Decision making in prostate-specific antigen screening National Health Interview Survey, 2000

Uncertainty: a neglected determinant of health behavior?

Health behaviors are critical determinants of the well-being of individuals and populations, and understanding the determinants of these behaviors has been a major focus of research. One important determinant that has received little direct attention in past health research is uncertainty: a complex phenomenon that pertains not only to scientific issues regarding the diagnosis, prognosis, prevention, and treatment of health problems, but also to personal issues regarding other important health-related concerns. Here, we make the case for greater attention to uncertainty in health behavior theory and research, and especially to personal uncertainties. We discuss three exemplary types of personal uncertainty-value uncertainty, capacity uncertainty, and motive uncertainty-which relate, respectively, to moral values, capacities to enact or change behaviors, and the motives and intentions of other persons or institutions. We argue that that personal uncertainties such as these influence health behaviors, but their influence has historically been obscured by a focus on other constructs such as self-efficacy and trust. Reconceptualizing and investigating health behavior as a problem of uncertainty can advance both our understanding of the determinants of healthy behaviors and our ability to promote them.

The Impact of Receipt of Information on Prostate-Specific Antigen Testing on Screening with the Prostate-Specific Antigen Test

There is controversy on prostate cancer screening with the prostate-specific antigen (PSA) test in the USA, and as a result, there has been an increased push for physicians to have a thorough discussion with patients on the advantages and disadvantages of prostate cancer screening with the PSA blood test. Prior studies showed that pre-screening discussions increased the likelihood of PSA testing. This study is aimed at examining the impact of discussions of the advantages and disadvantages of the PSA test among men that fit the prostate cancer screening guidelines determined by the American Urological Association (AUA). This cross-sectional study used secondary data from the 2018 Behavior Risk Factor Surveillance System (BRFSS) in the USA. The analytic sample was determined based on the American Urological Association (AUA) guidelines for prostate cancer screening (n = 54,607). Approximately, 89.5% of men underwent PSA testing. The odds of PSA testing were higher for men who received information on only the advantages of PSA testing (OR = 3.40, 95% CI = 2.80, 4.13), only the disadvantages of PSA testing (OR = 1.52, 95% CI = 1.02, 2.28), and both advantages and disadvantages of PSA testing (OR = 2.99, 95% CI = 2.46, 3.63) compared to men who received no information. Discussions with men, that meet the requirements for prostate cancer screening, about the advantages and disadvantages of PSA testing increased the likelihood that men would undergo PSA testing.

Higher Predictive Value Positive for MMA Than ACA MTM Eligibility Criteria Among Racial and Ethnic Minorities: An Observational Study

The objective of this study was to examine positive predictive value (PPV) of medication therapy management (MTM) eligibility criteria under Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial and ethnic groups. The study analyzed Medicare data (2012-2013) for 2 213 594 beneficiaries. Medication utilization issues were determined based on medication utilization measures mostly developed by Pharmacy Quality Alliance. MMA was associated with higher PPV than ACA in identifying individuals with medication utilization issues among non-Hispanic blacks (blacks) and Hispanics than non-Hispanic whites (whites). For example, odds ratio for having medication utilization issues to whites when examining MMA in 2013 and ACA were 1.09 (95% confidence interval [CI] = 1.04-1.15) among blacks, and 1.17 (95% CI = 1.10-1.24) among Hispanics, in the main analysis. Therefore, MMA was associated with 9% and 17% higher PPV than ACA in identifying patients with medication utilization issues among blacks and Hispanics, respectively, than whites.

Prostate cancer screening: Beliefs and practices of the Brazilian physicians with different specialties

RATIONALE, AIMS, AND OBJECTIVES

Prostate cancer (PC) presents with a high prevalence, but a low mortality. The evaluation of the risk-benefit ratio of current screening methods has led to conflicting results, which are reflected in some contradictory recommendations proposed by scientific and governmental entities. In this context of uncertainty, our objective is to verify the practices and beliefs of Brazilian physicians of different specialties regarding screening for PC.

METHODS

A cross-sectional study was conducted through a self-administered questionnaire survey during the main events of the target specialties (general practitioner, geriatrics, and urology) during the year 2016. We evaluated the practices on 6 main points of conduct in PC screening: previous discussion to informed decision, exams indicated, age of onset with and without additional risk factors, repeat interval, and age when screening is suspended. Responses were analysed with descriptive statistics and correlation, using the Statistical Package for the Social Sciences program (IBM SPSS Statistics version 20, 2010).

RESULTS

The screening recommendation for PC differs significantly among specialists in association with previous discussion of benefits/harm (P = 0.026), exams used (P < 0.001), age of beginning screening with and without additional risk (P < 0.001), and age of suspension of the screening program (P < 0.001).

CONCLUSIONS

Our findings indicate that there is a significant difference of conduct between doctors in different specialties. To the best of the author's knowledge, this is the first study that directly compares the practices of these different specialists in relation to the main points involved in screening for PC.

Barbershop Prostate Cancer Education: Factors Associated With Client Knowledge

The purpose of this paper is to identify characteristics of Black barbershop clients and barbers in an urban Midwestern city participating in a health promotion program called Affecting Cancer Together (ACT) that are associated with client knowledge about prostate cancer. Statistical analyses examined client and barber characteristics for their potential association with client prostate cancer knowledge, while controlling for ACT variables. Study findings suggested clients who are married (β = 0.99; CI [0.38, 1.59]; p < .01) and have higher levels of education (β = 0.34; CI [0.01, 0.67]; p = .04) may be more likely to know more about prostate cancer. Barbers with at least "some college" education may be more effective in increasing client knowledge (β = 0.85; CI [0.05, 1.64]; p = .04). Trained peer-helper programs may consider prioritizing limited educational resources for barbers with at least some college education and incorporating the social support of spouses for making informed decisions. Considering the potential of barbershop programs to reach Black men about a serious racially disproportionate health issue, ameliorating adoption, implementation, effectiveness, and sustainment are an important public health priority for underserved populations.

Association Between Online Information-Seeking and Adherence to Guidelines for Breast and Prostate Cancer Screening

Introduction

From 2012 through 2014, the US Preventive Services Task Force (USPSTF) recommended biennial mammography for women aged 50 to 75 and recommended against the prostate specific antigen (PSA) test for men of any age, emphasizing informed decision making for patients. Because of time constraints and other patient health priorities, health care providers often do not discuss benefits and risks associated with cancer screening. We analyzed the association between seeking information online about breast and prostate cancer and undergoing mammography and PSA screening.

