Why is prostate cancer screening so common when the evidence is so uncertain? A system without negative feedback

[A conceptual framework for good preventive practices (or for quaternary prevention)]

Prevention is universally advocated, especially in the case of noncommunicable diseases. However, given the proliferation of preventive technologies, it does not seem defensible to generically encourage preventive behaviors and tests for healthcare professionals and users. In this essay, we articulate concepts, ideas and criteria for considering preventive measures, providing a minimum guide to be used by professionals (especially in primary healthcare) and managers. The concepts of primary, secondary and quaternary prevention are explored, as well as those of reductive and additive prevention, high-risk and population-based preventive strategies; evidence-based medicine and its contemporary crisis; the precautionary principle; health promotion, an expanded, person-centered approach and shared decision-making. This discussion was designed to improve competence in the evaluation of preventive measures, making clinical and health decisions more judicious and less iatrogenic regarding primary and secondary prevention.

Health Promotion of Early and Sustained Allergenic Food Introduction for the Prevention of Food Allergy

Observational studies and landmark randomized control trials support early and sustained allergenic food introduction in infancy as an effective preventive strategy against food allergy development. Despite a consensus regarding the intended goals of early and sustained allergenic food introduction, there have been myriad policy recommendations among health authorities in how to achieve both individual and population-level health outcomes for food allergy prevention. This clinical management review provides an overview on the data that informs early and sustained allergenic food introduction strategies, suggestions on how to advise allergenic food introduction, principles of prevention programs as they relate to food allergy prevention, and health promotion and systems-level challenges that impede achievement of food allergy prevention goals.

Associations of Content and Context of Communication with Prostate-Specific Antigen Testing

There is limited research about the content and context of communication on prostate-specific antigen (PSA) testing among men in the state of Florida. The purpose of this study is to understand how the content communication (discussion of advantages and disadvantages of PSA testing between provider and patient; provider recommendations of PSA testing) and the context of communication (continuity of care denoted by the presence of a personal doctor) influence PSA testing. Data were drawn from the Florida Behavioral Risk Factor Surveillance System. Receipt of PSA testing was the primary outcome. Multiple logistic regression analyses were used to adjust for sociodemographic, clinical, healthcare access, and lifestyle characteristics when associating the content and context of communication with PSA testing. Discussions were classified into four mutually exclusive categories: discussions of advantages and disadvantages, only advantages, only disadvantages, and no discussion. The most significant predictors for PSA testing included physician recommendation, discussions including advantages, older age, non-smoking, and having a personal doctor. Individualized PSA screening may be a pathway to reducing racial disparities in screening for prostate cancer (PCa) and, by extension, lower incidence and mortality rates. Developing a bill to create an Office of Men's Health at Health & Human Services is recommended.

Cancer overdiagnosis: a challenge in the era of screening

"Screening" is a search for preclinical, asymptomatic disease, including cancer. Widespread cancer screening has led to large increases in early-stage cancers and pre-cancers. Ubiquitous public messages emphasize the potential benefits to screening for these lesions based on the underlying assumption that treating cancer at early stages before spread to other organs should make it easier to treat and cure, using more tolerable interventions. The intuition is so strong that public campaigns are sometimes launched without conducting definitive trials directly comparing screening to usual care. An effective cancer screening test should not only increase the incidence of early-stage preclinical disease but should also decrease the incidence of advanced and metastatic cancer, as well as a subsequent decrease in cancer-related mortality. Otherwise, screening efforts may be uncovering a reservoir of non-progressive and very slowly progressive lesions that were not destined to cause symptoms or suffering during the person's remaining natural lifespan: a phenomenon known as "overdiagnosis." We provide here a qualitative review of cancer overdiagnosis and discuss specific examples due to extensive population-based screening, including neuroblastoma, prostate cancer, thyroid cancer, lung cancer, melanoma, and breast cancer. The harms of unnecessary diagnosis and cancer therapy call for a balanced presentation to people considering undergoing screening, even with a test of accepted benefit, with a goal of informed decision-making. We also discuss proposed strategies to mitigate the adverse sequelae of overdiagnosis.

Self-efficacy and importance of participation reasons as predictors for prostate cancer screening intention in African American men

Objective: African American men have higher lifetime risk of developing prostate cancer (PCa), and face more health burdens from this disease due in part to limited participation in cancer screening. Therefore, it is important to study psychosocial factors associated with screening intention in African American men. Guided by social cognitive theory, the current study aims to examine the role of self-efficacy and importance of participation reasons as predictors of PCa screening intention in African American men.Design: This is a primary analysis using data collected from African American men in northeast Ohio and the Southeastern United States. PCa screening intention and self-efficacy were measured by single-item questions. Importance of participation reasons was measured in four domains: psychological, convenience, awareness, and medical. Hierarchical binary logistic regression was used to predict PCa screening intention in African American men.Results: The sample size was 174. The average age was 46.52. Adding self-efficacy and reasons for participation significantly improved prediction for PCa screening intention in African American men (Δχ² = 55.28, p < .001). The final model had χ² = 69.63 (p < .001). Higher self-efficacy (OR = 2.56, p < .05), more perceived importance of psychological reasons (OR = 2.42, p < .001) and medical reasons (OR = 1.10, p < .05) were significant predictors. Also, the perceived chance of developing PCa predicted higher odds of PCa screening intention.Conclusions: Enhancing self-efficacy might be an important intervention focus for African American men to improve PCa screening intention. In addition, the findings suggest that African American men intend to have PCa screening because they experience worries or physical symptoms, and unlikely because it is convenient to get screening or recommended by family members and friends. Thus, intervention efforts could focus on enhancing PCa knowledge and informed decision-making about PCa screening among African American men.

