued May 3 by the American Urological Assn. It recommends against the PSA test for men younger than 40 and doesn't recommend routine screening in average-risk men 40 to 54. Shared decision-making is strongly encouraged for men 55 to 69 who are considering the screen.
To ease the burden on physicians, researchers are examining ways to effectively educate men about the PSA test outside the clinical setting, said an editorial published in the July/August issue of Annals of Family Medicine. For instance, health plans have contracted with population-management firms to distribute educational materials and make health coaches available to discuss options by phone with members likely to face decisions for preference sensitive conditions, the editorial said.
Prostate cancer is the second-most common cancer among U.S. men, following skin cancer, and is the second-leading cause of cancer death in U.S. men behind lung cancer, the ACS said. The organization projects that in 2013 there will be 238,590 newly diagnosed cases of prostate cancer and 29,720 men will die of the disease. Nearly two-thirds of cases are diagnosed in men 65 and older and most aren't fatal, the cancer society said.
For Dr. Han's Annals study, researchers examined data on 3,427 older men who participated in the 2010 National Health Interview Survey. Men were excluded if they reported PSA testing for a specific problem, a personal history of prostate cancer or more than five PSA screens in the past five years. Researchers found that 56% of men reported having a PSA test in their lifetimes, and 66% were screened in the past year.
A lack of shared decision-making was more commonly reported among men who never were screened for the disease (88%) compared with men who were tested for the disease nearly every year (39%).
“Even though everyone recognizes the value of shared decision-making, it's really difficult to achieve it,” Dr. Han said.
Part of the problem is that some physicians don't know what such discussions entail, said Sacramento, Calif., internist Michael S. Wilkes, MD, PhD, MPH. He recommends using interactive online tools to enhance physicians' awareness of what decision-making is and how to use it during patient visits.
“Many doctors think that anytime they talk it's shared decision-making, but really it's a doctor lecturing or a doctor mentioning” something, said Dr. Wilkes, a professor of medicine at University of California Davis School of Medicine in Sacramento.
He led an Annals study of 120 California family doctors and internists and 712 of their male patients ages 50 to 75. For the study, Dr. Wilkes and his colleagues developed two 30-minute interactive Web-based programs on prostate cancer screening. One tool was geared toward physicians and the other toward patients. Both tools reviewed information on the PSA test.
Researchers used eight patients trained to portray a specific patient case to help examine physician communication about the screen. Each physician received an unannounced audio-recorded visit from a standardized patient during the study period.
PSA discussions were more common in visits where both the patient and physician used the online tool (65%) compared with appointments where the doctor didn't participate in the program (38%), the study said.
A third Annals study analyzed the standardized patients' audio-recorded visits with 118 of the California family doctors and internists. It showed that doctors who used the online program were more likely to mention not getting screened as an option and to encourage patients to seek input from others compared with physicians in the control group.
Dr. Palese supports the concept of shared decision-making, but said physicians need more tools and support from staff to effectively integrate such discussions into office visits.
“We're putting primary care physicians in a bad position,” he said. “We're just adding to the burden they're already carrying, trying to do everything, which is unrealistic.”