Methods

We assessed guideline concordance in mammogram and PSA screening, according to USPSTF guidelines for those at average risk for disease. We used data on 4,537 survey respondents from the National Cancer Institute’s Health Information National Trends Survey (HINTS) for 2012 through 2014 to assess online information-seeking, defined as whether people searched for cancer-related information online in the past 12 months. We used HINTS data to construct multivariable logistic regression models to isolate the effect of exposure to online information on the incidence of cancer screening.

Results

After controlling for available covariates, we found no significant association between online information-seeking and guideline-concordant screening for breast or prostate cancer. Significant covariate values suggest that factors related to access to care were significantly associated with conformance to mammography guidelines for women recommended for screening and that physician discussion was significantly associated with nonconformance to guidelines for prostate-specific antigen screening (ie, having a PSA test in spite of the recommendation not to have it). Decomposition of differences between those who sought online information and those who did not indicated that uncontrolled confounders probably had little effect on findings.

Conclusion

We found little evidence that online information-seeking significantly affected screening for breast or prostate cancer in accordance with USPSTF guidelines among people at average risk.

Recent Patterns in Shared Decision Making for Prostate-Specific Antigen Testing in the United States

PURPOSE

Previous studies report infrequent use of shared decision making for prostate-specific antigen (PSA) testing. It is unknown whether this pattern has changed recently considering increased emphasis on shared decision making in prostate cancer screening recommendations. Thus, the objective of this study is to examine recent changes in shared decision making.

METHODS

We conducted a retrospective cross-sectional study among men aged 50 years and older in the United States using 2010 and 2015 National Health Interview Survey (NHIS) data (n = 9,598). Changes in receipt of shared decision making were expressed as adjusted prevalence ratios (aPR) and 95% confidence intervals (CI). Analyses were stratified on PSA testing (recent [in the past year] or no testing). Elements of shared decision making assessed included the patient being informed about the advantages only, advantages and disadvantages, and full shared decision making (advantages, disadvantages, and uncertainties).

RESULTS

Among men with recent PSA testing, 58.5% and 62.6% reported having received ≥1 element of shared decision making in 2010 and 2015, respectively (P = .054, aPR = 1.04; 95% CI, 0.98-1.11). Between 2010 and 2015, being told only about the advantages of PSA testing significantly declined (aPR = 0.82; 95% CI, 0.71-0.96) and full shared decision making prevalence significantly increased (aPR = 1.51; 95% CI, 1.28-1.79) in recently tested men. Among men without prior PSA testing, 10% reported ≥1 element of shared decision making, which did not change with time.

CONCLUSION

Between 2010 and 2015, there was no increase in shared decision making among men with recent PSA testing though there was a shift away from only being told about the advantages of PSA testing towards full shared decision making. Many men receiving PSA testing did not receive shared decision making.

Primary goals, information-giving and men's understanding: a qualitative study of Australian and UK doctors' varied communication about PSA screening

OBJECTIVES

(1) To characterise variation in general practitioners' (GPs') accounts of communicating with men about prostate cancer screening using the prostate-specific antigen (PSA) test, (2) to characterise GPs' reasons for communicating as they do and (3) to explain why and under what conditions GP communication approaches vary.

STUDY DESIGN AND SETTING

A grounded theory study. We interviewed 69 GPs consulting in primary care practices in Australia (n=40) and the UK (n=29).

RESULTS

GPs explained their communication practices in relation to their primary goals. In Australia, three different communication goals were reported: to encourage asymptomatic men to either have a PSA test, or not test, or alternatively, to support men to make their own decision. As well as having different primary goals, GPs aimed to provide different information (from comprehensive to strongly filtered) and to support men to develop different kinds of understanding, from population-level to 'gist' understanding. Taking into account these three dimensions (goals, information, understanding) and building on Entwistle et al's Consider an Offer framework, we derived four overarching approaches to communication: Be screened, Do not be screened, Analyse and choose, and As you wish. We also describe ways in which situational and relational factors influenced GPs' preferred communication approach.

CONCLUSION

GPs' reported approach to communicating about prostate cancer screening varies according to three dimensions-their primary goal, information provision preference and understanding sought-and in response to specific practice situations. If GP communication about PSA screening is to become more standardised in Australia, it is likely that each of these dimensions will require attention in policy and practice support interventions.

Prevalence and associations of general practitioners' ordering of "non-symptomatic" prostate-specific antigen tests: A cross-sectional analysis

AIMS

Testing for asymptomatic prostate cancer with prostate specific antigen (PSA) is of uncertain benefit. Most relevant authorities recommend against screening, and for informed patient choice. We aimed to establish the prevalence and associations of "non-symptomatic" PSA-testing of men aged 40 or older by early-career general practitioners (GP registrars).

METHODS

A cross-sectional analysis from the ReCEnT cohort study of registrars' consultations, 2010-2014 (analysed in 2016). Registrars record 60 consecutive consultations each 6-month training term. The outcome factor was ordering an "asymptomatic" PSA test (a PSA ordered for an indication that was not prostate-related symptoms or prostatic disease monitoring). Independent variables were patient, registrar, practice, consultation and educational factors.

RESULTS

A total of 856 registrars contributed details of 21,372 individual consultations and 35,696 problems/diagnoses of males 40 or older. Asymptomatic PSAs were ordered for 1.8% (95%CI: 1.7-2.0%) of consultations and for 1.1% (95%CI: 1.0-1.2%) of problems/diagnoses. Multivariable associations of asymptomatic PSA testing (compared with problems/diagnoses for which a PSA was not ordered) included patient age (OR 2.32 [95%CI: 1.53-3.53] for 60-69 years compared with 40-49), patient ethnicity (OR 0.40 [95%CI: 0.19-0.86] for non-English speaking background), the patient being new to both the registrar and practice (ORs 1.46 [95%CI: 1.08-1.99] and 1.79 [95%CI: 1.03-3.10]), the number of problems/diagnoses addressed (OR 1.44 [95%CI: 1.25-1.66] for each extra problem) and more pathology tests being ordered (OR 1.88 [95%CI: 1.79-1.97] for each extra test).

CONCLUSION

GP registrars frequently order "asymptomatic" PSA tests. Our findings suggest that non-compliance with current guidelines for PSA screening may be relatively common and that targeted education is warranted.

Patient-Provider Communication About Prostate Cancer Screening and Treatment: New Evidence From the Health Information National Trends Survey

The American Urological Association, American Cancer Society, and American College of Physicians recommend that patients and providers make a shared decision with respect to prostate-specific antigen (PSA) testing for prostate cancer (PCa). The goal of this study is to determine the extent of patient-provider communication for PSA testing and treatment of PCa and to examine the patient specific factors associated with this communication. Using recent data from the Health Information National Trends Survey, this study examined the association of patient characteristics with four domains of patient-provider communication regarding PSA test and PCa treatment: (1) expert opinion of PSA test, (2) accuracy of PSA test, (3) side effects of PCa treatment, and (4) treatment need of PCa. The current results suggested low level of communication for PSA testing and treatment of PCa across four domains. Less than 10% of the respondents report having communication about all four domains. Patient characteristics like recent medical check-up, regular healthcare provider, global health status, age group, marital status, race, annual household income, and already having undergone a PSA test are associated with patient-provider communication. There are few discussions about PSA testing and PCa treatment options between healthcare providers and their patients, which limits the shared decision-making process for PCa screening and treatment as recommended by the current best practice guidelines. This study helps identify implications for changes in physician practice to adhere with the PSA screening guidelines.