Harms and Benefits of Cancer Screening

In recommending and offering screening, health services make a health claim ('it's good for you'). This article considers ethical aspects of establishing the case for cancer screening, building a service programme, monitoring its operation, improving its quality and integrating it with medical progress. The value of (first) screening is derived as a function of key parameters: prevalence of the target lesion in the detectable pre-clinical phase, the validity of the test and the respective net utilities or values attributed to four health states-true positives, false positives, false negatives and true negatives. Decision makers as diverse as public regulatory agencies, medical associations, health insurance funds or individual screenees can legitimately come up with different values even when presented with the same evidence base. The main intended benefit of screening is the reduction of cause-specific mortality. All-cause mortality is not measurably affected. Overdiagnosis and false-positive tests with their sequelae are the main harms. Harms and benefits accrue to distinct individuals. Hence the health claim is an invitation to a lottery with benefits for few and harms to many, a violation of the non-maleficence principle. While a public decision maker may still propose a justified screening programme, respect for individual rights and values requires preference-sensitive, autonomy-enhancing educational materials-even at the expense of programme effectiveness. Opt-in recommendations and more 'consumer-oriented' qualitative research are needed.

Physician Beliefs and Patient Preferences: A New Look at Regional Variation in Health Care Spendingf

There is considerable controversy about the causes of regional variations in health care expenditures. Using vignettes from patient and physician surveys linked to fee-for-service Medicare expenditures, this study asks whether patient demand-side factors or physician supply-side factors explain these variations. The results indicate that patient demand is relatively unimportant in explaining variations. Physician organizational factors matter, but the most important factor is physician beliefs about treatment. In Medicare, we estimate that 35 percent of spending for end-of-life care and 12 percent of spending for heart attack patients (and for all enrollees) is associated with physician beliefs unsupported by clinical evidence. (JEL D83, H75, I11, I18).

Understanding women's hesitancy to undergo less frequent cervical cancer screening

Inappropriate cervical cancer screening (e.g., screening too often) can result in unnecessary medical procedures, treatment, and psychological distress. To balance the benefits and harms, cervical cancer screening guidelines were recently modified in favor of less frequent screening (i.e., every 3 to 5 years). This study investigated women's acceptance of less frequent cervical cancer screening and their primary concerns about extending the screening interval beyond one year. A national sample of 376 U.S. women ages 21-65 completed an online survey in 2014. Predictors of willingness to get a Pap test every 3 to 5 years were identified using logistic regression. We also examined perceived consequences of less frequent screening. Over two thirds were willing to undergo less frequent screening if it was recommended by their healthcare provider. Nevertheless, nearly 20% expressed discomfort with less frequent screening and 45% were either in opposition or unsure whether they would be comfortable replacing Pap testing with primary HPV testing. Women whose most recent Pap test was (vs. was not) within the past year and women who ever (vs. never) had an abnormal Pap test were less willing to extend the screening interval. Additionally, women who typically saw an obstetrician/gynecologist or nurse practitioner for their Pap test (vs. a family physician) were less accepting of the guidelines. Hesitancy about the longer screening interval appears to stem from concern about developing cancer between screenings. Findings contribute to the growing body of research on cancer overscreening and may inform interventions for improving adherence to cancer screening guidelines.

Do men regret prostate biopsy: Results from the PiCTure study

Background

Understanding men’s experience of prostate biopsy is important as the procedure is common, invasive and carries potential risks. The psychological aspects of prostate biopsy have been somewhat neglected. The aim of this study was to explore the level of regret experienced by men after prostate biopsy and identify any associated factors.

Methods

Men attending four clinics in Republic of Ireland and two in Northern Ireland were given a questionnaire to explore their experience of prostate biopsy. Regret was measured on a Likert scale asking men how much they agreed with the statement “It [the biopsy] is something I regret.”

Results

Three hundred thirty-five men responded to the survey. The mean age was 63 years (SD ±7 years). Three quarters of respondents (76%) were married or co-habiting, and (75%) finished education at primary or secondary school level. For just over two thirds of men (70%) their recent biopsy represented their first ever prostate biopsy. Approximately one third of men reported a diagnosis of cancer, one third a negative biopsy result, and the remaining third did not know their result. Two thirds of men reported intermediate or high health anxiety. 5.1% of men agreed or strongly agreed that they regretted the biopsy.

Conclusions

Level of regret was low overall. Health anxiety was the only significant predictor of regret, with men with higher anxiety reporting higher levels of regret than men with low anxiety (OR = 3.04, 95% CI 1.58, 5.84).

Men with high health anxiety may especially benefit from careful counselling before and after prostate biopsy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-016-0194-y) contains supplementary material, which is available to authorized users.

Experiences of Uncertainty in Men With an Elevated PSA

A significant proportion of men, ages 50 to 70 years, have, and continue to receive prostate specific antigen (PSA) tests to screen for prostate cancer (PCa). Approximately 70% of men with an elevated PSA level will not subsequently be diagnosed with PCa. Semistructured interviews were conducted with 13 men with an elevated PSA level who had not been diagnosed with PCa. Uncertainty was prominent in men's reactions to the PSA results, stemming from unanswered questions about the PSA test, PCa risk, and confusion about their management plan. Uncertainty was exacerbated or reduced depending on whether health care providers communicated in lay and empathetic ways, and provided opportunities for question asking. To manage uncertainty, men engaged in information and health care seeking, self-monitoring, and defensive cognition. Results inform strategies for meeting informational needs of men with an elevated PSA and confirm the primary importance of physician communication behavior for open information exchange and uncertainty reduction.

