News and Highlights
Deciding whether or not to screen for prostate cancer with prostate-specific antigen (PSA) is problematic. PSA screening can save lives by finding cases of the disease when it is still localized and treatable. On the other hand, the test can lead to treatment of cases of the disease that would never have spread beyond the prostate and become life-threatening. Since treatment has the potential to cause significant complications (incontinence, erectile dysfunction, bowel problems), it is important to be able to understand and weigh the benefits and harms of screening, as well the options available, such as careful monitoring, or “active surveillance,” instead of immediate treatment.
In their recent opinion piece in the Annals of Internal Medicine, Andrew J. Vickers, PhD, Attending Research Methodologist at Memorial Sloan Kettering Cancer Center and Professor of Healthcare Policy and Research, Alvin I. Mushlin, MD, ScM, Professor of Healthcare Policy and Research, and of Medicine, and their colleagues present a simple schema that primary care physicians can use to help their patients decide if PSA testing is right for them. “Physician organizations generally recommend shared decision-making between doctors and their patients about prostate cancer screening,” said Dr. Vickers. “But implementing shared decision making in primary care is not straightforward because it must account for the wide range of information and data that could be discussed, the complex tradeoff between immediate harms and long-term benefits, and the limited time primary care clinicians have for in-depth discussions about PSA testing in the context of the many other issues in a typical visit.”
To address these difficulties, the authors propose an alternative approach to informed decision making about PSA testing in primary care, based on presenting the best evidence to appropriate patients in a simple form and a clear framework for making a decision. The authors base their schema on a previously advocated “ask-tell-ask” approach. Starting with the initial “ask,” the clinician would gain critical information on what the patient already knows about PSA screening or what the patient’s level of concern or interest may be. This would allow the clinician to the tailor the “tell” portion of the conversation more succinctly and directly to the patient’s particular needs and level of current understanding. This sharing of information would be followed by a final “ask,” in which the clinician would confirm that what he or she has just explained makes sense and would ask for the patient’s preference regarding the decision.
“Our decision tool is evidence-based, facilitates a discrete decision, and should be ideal for primary care in that it requires a relatively limited amount of time and additional information about PSA screening,” said Dr. Mushlin. “With this revised, streamlined approach, clinicians will have clear framework for discussions with patients about PSA screening.”
- Vickers AJ, Edwards K, Cooperberg MR, Mushlin AI. A Simple Schema for Informed Decision Making About Prostate Cancer Screening. Ann Intern Med. 2014;161:441-442.
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