Do Men Receive Information Required for Shared Decision Making About PSA Testing? Results from a National Survey

Most professional organizations, including the American College of Physicians and U.S. Preventive Services Task Force, emphasize that screening for prostate cancer with the prostate-specific antigen (PSA) test should only occur after a detailed discussion between the health-care provider and patient about the known risks and potential benefits of the test. In fact, guidelines strongly advise health-care providers to involve patients, particularly those at elevated risk of prostate cancer, in a "shared decision making" (SDM) process about PSA testing. We analyzed data from the National Cancer Institute's Health Information National Trends Survey 2011-2012-a nationally representative, cross-sectional survey-to examine the extent to which health professionals provided men with information critical to SDM prior to PSA testing, including (1) that patients had a choice about whether or not to undergo PSA testing, (2) that not all doctors recommend PSA testing, and (3) that no one is sure if PSA testing saves lives. Over half (55 %) of men between the ages of 50 and 74 reported ever having had a PSA test. However, only 10 % of men, regardless of screening status, reported receiving all three pieces of information: 55 % reported being informed that they could choose whether or not to undergo testing, 22 % reported being informed that some doctors recommend PSA testing and others do not, and 14 % reported being informed that no one is sure if PSA testing actually saves lives. Black men and men with lower levels of education were less likely to be provided this information. There is a need to improve patient-provider communication about the uncertainties associated with the PSA test. Interventions directed at patients, providers, and practice settings should be considered.

Barbershop Prostate Cancer Education: Factors Associated With Client Knowledge

The purpose of this article is to identify characteristics of Black barbershop clients and barbers in an urban Midwestern city participating in a health promotion program called Affecting Cancer Together (ACT) that are associated with client knowledge about prostate cancer. Statistical analyses examined client and barber characteristics for their potential association with client prostate cancer knowledge, while controlling for ACT variables. Study findings suggested clients who are married (β = 0.99; confidence interval [CI] = 0.38, 1.59; p < .01) and have higher levels of education (β = 0.34; CI = 0.01, 0.67; p = .04) may be more likely to know more about prostate cancer. Barbers with at least "some college" education may be more effective in increasing client knowledge (β = 0.85; CI = 0.05, 1.64; p = .04). Trained peer-helper programs may consider prioritizing limited educational resources for barbers with at least some college education and incorporating the social support of spouses for making informed decisions. Considering the potential of barbershop programs to reach Black men about a serious racially disproportionate health issue, ameliorating adoption, implementation, effectiveness, and sustainment are an important public health priority for underserved populations.

Colorectal Cancer Screening in US Seniors Ages 76-84 Years

The US Preventive Services Task Force recommends patient-physician discussions about the appropriateness of colorectal cancer (CRC) screening among adults ages 76-84 years who have never been screened. In this study, we used data from the 2010 National Health Interview Survey to examine patterns of CRC screening and provider recommendation among seniors ages 76-84 years, and made some comparisons to younger adults. Nationally-representative samples of 1379 adults ages 76-84 years and 8797 adults ages 50-75 years responded to questions about CRC screening status, receipt of provider recommendation, and discussion of test options; 22.7% (95% CI 20.1-25.3) of seniors ages 76-84 had never been tested for CRC and therefore were not up-to-date with guidelines; 3.9% (95% CI 2.0-7.6) of these individuals reported a recent provider recommendation for screening. In multivariate analyses, the likelihood of never having been tested was significantly greater for seniors of other/multiple race or Hispanic ethnicity; with high school or less education; without private health insurance coverage; who had ≤ 1 doctor visit in the past year; without recent screening for breast, cervical, or prostate cancer; with no or unknown CRC family history; or with ≤ 1 chronic disease. Among the minority of respondents ages 50-75 and 76-84 reporting a provider recommendation, 73.2% indicated that the provider recommended particular tests, which was overwhelmingly colonoscopy (≥ 89 %). Nearly one-quarter of adults 76-84 have never been screened for CRC, and rates of provider recommendation in this group are very low. Greater attention to informed CRC screening discussions with screening-eligible seniors is needed.

Screening for Cervical, Prostate, and Breast Cancer: Interpreting the Evidence

Cancer screening is an important component of prevention and early detection in public health and clinical medicine. The evidence for cancer screening, however, is often contentious. A description and explanation of disagreements over the evidence for cervical, breast, and prostate screening may assist physicians, policymakers, and citizens faced with screening decisions and suggest directions for future screening research. There are particular issues to be aware of in the evidence base for each form of screening, which are summarized in this paper. Five tensions explain existing conflicts over the evidence: (1) data from differing contexts may not be comparable; (2) screening technologies affect evidence quality, and thus evidence must evolve with changing technologies; (3) the quality of evidence of benefit varies, and the implications are contested; (4) evidence about harm is relatively new, there are gaps in that evidence, and there is disagreement over what it means; and (5) evidence about outcomes is often poorly communicated. The following principles will assist people to evaluate and use the evidence: (1) attend closely to transferability; (2) consider the influence of technologies on the evidence base; (3) query the design of meta-analyses; (4) ensure harms are defined and measured; and (5) improve risk communication practices. More fundamentally, there is a need to question the purpose of cancer screening and the values that inform that purpose, recognizing that different stakeholders may value different things. If implemented, these strategies will improve the production and interpretation of the methodologically challenging and always-growing evidence for and against cancer screening.

Prostate-specific antigen (PSA) screening and follow-up investigations in Māori and non-Māori men in New Zealand

Background

Māori men in New Zealand have higher mortality from prostate cancer, despite having lower incidence rates. The objective of this study was to examine patterns of screening for prostate cancer in primary care and follow-up investigations after an elevated prostate-specific antigen (PSA) result in Māori and non-Māori men in order to help explain the observed differences in incidence and mortality.

Methods

Men aged 40+ years were identified from 31 general practices across the Midland Cancer Network region. Computerised practice records were cross-referenced with laboratory data to determine the number and value of PSA tests undertaken between January 2007 and December 2010. Screening rates were calculated for the year 2010 by age, ethnicity, and practice. For men with an elevated PSA result information on specialist referrals and biopsy was extracted from practice records. Practice characteristics were assessed with respect to screening rates for Māori and non-Māori men.