Mode of prostate cancer detection is associated with the psychological wellbeing of survivors: results from the PiCTure study

PURPOSE

Many men with prostate cancer are asymptomatic, diagnosed following prostate specific antigen (PSA) testing. We investigate whether mode of detection, i.e. 'PSA detected' or 'clinically detected', was associated with psychological wellbeing among prostate cancer survivors.

METHODS

A cross-sectional postal questionnaire was administered in 2012 to 6559 prostate cancer (ICD10 C61) survivors up to 18 years post-diagnosis, identified through population-based cancer registries in Ireland. Psychological wellbeing was assessed using the Depression Anxiety Stress Scale-21. Logistic regression was used to investigate associations between mode of detection and depression, anxiety and stress, adjusting for socio-demographic and clinical confounders.

RESULTS

The response rate was 54 % (3348/6262). Fifty-nine percent of survivors were diagnosed with asymptomatic PSA-tested disease. Prevalence of depression (13.8 vs 20.7 %; p < 0.001), anxiety (13.6 vs 20.9 %; p < 0.001) and stress (8.7 vs 13.8 %; p < 0.001) were significantly lower among survivors diagnosed with PSA-detected, than clinically detected disease. After adjusting for clinical and socio-demographic factors, survivors with clinically detected disease had significantly higher risk of depression (odds ratio (OR) = 1.46 95 % CI 1.18, 1.80; p = 0.001), anxiety (OR = 1.36 95 % CI 1.09, 1.68; p = 0.006) and stress (OR = 1.43 95 % CI 1.11, 1.85; p = 0.006) than survivors with PSA-detected disease.

CONCLUSIONS

These findings contribute to the ongoing debate on benefits and risks of PSA testing and may be considered by policy makers formulating population-based prostate cancer screening policies. The relatively high prevalence of negative psychological states among survivors means that a 'risk-adapted approach' should be implemented to screen survivors most at risk of psychological morbidity for psychological health, and mode of detection could be considered as a risk stratum.

A value framework for cancer screening: advice for high-value care from the American College of Physicians

Experts, professional societies, and consumer groups often recommend different strategies for cancer screening. These strategies vary in the intensity of their search for asymptomatic lesions and in their value. This article outlines a framework for thinking about the value of varying intensities of cancer screening. The authors conclude that increasing intensity beyond an optimal level leads to low-value screening and speculate about pressures that encourage overly intensive, low-value screening.

Determinants of participation in prostate cancer screening: a simple analytical framework to account for healthy-user bias

In Japan at present, fecal occult blood testing (FOBT) is recommended for cancer screening while routine population-based prostate-specific antigen (PSA) screening is not. In future it may be necessary to increase participation in the former and decrease it in the latter. Our objectives were to explore determinants of PSA-screening participation while simultaneously taking into account factors associated with FOBT. Data were gathered from a cross-sectional study conducted with random sampling of 6191 adults in Osaka city in 2011. Of 3244 subjects (return rate 52.4%), 936 men aged 40-64 years were analyzed using log-binomial regression to explore factors related to PSA-screening participation within 1 year. Only responders for cancer screening, defined as men who participated in either FOBT or PSA-testing, were used as main study subjects. Men who were older (prevalence ratio [PR] [95% confidence interval (CI)] = 2.17 [1.43, 3.28] for 60-64 years compared with 40-49 years), had technical or junior college education (PR [95% CI] = 1.76 [1.19, 2.59] compared with men with high school or less) and followed doctors' recommendations (PR [95% CI] = 1.50 [1.00, 2.26]) were significantly more likely to have PSA-screening after multiple variable adjustment among cancer-screening responders. Attenuation in PR of hypothesized common factors was observed among cancer-screening responders compared with the usual approach (among total subjects). Using the analytical framework to account for healthy-user bias, we found three factors related to participation in PSA-screening with attenuated association of common factors. This approach may provide a more sophisticated interpretation of participation in various screenings with different levels of recommendation.

Prostate cancer survivors' beliefs about screening and treatment decision-making experiences in an era of controversy

OBJECTIVE

Controversy about the costs and benefits of screening and treatment of prostate cancer (PCa) has recently intensified. However, the impact of the debate on PCa patients has not been systematically studied.

METHODS

We assessed knowledge of, and attitudes toward, the U.S. Preventive Services Task Force's (USPSTF) May 2012 recommendation against PSA-based screening among men diagnosed with clinically localized PCa, and tested whether exposure to the recommendation and associated controversy about overtreatment of PCa predicted treatment decisional conflict, affected treatment choice, or increased regret about PSA testing.

RESULTS

Accurate knowledge of the USPSTF recommendation was uncommon (19.1%). Attitudes toward the recommendation were negative, and the vast majority (86.5%) remained highly supportive of annual PSA testing in men ≥50. Although exposure to the recommendation and controversy about treatment was associated with lower enthusiasm for screening and treatment, it was not associated with treatment decisions, or greater decisional-conflict, or regret.

CONCLUSIONS

Findings may alleviate concern that exposure to PSA-based screening and overtreatment controversies has adversely affected recent cohorts of PCa patients. However, patients remain highly supportive of PSA-based screening. As survivor anecdotes often influence people's medical decisions, it is important to appreciate the scale of opposition to the new recommendation.

Lack of shared decision making in cancer screening discussions: results from a national survey

BACKGROUND

Clinicians are encouraged to support patients in achieving shared decision making (SDM) for cancer screening.

PURPOSE

To describe decision making processes and outcomes for cancer screening discussions.

METHODS

A 2011 national Internet survey of adults aged ≥50 years who made cancer screening decisions (breast, BrCa; colorectal, CRC; prostate, PCa) within the previous 2 years was conducted. Participants were asked about their perceived cancer risk; how informed they felt about cancer tests; whether their healthcare provider addressed pros/cons of testing, presented the option of no testing, and elicited their input; whether they were tested; and their confidence in the screening decision. Data were analyzed in 2013-2014 with descriptive statistics and logistic regression.

RESULTS

Overall, 1,134 participants (477 men, 657 women) aged ≥50 years made cancer screening decisions, and 1,098 (354, BrCa; 598, CRC; 146, PCa) decisions were discussed with a healthcare provider. Most discussions (51%-67%) addressed pros of screening some or a lot, but few (7%-14%) similarly addressed cons. For all cancer screening decisions, providers usually (63%-71%) explained that testing was optional, but less often asked women (43%-57%) than men (70%-71%) whether they wanted testing. Only 27%-38% of participants reported SDM, 69%-93% underwent screening, and 55%-76% would definitely make the same decision again. Perceived high/average cancer risk and feeling highly informed were associated with confidence in the screening decision.

CONCLUSIONS

Discussions often failed to provide balanced information and meet SDM criteria. Supporting SDM could potentially improve the quality of cancer screening decisions.

Addressing overdiagnosis and overtreatment in cancer: a prescription for change

A vast range of disorders--from indolent to fast-growing lesions--are labelled as cancer. Therefore, we believe that several changes should be made to the approach to cancer screening and care, such as use of new terminology for indolent and precancerous disorders. We propose the term indolent lesion of epithelial origin, or IDLE, for those lesions (currently labelled as cancers) and their precursors that are unlikely to cause harm if they are left untreated. Furthermore, precursors of cancer or high-risk disorders should not have the term cancer in them. The rationale for this change in approach is that indolent lesions with low malignant potential are common, and screening brings indolent lesions and their precursors to clinical attention, which leads to overdiagnosis and, if unrecognised, possible overtreatment. To minimise that potential, new strategies should be adopted to better define and manage IDLEs. Screening guidelines should be revised to lower the chance of detection of minimal-risk IDLEs and inconsequential cancers with the same energy traditionally used to increase the sensitivity of screening tests. Changing the terminology for some of the lesions currently referred to as cancer will allow physicians to shift medicolegal notions and perceived risk to reflect the evolving understanding of biology, be more judicious about when a biopsy should be done, and organise studies and registries that offer observation or less invasive approaches for indolent disease. Emphasis on avoidance of harm while assuring benefit will improve screening and treatment of patients and will be equally effective in the prevention of death from cancer.

Discussing uncertainty and risk in primary care: recommendations of a multi-disciplinary panel regarding communication around prostate cancer screening

BACKGROUND

Shared decision making improves value-concordant decision-making around prostate cancer screening (PrCS). Yet, PrCS discussions remain complex, challenging and often emotional for physicians and average-risk men.

OBJECTIVE

In July 2011, the Centers for Disease Control and Prevention convened a multidisciplinary expert panel to identify priorities for funding agencies and development groups to promote evidence-based, value-concordant decisions between men at average risk for prostate cancer and their physicians.

DESIGN

Two-day multidisciplinary expert panel in Atlanta, Georgia, with structured discussions and formal consensus processes.

PARTICIPANTS

Sixteen panelists represented diverse specialties (primary care, medical oncology, urology), disciplines (sociology, communication, medical education, clinical epidemiology) and market sectors (patient advocacy groups, Federal funding agencies, guideline-development organizations).

MAIN MEASURES

Panelists used guiding interactional and evaluation models to identify and rate strategies that might improve PrCS discussions and decisions for physicians, patients and health systems/society. Efficacy was defined as the likelihood of each strategy to impact outcomes. Effort was defined as the relative amount of effort to develop, implement and sustain the strategy. Each strategy was rated (1-7 scale; 7 = maximum) using group process software (ThinkTank(TM)). For each group, intervention strategies were grouped as financial/regulatory, educational, communication or attitudinal levers. For each strategy, barriers were identified.

KEY RESULTS

Highly ranked strategies to improve value-concordant shared decision-making (SDM) included: changing outpatient clinic visit reimbursement to reward SDM; development of evidence-based, technology-assisted, point-of-service tools for physicians and patients; reframing confusing prostate cancer screening messages; providing pre-visit decision support interventions; utilizing electronic health records to promote benchmarking/best practices; providing additional training for physicians around value-concordant decision-making; and using re-accreditation to promote training.

CONCLUSIONS

Conference outcomes present an expert consensus of strategies likely to improve value-concordant prostate cancer screening decisions. In addition, the methodology used to obtain agreement provides a model of successful collaboration around this and future controversial cancer screening issues, which may be of interest to funding agencies, educators and policy makers.