Results

The final study population included 34,960 men aged 40+ years; 14% were Māori. Māori men were less likely to be screened in 2010 compared with non-Māori men (Mantel Haenszel (M-H) age-adjusted risk ratio (RR), 0.52 [95% CI, 0.48, 0.56]). When screened, Māori men were more than twice as likely to have an elevated PSA result compared with non-Māori men (M-H age-adjusted RR, 2.16 [95% CI, 1.42, 3.31]). There were no significant differences between Māori and non-Māori men in the rate of follow-up investigations and cancer detection. Māori provider practices showed equal screening rates for Māori and non-Māori men, but they were also the practices with the lowest overall screening rates.

Conclusions

Māori men were half as likely to be screened compared to non-Māori men. This probably explains the lower reported incidence of prostate cancer for Māori men. Practice characteristics had a major influence on screening rates. Large variation in screening behaviour among practices and differences in follow-up investigations for men with an elevated PSA result seems to reflect the uncertainty among GPs regarding PSA screening and management.

Sonablate®-500: transrectal high-intensity focused ultrasound for the treatment of prostate cancer

Prostate cancer (PCa) is the most common cancer in men and the second leading cause of death from malignancy in the UK. The number of men diagnosed with PCa is increasing, due in part to an increased willingness of men to visit their family doctors with lower urinary tract symptoms, and also a willingness of physicians to test for it. As the demographic of men diagnosed with PCa becomes younger and better informed, so the demand for a less-invasive alternative to standard therapies becomes greater. The Sonablate-500 is one of only two high-intensity focused ultrasound (HIFU) devices commercially available to treat PCa. HIFU is an attractive treatment option as it is the only form of therapy that neither involves direct instrumentation of the prostate nor ionizing radiation. This article describes the unique features of both the Sonablate-500 system hardware and software, and the outcome data from this device in the context of current standard therapies. Finally, a view into the future attempts to outline where this technology is heading and how a paradigm shift in the way that PCa is considered may make HIFU even more relevant.

Evaluation of systems-oriented public health interventions: alternative research designs

The need to provide sound evidence of the costs and benefits of real-world public health interventions has driven advances in the development and analysis of designs other than the controlled trial in which individuals are randomized to an experimental condition. Attention to methodological quality is of critical importance to ensure that any evaluation can accurately answer three fundamental questions: (a) Has a change occurred, (b) did the change occur as a result of the intervention, and (c) is the degree of change significant? A range of alternatives to the individual randomized controlled trial (RCT) can be used for evaluating such interventions, including the cluster RCT, stepped wedge design, interrupted time series, multiple baseline, and controlled prepost designs. The key features and complexities associated with each of these designs are explored.

Prostate specific antigen testing in family practice: a cross sectional survey of self-reported rates of and reasons for testing participation and risk disclosure

Background

Despite controversy about the benefits of routine prostate specific antigen (PSA) testing, rates of participation continue to rise. It is important to ensure that men are fully informed about the potential risks associated with this test. Little is known about the processes of shared decision making for PSA testing in the family practice setting. This study aimed to explore men’s experiences of PSA testing participation and risk disclosure for PSA testing.

Methods

A cross-sectional survey of male family practice attendees aged 40 years or older, with no previous history of prostate cancer, between June 2010 and November 2011. Questions related to whether participants had undertaken PSA testing or discussed this with their doctor over the past 5 years, whether the patient or doctor had initiated the discussion, reasons for undergoing testing, and whether their doctor had discussed particular risks associated with PSA testing.

Results

Sixty-seven percent (215/320) of men recalled having a PSA test in the past five years. Of the respondents who reported not having a test, 14% had discussed it with their doctor. The main reasons for having a PSA test were doctor recommendation and wanting to keep up to date with health tests. Thirty-eight percent or fewer respondents reported being advised of each potential risk.

Conclusions

Despite debate over the benefits of routine PSA testing, a high proportion of male family practice attendees report undertaking this test. Risks associated with testing appear to be poorly disclosed by general practitioners. These results suggest the need to improve the quality of informed consent for PSA testing in the family practice setting.

Shared decision making in prostate-specific antigen testing with men older than 70 years

BACKGROUND

Little is known about how shared decision making (SDM) is being carried out between older men and their health care providers. Our study aimed to describe the use of SDM key elements and assess their associations with prostate-specific antigen (PSA) testing among older men.

METHODS

We conducted descriptive and logistic regression modeling analyses using the 2005 and 2010 National Health Interview Survey data.

RESULTS

Age-specific prevalence of PSA testing was similar in 2005 and 2010. In 2010, 44.1% of men aged ≥70 years had PSA testing. Only 27.2% (95% confidence interval, 22.2-32.9) of them reported having discussions about both advantages and disadvantages of testing. Multiple regression analyses showed that PSA-based screening was positively associated with discussions of advantages only (P < .001) and with discussions of both advantages and disadvantages (P < .001) compared with no discussion. Discussion of scientific uncertainties was not associated with PSA testing.

CONCLUSIONS

Efforts are needed to increase physicians' awareness of and adherence to PSA-based screening recommendations. Given that discussions of both advantages and disadvantages increased the uptake of PSA testing and discussion of scientific uncertainties has no effect, additional research about the nature, context, and extent of SDM and about patients' knowledge, values, and preferences regarding PSA-based screening is warranted.

National evidence on the use of shared decision making in prostate-specific antigen screening

PURPOSE

Recent clinical practice guidelines on prostate cancer screening using the prostate-specific antigen (PSA) test (PSA screening) have recommended that clinicians practice shared decision making-a process involving clinician-patient discussion of the pros, cons, and uncertainties of screening. We undertook a study to determine the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making.

METHODS

A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past 5 years), and sociodemographic and health-related characteristics.

RESULTS

Nearly two-thirds (64.3%) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (no shared decision making); 27.8% reported discussion of 1 to 2 elements only (partial shared decision making); 8.0% reported discussion of all 3 elements (full shared decision making). Nearly one-half (44.2%) reported no PSA screening, 27.8% reported low-intensity (less-than-annual) screening, and 25.1% reported high-intensity (nearly annual) screening. Absence of shared decision making was more prevalent in men who were not screened; 88% (95% CI, 86.2%-90.1%) of nonscreened men reported no shared decision making compared with 39% (95% CI, 35.0%-43.3%) of men undergoing high-intensity screening. Extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial vs no or full shared decision making.

CONCLUSIONS

Most US men report little shared decision making in PSA screening, and the lack of shared decision making is more prevalent in nonscreened than in screened men. Screening intensity is greatest with partial shared decision making, and different elements of shared decision making are associated with distinct patient characteristics. Shared decision making needs to be improved in decisions for and against PSA screening.