A Conceptual Framework for Understanding and Reducing Overuse by Primary Care Providers

Primary care providers frequently recommend, administer, or prescribe health care services that are unlikely to benefit their patients. Yet little is known about how to reduce provider overuse behavior. In the absence of a theoretically grounded causal framework, it is difficult to predict the contexts under which different types of interventions to reduce provider overuse will succeed and under which they will fail. In this article, we present a framework based on the theory of planned behavior that is designed to guide overuse research and intervention development. We describe categories of primary care provider beliefs that lead to the formation of intentions to assess the appropriateness of services, and propose factors that may affect whether the presence of assessment intentions results in an appropriate recommendation. Interventions that have been commonly used to address provider overuse behavior are reviewed within the context of the framework.

A survey of a small sample of emergency department and admitted patients asking whether they expect to be tested for HIV routinely

OBJECTIVES

Many US HIV-positive patients are unaware of their infection. Although there are multiple studies assessing the acceptance of testing, there are none that assess the patient's expectations of routine HIV testing.

METHODS

Through a prospective, cross-sectional, unfunded, convenience sample survey, we assessed the patient's expectation of testing at a regional medical center serving an indigent population. Also, we compared the providers' predictions of the proportion of patients expecting a test.

RESULTS

Of the 69 patients, 23% expected a test. The only factor that correlated with this was their desire to be tested (P = .004). Providers' (N = 59) mean prediction was that 21% of the patients expected a test (range: 0%-100%). The proportion of emergency department (ED) patients wanting a test was 52% (of 30) and internal medicine inpatients were 44% (of 39).

CONCLUSIONS

Nearly a quarter of patients expected routine HIV testing. This finding should encourage a review of policies promoting HIV testing, especially within the ED.

Primary care physicians' use of an informed decision-making process for prostate cancer screening

PURPOSE

Leading professional organizations acknowledge the importance of an informed decision-making process for prostate cancer screening. We describe primary care physicians' reports of their prescreening discussions about the potential harms and benefits of prostate cancer screening.

METHODS

Members of the American Academy of Family Physicians National Research Network responded to a survey that included (1) an indicator of practice styles related to discussing harms and benefits of prostate-specific antigen testing and providing a screening recommendation or letting patients decide, and (2) indicators reflecting physicians' beliefs about prostate cancer screening. The survey was conducted between July 2007 and January 2008.

RESULTS

Of 426 physicians 246 (57.7%) completed the survey questionnaire. Compared with physicians who ordered screening without discussion (24.3%), physicians who discussed harms and benefits with patients and then let them decide (47.7%) were more likely to endorse beliefs that scientific evidence does not support screening, that patients should be told about the lack of evidence, and that patients have a right to know the limitations of screening; they were also less likely to endorse the belief that there was no need to educate patients because they wanted to be screened. Concerns about medicolegal risk associated with not screening were more common among physicians who discussed the harms and benefits and recommended screening than among physicians who discussed screening and let their patients decide.

CONCLUSIONS

Much of the variability in physicians' use of an informed decision-making process can be attributed to beliefs about screening. Concerns about medicolegal risk remain an important barrier for shared decision making.

Simulation optimization of PSA-threshold based prostate cancer screening policies

We describe a simulation optimization method to design PSA screening policies based on expected quality adjusted life years (QALYs). Our method integrates a simulation model in a genetic algorithm which uses a probabilistic method for selection of the best policy. We present computational results about the efficiency of our algorithm. The best policy generated by our algorithm is compared to previously recommended screening policies. Using the policies determined by our model, we present evidence that patients should be screened more aggressively but for a shorter length of time than previously published guidelines recommended.

Prostate cancer screening practices of African-American and non-African-American US primary care physicians: a cross-sectional survey

Purpose:

We explored whether African-American (AA) primary care physicians (PCPs) have different prostate cancer screening practices compared to non-AA PCPs, after adjustment for potential confounding factors such as the proportion of AA patients in PCP practices.

Methods:

We used SAS/SUDAAN to compare weighted responses from AA PCPs (n = 604) with those from non-AA PCPs (n = 647) in the 2007–2008 National Survey of Primary Care Physician Practices Regarding Prostate Cancer Screening. We used multivariate logistic regression to calculate the weighted odds ratios (OR) and 95% confidence intervals (CI).

Results:

We found that AA PCPs had higher odds of working in practices with above-the-median (≥ 21%) proportions of AA male patients (OR, 9.02; 95% CI: 5.85–13.91). A higher proportion of AA PCPs (53.5%; 95% CI: 49.5–57.4) reported an above-the-median proportion (≥ 91%) of PSA testing during health maintenance exams as compared to non-AA PCPs (39.4%; 95% CI: 35.5–43.4; P < 0.0002). After adjusting for the proportion of AA patients and other factors, we found that AA PCPs had higher odds of using PSA tests to screen men (OR, 1.74; 95% CI: 1.11–2.73).

Conclusion:

This study quantifies the magnitude of the differences reported in previous focus group studies. Our results may be helpful in hypothesis generation and in planning future research studies.

Serious health events and discontinuation of routine cancer screening

Recently revised US Preventive Services Task Force screening guidelines for colorectal, breast, and prostate cancer contain separate recommendations for persons younger than 75 years and those 75 years or older. Developing an understanding of whether and how patients discontinue screening is important for evaluating the potential benefits and drawbacks of age-delimited screening recommendations as a tool for reducing overdiagnosis rates. Using Surveillance, Epidemiology, and End

RESULTS

-Medicare data from 1998 to 2007, the authors identified a sample of 32,189 female and 27,669 male fee-for-service Medicare beneficiaries who received 2 consecutive breast or prostate screens, 1 year apart. They then estimated the impact of serious health events, such as heart attacks and strokes, on continuation of screening. Rescreening rates among beneficiaries who did not experience a serious health event were 78% for women and 82% for men. Rescreening rates among beneficiaries who experienced a serious health event were 55% for women and 57% for men. The rate ratios associated with a time-varying indicator for the 2-year period following a serious health event were 0.79 (95% confidence interval: 0.76 to 0.81); P < 0.001) for women and 0.87 (95% confidence interval: 0.85 to 0.89; P < 0.001) for men. Approximately one-third of patients and physicians discontinue or temporarily suspend screening for breast and prostate cancer following serious health events. Findings suggest that not all patients persist with screening until they die.