Primary care physician reports of amount of time spent with male patients in prostate cancer screening discussions

BACKGROUND

Major health organizations recommend that physicians discuss the risks and benefits of prostate cancer screening with men before ordering tests. The length of time that health care providers spend discussing prostate cancer screening-related issues with patients has been given little attention. The purpose of this study was to determine the amount of time that primary care physicians (PCP) in the United States reported spending in discussions about prostate cancer screening with patients by selected PCP individual, practice-related, and screening-related factors.

METHODS

Data were obtained from the 2007-2008 National Survey of Primary Care Physician Practices Regarding Prostate Cancer Screening. We determined whether PCP characteristics were associated with amount of time spent with patients.

RESULTS

Results showed that female, African American or other race, and older PCP spend more time (above the median) with patients compared to their referents. Also, more time spent with male patients was more often associated with PCP having practices in urban inner city areas as well as when the screening decision was shared between the PCP and the patient/family.

CONCLUSION

Results from this study offer some insight into the amount of time that PCP report spending with patients in discussing prostate cancer screening-related issues specifically, and confirms the involvement of individual as well as practice-level factors.

The influence of stress, depression, and anxiety on PSA screening rates in a nationally representative sample

BACKGROUND

Prostate-specific antigen (PSA) testing for prostate cancer is controversial, with concerning rates of both overscreening and underscreening. The reasons for the observed rates of screening are unknown, and few studies have examined the relationship of psychological health to PSA screening rates. Understanding this relationship can help guide interventions to improve informed decision-making for screening.

METHODS

A nationally representative sample of men 57-85 years old without prostate cancer (N = 1169) from the National Social life, Health and Aging Project was analyzed. The independent relationship of validated psychological health scales measuring stress, anxiety, and depression to PSA testing rates was assessed using multivariable logistic regression analyses.

RESULTS

PSA screening rates were significantly lower for men with higher perceived stress [odds ratio (OR) = 0.76, P = 0.006], but not for higher depressive symptoms (OR = 0.89, P = 0.22) when accounting for stress. Anxiety influences PSA screening through an interaction with number of doctor visits (P = 0.02). Among the men who visited the doctor once those with higher anxiety were less likely to be screened (OR = 0.65, P = 0.04). Conversely, those who visited the doctor 10+ times with higher anxiety were more likely to be screened (OR = 1.71, P = 0.04).

CONCLUSIONS

Perceived stress significantly lowers PSA screening likelihood, and it seems to partly mediate the negative relationship of depression with screening likelihood. Anxiety affects PSA screening rates differently for men with different numbers of doctor visits. Interventions to influence PSA screening rates should recognize the role of the patients' psychological state to improve their likelihood of making informed decisions and improve screening appropriateness.

Conceptual, methodological, and ethical problems in communicating uncertainty in clinical evidence

The communication of uncertainty in clinical evidence is an important endeavor that poses difficult conceptual, methodological, and ethical problems. Conceptual problems include logical paradoxes in the meaning of probability and "ambiguity"--second-order uncertainty arising from the lack of reliability, credibility, or adequacy of probability information. Methodological problems include questions about optimal methods for representing fundamental uncertainties and for communicating these uncertainties in clinical practice. Ethical problems include questions about whether communicating uncertainty enhances or diminishes patient autonomy and produces net benefits or harms. This article reviews the limited but growing literature on these problems and efforts to address them and identifies key areas of focus for future research. It is argued that the critical need moving forward is for greater conceptual clarity and consistent representational methods that make the meaning of various uncertainties understandable, and for clinical interventions to support patients in coping with uncertainty in decision making.

Remaining Life Expectancy Measurement and PSA Screening of Older Men

BACKGROUND: Guidelines recommend informed decision-making regarding prostate specific antigen (PSA) screening for men with at least 10 years of remaining life expectancy (RLE). Comorbidity measures have been used to judge RLE in previous studies, but assessments based on other common RLE measures are unknown. We assessed whether screening rates varied based on four clinically relevant RLE measures, including comorbidities, in a nationally-representative, community-based sample. METHODS: Using the National Social Life, Health and Aging Project (NSHAP), we selected men over 65 without prostate cancer (n=709). They were stratified into three RLE categories (0-7 years, 8-12 years, and 13+ years) based on validated measures of comorbidities, self-rated health status, functional status, and physical performance. The independent relationship of each RLE measure and a combined measure to screening was determined using multivariable logistic regressions. RESULTS: Self-rated health (OR = 6.82; p < 0.01) most closely correlated with RLE-based screening, while the comorbidity index correlated the least (OR = 1.50; p = 0.09). The relationship of RLE to PSA screening significantly strengthened when controlling for the number of doctor visits, particularly for comorbidities (OR= 43.6; p < 0.001). Men who had consistent estimates of less than 7 years RLE by all four measures had an adjusted PSA screening rate of 43.3%. CONCLUSIONS: Regardless of the RLE measure used, men who were estimated to have limited RLE had significant PSA screening rates. However, different RLE measures have different correlations with PSA screening. Specific estimates of over-screening should therefore carefully consider the RLE measure used.

Discussions about prostate cancer screening between U.S. primary care physicians and their patients

OBJECTIVE

This study examined the likelihood that U.S. primary care physicians (PCPs) discuss and recommend prostate cancer screening with their patients and physician-related and practice-related factors associated with this behavior.

METHODS

We analyzed data from the 2007-2008 National Survey of Primary Care Physician Practices Regarding Prostate Cancer Screening (N = 1,256), the most recent and comprehensive survey specifically designed to address issues concerning prostate cancer screening and representing nearly 95,000 PCPs. We evaluated the relationship between PCP behavior regarding prostate cancer screening discussions and covariates, including PCP demographic and practice-related factors. Weighted percentages and Chi-square tests were used to compare use of screening discussions by PCP characteristics. Adjusted odds of discussing screening and recommending the PSA test were determined from logistic regression.

RESULTS

Eighty percent of PCPs reported that they routinely discuss prostate cancer screening with all of their male patients, and 64.1% of PCPs who discussed screening with any patients reported that they attempted to talk their patients into getting the PSA test. In multivariate analyses, encouraging PSA testing was more likely among non-Hispanic black PCPs (OR = 2.80, 95% CI [1.88, 4.16]), PCPs serving 100 or more patients per week (OR = 2.16, 95% CI [1.38, 3.37]), and PCPs spending longer hours per week in direct patient care (31-40 hours: OR = 1.90, 95% CI [1.13, 3.20]; 41 or more hours: OR = 2.09, 95% CI [1.12, 3.88]), compared to their referents. PCPs in multi-specialty group practice were more likely to remain neutral or discourage PSA testing compared to PCPs in solo practice.

CONCLUSIONS

Both individual and practice-related factors of PCPs were associated with the use of prostate cancer screening discussions by U.S. PCPs. Results from this study may prove valuable to researchers and clinicians and help guide the development and implementation of future prostate cancer screening interventions in the U.S.

A community-based intervention to promote informed decision making for prostate cancer screening among Hispanic American men changed knowledge and role preferences: a cluster RCT

OBJECTIVE

We assessed the short-term effects of a community-based intervention for Hispanic men to encourage informed decision making (IDM) about prostate cancer screening with prostate specific antigen (PSA).

METHODS

All senior social and housing centers in El Paso, TX were randomized to intervention, a group-based Spanish language educational program facilitated by promotores (12 centers; 161 men) [I's], or to control, promotores-facilitated diabetes video and discussion (13 centers; 160 men) [C's].

RESULTS

Participants had low levels of schooling and baseline knowledge; 44% reported previous PSA testing. At post-test, the I's made large knowledge gains, increased their understanding that experts disagree about testing, shifted toward more active decision making roles, were more likely to believe that it is important to weigh the advantages and disadvantages of screening and to anticipate potential screening outcomes in making a decision, and were less likely to consider the screening decision easy. The I's did not change in their screening intention or the belief that choosing not to be screened could be a responsible choice.

CONCLUSIONS

A community-based intervention to support IDM for prostate cancer screening can increase knowledge and may promote more active involvement in decision making about prostate cancer screening. Such an approach can increase knowledge and may promote more active involvement in decision making about prostate cancer screening.

PRACTICE IMPLICATIONS

It is feasible to develop and implement a community-based intervention program to promote IDM for prostate cancer screening.

Translating medical evidence to promote informed health care decisions

OBJECTIVE

To examine the effects of a community-based intervention on decisions about prostate-specific antigen (PSA) screening using multiple measures of informed decision making (IDM).

DATA SOURCES/STUDY SETTING

Nonequivalent control group time series design collecting primary data in late 2004 and 2005.

STUDY DESIGN

We developed a multimodal intervention designed to convey the medical uncertainty about the benefits of PSA screening and early treatment and the limited predictive ability of both the PSA test and pathological specimens collected from prostate biopsy. We examined (1) patients' recognition that there is a decision to be made about PSA screening, (2) prostate cancer knowledge levels, (3) their preferred and actual levels of participation in decision making about screening at three points in time, and (4) screening decision.

DATA COLLECTION

Baseline data collection occurred in community-based organizations. These organizations served as recruiting sources and as sites for the intervention. We collected follow-up data by mail with telephone reminders.

PRINCIPAL FINDINGS

Our intervention was associated with greater recognition of the PSA test as a decision to be made, levels of knowledge, both preferred and actual levels of involvement in decision making, but did not have an impact on the screening decision.

CONCLUSIONS

Community-based interventions can influence key measures of IDM about PSA screening.

Decision-making processes for breast, colorectal, and prostate cancer screening: the DECISIONS survey

BACKGROUND

Patients should understand the risks and benefits of cancer screening in order to make informed screening decisions.

OBJECTIVES

To evaluate the extent of informed decision making in patient-provider discussions for colorectal (CRC), breast (BrCa), and prostate (PCa) cancer screening.

SETTING

National sample of US adults identified by random-digit dialing.

DESIGN

Cross-sectional survey conducted between November 2006 and May 2007.

PARTICIPANTS

English-speaking US adults aged 50 y and older who had discussed cancer screening with a health care provider within the previous 2 y.

MEASUREMENTS

Cancer screening survey modules that asked about demographic characteristics, cancer knowledge, the importance of various sources of information, and self-reported cancer screening decision-making processes.

RESULTS

Overall, 1082 participants completed 1 or more of the 3 cancer modules. Although participants generally considered themselves well informed about screening tests, half or more could not correctly answer even 1 open-ended knowledge question for any given module. Participants consistently overestimated risks for being diagnosed with and dying from each cancer and overestimated the positive predictive values of prostate-specific antigen tests and mammography. Providers were the most highly rated information source, usually initiated screening discussions (64%-84%), and often recommended screening (73%-90%). However, participants reported that providers elicited their screening preferences in only 31% (CRC women) to 57% (PCa) of discussions. Although more than 90% of the discussions addressed the pros of screening, only 19% (BrCa) to 30% (PCa) addressed the cons of screening.

LIMITATIONS

Recall bias is possible because screening process reports were not independently validated.

CONCLUSIONS

Cancer screening decisions reported by patients who discussed screening with their health care providers consistently failed to meet criteria for being informed. Given the high ratings for provider information and frequent recommendations for screening, providers have important opportunities to ensure that informed decision making occurs for cancer screening decisions.

Pros and cons of prostate cancer screening: associations with screening knowledge and attitudes among urban African American men

Discussion of the pros and cons of prostate cancer screening tests, rather than routine screening, is recommended to support informed screening decisions, particularly among African American men. This study explored physician explanation of pros and cons of the prostate-specific antigen (PSA) test and digital rectal exam (DRE) and its association with knowledge and screening attitudes. Two hundred-one African American men were asked if a physician had ever provided a comprehensive explanation of pros and cons of the PSA test and DRE. All men completed a 10-item prostate cancer knowledge scale and a subset completed a 26-item attitudes measure. Only 13% of the sample reported receiving a comprehensive explanation. Also, prostate cancer knowledge in the sample was low (mean = 43% correct). Multivariate analyses revealed that total prostate cancer knowledge was associated with men receiving a comprehensive explanation (p = .05), as well as past prostate cancer screening (p = .02) and younger age (p = .009). Although comprehensive explanation of prostate cancer screening was related to total prostate cancer knowledge, it was unrelated to a subset of items that may be central to fully informed screening decisions. Furthermore, comprehensive explanation of prostate cancer screening (p = .02), along with DRE recommendation (p = .009) and older age (p = .02), were related to fewer negative screening attitudes. Findings suggest that continued focus on patient education and physician communication is warranted.

Variation in prostate-specific antigen screening in men aged 80 and older in fee-for-service Medicare

OBJECTIVES

To determine the rate of prostate-specific antigen (PSA) screening in men aged 80 and older in Medicare and to examine geographic variation in screening rates across the U.S.

DESIGN

Retrospective cohort study of variation across hospital referral regions using administrative data.

SETTING

National random sample in fee-for-service Medicare.

PARTICIPANTS

Medicare beneficiaries aged 80 and older in 2003.

MEASUREMENTS

Percentage of men aged 80 and older screened using the PSA test.