Recommendations for post-polypectomy surveillance in community practice

BACKGROUND

After colon cancer screening, large numbers of persons discovered with colon polyps may receive post-polypectomy surveillance with multiple colonoscopy examinations over time. Decisions about surveillance interval are based in part on polyp size, histology, and number.

AIMS

To learn physicians' recommendations for post-polypectomy surveillance from physicians' office charts.

METHODS

Among 322 physicians performing colonoscopy in 126 practices in N. Carolina, offices of 152 physicians in 55 practices were visited to extract chart data, for each physician, on 125 consecutive persons having colonoscopy in 2003. Subjects included persons with first-time colonoscopy and no positive family history or other indication beyond colonoscopy findings that might affect post-polypectomy surveillance recommendations. Data were extracted about demographics, reason for colonoscopy, family history, symptoms, bowel prep, extent of examination, and features of each polyp including location, size, histology. Recommendations for post-polypectomy surveillance were noted.

RESULTS

Among 10,089 first-time colonoscopy examinations, hyperplastic polyps were found in 4.5% of subjects, in whom follow-up by 4-6 years was recommended in 24%, sooner than recommended in guidelines. Of the 6.6% of persons with only small adenomas, 35% were recommended to return in 1-3 years (sooner than recommended in some guidelines) and 77% by 6 years. Surveillance interval tended to be shorter if colon prep was less than "excellent." Prep quality was not reported for 32% of examinations.

CONCLUSIONS

Surveillance intervals after polypectomy of low-risk polyps may be more aggressive than guidelines recommend. The quality of post-polypectomy surveillance might be improved by increased attention to guidelines, bowel prep, and reporting.

The promises of genomic screening: building a governance infrastructure. Special issue: genetics and democracy

New screening possibilities become available at a high rate, both useful and unsound possibilities. All screening programmes do harm, and only few have more advantages than disadvantages at reasonable cost. Horizon scanning is needed to identify those few possibilities with more pros than cons. Attunement is needed between actors involved: scientists developing new high-throughput screening techniques and treatment, health care workers, patients and consumers and governmental agencies. The product of a process of attunement may be a quality mark as a norm for professional conduct, rather than legal measures, as the field is moving fast. As actors may have varying perspectives, a governance structure is needed to develop an agenda that is agreed upon by all or most actors involved. A standing committee might oversee the evaluation of benefits and disadvantages in an integrated approach, taking evidence, economics and ethics into account. A proactive role of governmental agencies is needed to facilitate agenda setting and attunement. Policy making has to be transparent and open to stakeholder engagement.

Deciding on PSA-screening - Quality of current consumer information on the Internet

PURPOSE OF THE STUDY

Given that screening for prostate cancer has the potential to reduce prostate cancer mortality at the expense of considerable overdiagnosis and overtreatment, the availability of core consumer information - correct, balanced and supportive of autonomous decision-making - is a must. We assessed the quality of consumer information available through the Internet per November 2009 and its possible contribution to informed decision-making by potential screenees.

METHODS

Consumer information on PSA-screening was sought through the Internet in November 2009. Materials had to be targeted at potential consumers, offered by not-for-profit organisations, released in 2005 or after, in English or Dutch. Per material 2 of the authors assessed independently from each other whether standardised pre-defined topics were addressed, whether the content was correct and which approach was taken towards the decision-making process about uptake.

RESULTS

Twenty-three materials were included, of which 11 were released (shortly) after the results of 2 large randomized-controlled trials (RCTs) that evaluated the effectiveness of screening for prostate cancer had been published in March 2009. That a PSA-test result can be abnormal because of non-cancerous conditions (false positive) and that it may miss prostate cancer (false negative) was not addressed in 2/23 and 8/23 materials, respectively. The risk of overdiagnosis and overtreatment was not mentioned in 6 out of 23. PSA-screening was presented as a usual thing to do in some materials, whereas other materials emphasised the voluntary nature of PSA-screening ('it is your decision'). The content of 19/23 materials was considered sufficiently informative according to the pre-defined criteria, 12/23 materials were considered supportive of informed decision-making by men.

CONCLUSIONS

Most materials of not-for-profit organizations supplied adequate information about PSA-screening, whilst the degree of persuasion towards uptake reflected variations in opinions on men's autonomy regarding their own health.

Applying strategies from libertarian paternalism to decision making for prostate specific antigen (PSA) screening

BACKGROUND

Despite the recent publication of results from two randomized clinical trials, prostate specific antigen (PSA) screening for prostate cancer remains a controversial issue. There is lack of agreement across studies that PSA screening significantly reduces prostate cancer mortality. In spite of these facts, the widespread use of PSA testing in the United States leads to overdetection and overtreatment of clinically indolent prostate cancer, and its associated harms of incontinence and impotence.

DISCUSSION

Given the inconclusive results from clinical trials and incongruent PSA screening guidelines, the decision to screen for prostate cancer with PSA testing is an uncertain one for patients and health care providers. Screening guidelines from some health organizations recommend an informed decision making (IDM) or shared decision making (SDM) approach for deciding on PSA screening. These approaches aim to empower patients to choose among the available options by making them active participants in the decision making process. By increasing involvement of patients in the clinical decision-making process, IDM/SDM places more of the responsibility for a complex decision on the patient. Research suggests, however, that patients are not well-informed of the harms and benefits associated with prostate cancer screening and are also subject to an assortment of biases, emotion, fears, and irrational thought that interferes with making an informed decision. In response, the IDM/SDM approaches can be augmented with strategies from the philosophy of libertarian paternalism (LP) to improve decision making. LP uses the insights of behavioural economics to help people better make better choices. Some of the main strategies of LP applicable to PSA decision making are a default decision rule, framing of decision aids, and timing of the decision. In this paper, we propose that applying strategies from libertarian paternalism can help with PSA screening decision-making.

SUMMARY

Our proposal to augment IDM and SDM approaches with libertarian paternalism strategies is intended to guide patients toward a better decision about testing while maintaining personal freedom of choice. While PSA screening remains controversial and evidence conflicting, a libertarian-paternalism influenced approach to decision making can help prevent the overdiagnosis and overtreatment of prostate cancer.

Difference in willingness-to-pay for prostate cancer screening between ill-informed and well-informed men: a contingent valuation survey

OBJECTIVES

To use a contingent valuation method to compare the willingness of well-informed and ill-informed men to pay for PSA screening. Prostate cancer screening by analysis of prostate-specific antigen (PSA) levels has recently been confirmed to reduce prostate cancer death. However, PSA screening is associated with considerable risks, and men should be well informed about the risks before deciding to undergo the test.

METHODS

A total of 1800 men aged 50-69 years old participated in an Internet-based, computer-assisted questionnaire survey. The subjects were randomly divided into 2 groups. Group 1 (n = 900) was provided with information about the procedure, detection rate, and mortality-reducing effects of PSA screening. Additional information was given to group 2 (n = 900), including the possibility of false-positive or false-negative results, the risks of close examination, and the possibility of overdiagnoses. The willingness to pay (WTP) was assessed using a double-bound dichotomous choice method.

RESULTS

The average WTP was significantly greater in group 1 than in group 2 ($31.1 vs $25.1, P < .01). Weibull regression analysis showed that patients with a history of receiving PSA screening or with greater incomes had a significantly greater WTP.

CONCLUSIONS

Although providing information on the risks of PSA screening significantly decreased men's WTP for such tests, the well-informed group was still willing to pay $25.1. These findings suggest that men can balance the potential disadvantages of PSA screening against its effectiveness in saving lives.

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.

Too much of a good thing? Physician practices and patient willingness for less frequent pap test screening intervals

BACKGROUND

Recent guidelines recommend longer Pap test intervals. However, physicians and patients may not be adopting these recommendations.

OBJECTIVES

Identify (1) physician and practice characteristics associated with recommending a less frequent interval, and (2) characteristics associated with women's willingness to adhere to a 3-year interval.

RESEARCH DESIGN

We used 2 national surveys: (1) a 2006/2007 National Survey of Primary Care Physicians for physician cervical cancer screening practices (N = 1114), and (2) the 2005 Health Information Trends Survey for women's acceptance of longer Pap intervals (N = 2206). MEASURES AND METHODS: Physician recommendation regarding Pap intervals was measured using a clinical vignette involving a 35-year-old with no new sexual partners and 3 consecutive negative Pap tests; associations with independent variables were evaluated with logistic regression. In parallel models, we evaluated women's willingness to follow a 3-year Pap test interval.

RESULTS

A minority of physicians (32%) have adopted-but more than half of women are willing to adopt-3-year Pap test intervals. In adjusted models, physician factors associated with less frequent screening were: serving a higher proportion of Medicaid patients, white, non-Hispanic race, fewer years since medical school graduation, and US Preventive Services Task Force being very influential in physician clinical practice. Women were more willing to follow a 3-year interval if they were older, but less willing if they had personal or family experiences with cancer or followed an annual Pap test schedule.

CONCLUSIONS

Many women are accepting of a 3-year interval for Pap tests, although most primary care physicians continue to recommend shorter intervals.

Physical activity and genitourinary cancer survivorship

In this chapter we discuss common toxicities arising from genitourinary cancer treatments, in particular the adverse effects from androgen deprivation therapy (ADT) for prostate cancer given its well established detrimental effects on physical, physiological, and psychological function, and existing physical activity research in the postdiagnosis period including studies focusing on supportive care and some limited data on disease outcomes. Overall, consistent positive outcomes have been reported across studies showing that exercise is beneficial to reduce a number of treatment-related toxicities and improve symptoms. Additional studies are needed in genitourinary cancers other than prostate to establish specific physical activity requirements and implementation strategies.

A model of the influence of false-positive mammography screening results on subsequent screening

Decades of empirical research have demonstrated psychological and behavioural consequences of false-positive medical tests. To organise this literature and offer novel predictions, we propose a model of how false-positive mammography results affect return for subsequent mammography screening. We propose that false-positive mammography results alter how women think about themselves (e.g., increasing their perceived likelihood of getting breast cancer) and the screening test (e.g., believing mammography test results are less accurate). We further hypothesise that thoughts elicited by the false-positive experience will, in turn, affect future use of screening mammography. In addition, we discuss methodological considerations for statistical analyses of these mediational pathways and propose two classes of potential moderators. While our model focuses on mammography screening, it may be applicable to psychological and behavioural responses to other screening tests. The model is especially timely as false-positive medical test results are increasingly common, due to efforts to increase uptake of cancer screening, new technologies that improve existing tests' ability to detect disease at the cost of increased false alarms, and growing numbers of new medical tests.