RESULTS

The national rate of PSA screening in men aged 80 and older was 17.2%, but there was wide variation across regions (<2-38%). Higher PSA screening in a region was positively associated with greater total costs (correlation coefficient (r)=0.49, P<.001), greater intensive care unit use at the end of life (r=0.46, P<.001), and greater number of unique physicians seen (r=0.36, P<.001). PSA screening was negatively associated with proportion of beneficiaries using a primary care physician as opposed to a medical subspecialist for the predominance of ambulatory care (r=-0.38, P<.001).

CONCLUSION

PSA screening in men aged 80 and older is common practice, although its frequency is highly variable across the United States. Its association with fragmented physician care and aggressive end-of-life care may reflect less reliance on primary care and consequent difficulty informing patients of the potential harms and low likelihood of benefit of this procedure.

Lack of follow-up of prostate-specific antigen test results

OBJECTIVES

We obtained population estimates of the prevalence of lack of diagnostic follow-up after an abnormal prostate-specific antigen (PSA) result and assessed the role of sociodemographic, access, and risk perception factors on follow-up of abnormal tests.

METHODS

We used data from the 2000 National Health Interview Survey cancer control supplement. For 3,310 men aged 40 or older with a PSA test, 463 men reported an abnormal PSA test. Outcomes were abnormal PSA and lack of diagnostic follow-up in the latter group. Covariates for logistic regression included sociodemographic variables (age, race/ethnicity, and education), access to care (health insurance and usual source), and risk of cancer (family history and perceived risk). Survey analysis procedures accounted for the complex survey design.

RESULTS

Abnormal PSA results were associated with age, family history, and perceived risk of cancer. Approximately 15% of men with abnormal PSA tests reported no follow-up. The estimated number was 423,549 (95% confidence interval [CI] 317,755, 529,343). No follow-up was more likely in Hispanic men (odds ratio [OR] = 2.21, 95% CI 1.04, 4.70) and men without insurance (OR=6.56, 95% CI 2.02, 21.29), but less likely in men with a family history of prostate cancer or higher perceived risk of cancer.

CONCLUSIONS

Substantial numbers of men had no follow-up of abnormal PSA tests. Primary care physicians should assess continuity of care following abnormal PSA results. Data about prostate cancer screening and follow-up are needed to support clinical and policy decisions.

Prostate-specific antigen testing among the elderly in community-based family medicine practices

BACKGROUND

Controversy surrounds prostate-specific antigen (PSA) testing for prostate cancer screening, especially among elderly men aged 75 and older. This study examines whether patient age results in differential use of PSA testing and if organizational attributes such as communication, stress, decision making, and practice history of change predict PSA testing among men aged 75 and older.

METHODS

Data came from chart audits of 1149 men > or =50 years old who were patients of 46 family medicine practices participating in 2 northeastern practice-based research networks. Surveys administered to clinicians and staff in each practice provide practice-level data. A stratified Cochran-Mantel-Haenszel test was applied to examine whether PSA testing decreased with age. Hierarchical logistic regression analyses determined characteristics associated with PSA testing for men > or =75 years old.

RESULTS

Comparable rates for annual PSA testing of 77.2% for men aged 50 to 74 years and 74.6% for men > or =75 years old were reported. The Cochran-Mantel-Haenszel test indicated no significant change in trend. Hierarchical models suggest that practice communication is the only organizational attribute that influences PSA testing for men 75 years of age or older (odds ratio, 5.04; P = .022). Practices with higher communication scores (eg, promoted constructive work relationships and a team atmosphere between staff and clinicians) screened men aged 75 and older at lower rates than others.

CONCLUSIONS

Elderly men in community settings receive PSA testing at rates comparable to their younger counterparts even though major clinical practice guidelines discourage the practice for this population. Intraoffice practice interventions that target PSA testing to the most appropriate populations and focus on communication (both within the office and with patients) are needed.

Effect of guidelines on primary care physician use of PSA screening: results from the Community Tracking Study Physician Survey

BACKGROUND

Little is known about the effect of guidelines that recommend shared decision making on physician practice patterns. The objective of this study was to determine the association between physicians' perceived effect of guidelines on clinical practice and self-reported prostate-specific antigen (PSA) screening patterns.

METHODS

This was a cross-sectional study using a nationally representative sample of 3914 primary care physicians participating in the 1998-1999 Community Tracking Study Physician Survey. Responses to a case vignette that asked physicians what proportion of asymptomatic 60-year-old white men they would screen with a PSA were divided into 3 distinct groups: consistent PSA screeners (screen all), variable screeners (screen 1%- 99%), and consistent nonscreeners (screen none). Logistic regression was used to determine the association between PSA screening patterns and physician-reported effect of guidelines (no effect v. any magnitude effect).

RESULTS

Only 27% of physicians were variable PSA screeners; the rest were consistent screeners (60%) and consistent nonscreeners (13%). Only 8% of physicians perceived guidelines to have no effect on their practice. After adjustment for demographic and practice characteristics, variable screeners were more likely to report any magnitude effect of guidelines on their practice when compared with physicians in the other 2 groups (adjusted odds ratio= 1.73; 95% confidence interval=1:25-2:38;P=0:001).

CONCLUSIONS

Physicians who perceive an effect of guidelines on their practice are almost twice as likely to exhibit screening PSA practice variability, whereas physicians who do not perceive an effect of guidelines on their practice are more likely to be consistent PSA screeners or consistent PSA nonscreeners.

Community-based preferences for stool cards versus colonoscopy in colorectal cancer screening

BACKGROUND

In the United States, compliance with colorectal cancer (CRC) screening recommendations remains suboptimal. Professional organizations advocate use of shared decision making in screening test discussions, but strategies to facilitate informed choice in CRC screening have not been well elucidated.

OBJECTIVE

The objectives of the study were to determine screening test preference among colonoscopy-naïve adults after considering a detailed, written presentation of fecal occult blood testing (FOBT) and colonoscopy and to assess whether their preferences are associated with demographic characteristics, attitudes, and knowledge.

DESIGN

The design of the study was a cross-sectional survey.

PARTICIPANTS

Colonoscopy-naïve supermarket shoppers age 40-79 in low- and middle-income, multiethnic neighborhoods in Denver, CO, reviewed a detailed, side-by-side description of FOBT and colonoscopy and answered questions about test preference, strength of preference, influence of physician recommendation, basic knowledge of CRC, and demographic characteristics.

MEASUREMENTS AND MAIN RESULTS

Descriptive statistics characterized the sample, and bivariate and multivariable logistic regression analyses identified correlates of screening test preference. In a diverse sample of 323 colonoscopy-naïve adults, 53% preferred FOBT, and 47% preferred colonoscopy for CRC screening. Individuals of Latino ethnicity and those with lower educational attainment were more likely to prefer FOBT than non-Latino whites and those with at least some college. Almost half of the respondents felt "very strongly" about their preferences, and one third said they would adhere to their choice regardless of physician recommendation.

CONCLUSION

After considering a detailed, side-by-side comparison of the FOBT and colonoscopy, a large proportion of community-dwelling, colonoscopy-naïve adults prefer FOBT over colonoscopy for CRC screening. In light of professional guidelines and time-limited primary care visits, it is important to develop improved ways of facilitating informed patient decision making for CRC screening.

Determinants of prostate cancer stage in northern New England: USA Franco-American contextual effects

Despite screening for prostate cancer, mortality in the United States remains substantial. In northern New England, we know little about either determinants of stage at diagnosis--an important predictor of survival--or health outcomes for Franco-Americans, the region's largest ethnic minority. The objective of this investigation was to identify predictors of late prostate cancer stage in a rural, predominantly white state with a large Franco-American population. The Maine Cancer Registry provided incident cases from 1995 to 1998. We modeled individual-level variables (age, sex, race, French ethnicity by surname, and payer) and contextual/town-level variables (socioeconomic measures, population density, Franco ancestry proportion, distance to health care, and weather severity) with multiple logistic regression for late stage. We found that age categories 50-64, 65-74, and 75-84 years--but not 40-49 years--(versus 85+) were protective for late stage, as was residence in higher snowfall areas. Diagnosis in the earlier years of the study, particularly for French-surnamed men, and residence in a high-Franco area conferred greater risk for late disease. However, in a two-way interaction, residence in towns with high Franco ancestry proportion protected French-surnamed men (OR=0.09, type 3 p<0.0593). Using an established framework for social network theory we explore the potential reasons for this interaction, including: high social cohesion, a wide range of strong ties of long duration, and frequent contact, which might have facilitated access to resources as well as social support and normative influences toward health care seeking. The absence of an association of cancer stage with socioeconomic variables may stem from the mixed sociodemographic profiles in rural and urban regions of Maine. We feel that further research should therefore refine these and other contextual measures to elucidate effects on preventable morbidity and mortality; expand our knowledge of Franco-American health outcomes and social networks; and evaluate the utility of assigning French ethnicity by surname.

Prostate cancer testing following a negative prostate biopsy: over testing the elderly

BACKGROUND

Screening elderly men for prostate cancer is not recommended because definitive treatments are unlikely to extend life expectancy.

OBJECTIVE

Describe clinical outcomes after a negative prostate biopsy in a population-based cohort of men ages 65 and older.

DESIGN

Retrospective cohort study.

PARTICIPANTS

9,410 Medicare-eligible men who underwent a prostate biopsy in Los Angeles or New Mexico in 1992.

MEASUREMENTS

We used Medicare and SEER databases to identify a cohort with an initial negative biopsy (n = 7,119) and to ascertain survival, subsequent PSA testing, prostate biopsies, and prostate cancer detection and treatment through 1997.

RESULTS

The overall 5-year survival was 79.4% (95% CI 78.4-80.3), but only 74.6% (72.4-76.7) for men ages 75-79 at the time of the initial negative biopsy and 55.0% (51.9-57.9) for men ages 80+. During a median 4.5 years follow-up, a cumulative 75.0% (73.9-76.1) of the cohort underwent PSA testing. Among men ages 75-79 and 80+, the cumulative proportions that underwent PSA testing were 75.4% (73.0-77.8) and 74.3% (71.1-77.5), respectively. Additionally, 29.1% (26.7-31.6) of men ages 75-79 and 20.1% (17.6-23.1) of men ages 80+ underwent repeat prostate biopsy, and 10.9% (9.4-12.7) and 8.3% (6.6-10.4), respectively, were diagnosed with cancer. Among men ages 75+ with localized cancers, approximately 34% received definitive treatment.

CONCLUSIONS

High proportions of men ages 75+ underwent PSA testing and repeat prostate biopsies after an initial negative prostate biopsy. Given the known harms and uncertain benefits for finding and treating localized cancer in elderly men, most continued PSA testing after a negative biopsy is potentially inappropriate.

Are physicians discussing prostate cancer screening with their patients and why or why not? A pilot study

BACKGROUND

Prostate cancer screening (PCS) is controversial. Ideally, patients should understand the risks and benefits of screening before undergoing PSA testing. This study assessed whether primary care physicians routinely discuss PCS and explored the barriers to and facilitators of these discussions.

METHODS

Qualitative pilot study involving in-depth, semistructured interviews with 18 purposively sampled, academic and community-based primary care physicians. Barriers and facilitators of PCS discussions were ascertained using both interviews and chart-stimulated recall--a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinic encounters. Analysis was performed using consensus conferences based on grounded theory techniques.

RESULTS

All 18 participating physicians reported that they generally discussed PCS with patients, though 6 reported sometimes ordering PSA tests without discussion. A PCS discussion occurred in only 16 (36%) of the 44 patient-physician encounters when patients were due for PCS that also met criteria for chart-stimulated recall. Barriers to PCS discussion were patient comorbidity, limited education/health literacy, prior refusal of care, physician forgetfulness, acute-care visits, and lack of time. Facilitators of PCS discussion included patient-requested screening, highly educated patients, family history of prostate cancer, African-American race, visits for routine physicals, review of previous PSA results, extra time during encounters, and reminder systems.

CONCLUSIONS

PCS discussions sometimes do not occur. Important barriers to discussion are inadequate time for health maintenance, physician forgetfulness, and patient characteristics. Future research should explore using educational and decision support interventions to involve more patients in PCS decisions.

Hidden barriers between knowledge and behavior: the North Carolina prostate cancer screening and treatment experience

BACKGROUND

Prostate cancer (PC) mortality is much greater for African American than for Caucasian men. To identify patient factors that might account for some of this disparity, men within 6 months of diagnosis were surveyed about health attitudes and behavior.

METHODS

Using Rapid Identification in the North Carolina Cancer Registry, 207 African American and 348 Caucasian recently diagnosed PC patients were identified and surveyed.

RESULTS

African American men were younger and less often currently married, and had lesser education, job status, and income than Caucasian men (all P < .001). African American men were at no greater distance to medical care, but had less access: poorer medical insurance coverage, more use of public clinics and emergency wards, less continuity with a primary physician, and more often omitted physician visits they felt they needed. They also expressed less trust in physicians. African American men acknowledged their greater risk of PC, accepted greater responsibility for their health, and reported more personal failures that delayed diagnosis. African American men more often requested the tests that diagnosed their cancers, which resulted more often from routinely ordered screening tests for Caucasian men. African American men expressed less interest in nontraditional treatments.

CONCLUSIONS

Despite lesser education, African American men in North Carolina are aware of their increased risk of cancer, the importance of treatment, and their responsibility for their health. Obstacles to timely diagnosis and appropriate care, including greater physician distrust, appear more likely to arise from reduced access and continuity of medical care arising from their worse socioeconomic position.