Cancer screening: the clash of science and intuition

The concept of early detection of cancer holds great promise and intuitive appeal. However, powerful biases can mislead clinicians when evaluating the efficacy of screening tests by clinical observation alone. Selection bias, lead-time bias, length-biased sampling, and overdiagnosis are counterintuitive concepts with critical implications for early-detection efforts. This article explains these biases and other common confounders in cancer screening. The most direct and reliable way to avoid being led astray by intuitions is through the use of randomized controlled trials.

The National Prostate Cancer Register in Sweden 1998—2002: Trends in incidence, treatment and survival

OBJECTIVES

To provide a descriptive review of the establishment of the National Prostate Cancer Register (NPCR) in Sweden, to present clinical characteristics at diagnosis and to calculate the relative survival of different risk groups after 5 years.

MATERIAL AND METHODS

Since 1998, data on all newly diagnosed prostate cancers, including TNM classification, grade of malignancy, prostate-specific antigen (PSA) level and treatment, have been prospectively collected. For the 35,223 patients diagnosed between 1998 and 2002, relative survival in different risk groups has been calculated.

RESULTS

Between 1998 and 2002, 96% of all prostate cancer cases diagnosed in Sweden were registered in the NPCR. The number of new cases increased from 6137 in 1998 to 7385 in 2002. The age-standardized rate rose in those aged < 70 years, while it was stable, or possibly declining from 1999, in the older age groups. The proportion of T1c tumours increased from 14% to 28% of all recorded cases. The age-adjusted incidence of advanced tumours (M1 or PSA > 100 ng/ml) decreased by 17%. The proportion of patients receiving curative treatment doubled. Patients with N1 or M1 disease or poorly differentiated tumours (G3 or Gleason score 8-10) had a markedly reduced relative 5-year survival rate.

CONCLUSIONS

It is possible to establish a nationwide prostate cancer register including basic data for assessment of the disease in the whole of Sweden. The introduction of PSA screening has increased the detection of early prostate cancer in younger men and, to a lesser extent, decreased the incidence of advanced disease. The effect of these changes on mortality is obscure but the NPCR in Sweden will serve as an important tool in such evaluation.

A phase III clinical trial of exercise modalities on treatment side-effects in men receiving therapy for prostate cancer

Background

Androgen deprivation therapy (ADT) is accompanied by a number of adverse side effects including reduced bone mass and increased risk for fracture, reduced lean mass and muscle strength, mood disturbance and increased fat mass compromising physical functioning, independence, and quality of life. The purpose of this investigation is to examine the effects of long term exercise on reversing musculoskeletal-related side effects, and cardiovascular and diabetes risk factors in men receiving androgen deprivation for their prostate cancer. Specifically, we aim to investigate the effects of a 12-month exercise program designed to load the musculoskeletal system and reduce cardiovascular and diabetes disease progression on the following primary endpoints: 1) bone mineral density; 2) cardiorespiratory function and maximal oxygen capacity; 3) body composition (lean mass and fat mass); 4) blood pressure and cardiovascular function; 5) lipids and glycemic control; and 6) quality of life and psychological distress.

Methods/Design

Multi-site randomized controlled trial of 195 men (65 subjects per arm) undergoing treatment for prostate cancer involving ADT in the cities of Perth and Brisbane in Australia. Participants will be randomized to (1) resistance/impact loading exercise, (2) resistance/cardiovascular exercise groups and (3) usual care/delayed exercise. Participants will then undergo progressive training for 12 months. Measurements for primary and secondary endpoints will take place at baseline, 6 and 12 months (end of the intervention).

Discussion

The principal outcome of this project will be the determination of the strength of effect of exercise on the well established musculoskeletal, cardiovascular and insulin metabolism side effects of androgen deprivation in prostate cancer patients. As this project is much longer term than previous investigations in the area of exercise and cancer, we will gain knowledge as to the continuing effects of exercise in this patient population specifically targeting bone density, cardiovascular function, lean and fat mass, physical function and falls risk as primary study endpoints. In terms of advancement of prostate cancer care, we expect dissemination of the knowledge gained from this project to reduce fracture risk, improve physical and functional ability, quality of life and ultimately survival rate in this population.

Clinical Trial Registry

A Phase III clinical trial of exercise modalities on treatment side-effects in men receiving therapy for prostate cancer; ACTRN12609000200280

Quantitative RT-PCR gene expression analysis of laser microdissected tissue samples

Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) is a valuable tool for measuring gene expression in biological samples. However, unique challenges are encountered when studies are performed on cells microdissected from tissues derived from animal models or the clinic, including specimen-related issues, variability of RNA template quality and quantity, and normalization. qRT-PCR using small amounts of mRNA derived from dissected cell populations requires adaptation of standard methods to allow meaningful comparisons across sample sets. The protocol described here presents the rationale, technical steps, normalization strategy and data analysis necessary to generate reliable gene expression measurements of transcripts from dissected samples. The entire protocol from tissue microdissection through qRT-PCR analysis requires approximately 16 h.

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.

Primary care physicians' reported use of pre-screening discussions for prostate cancer screening: a cross-sectional survey

Background

Professional medical organizations recommend individualized patient decision making about prostate cancer screening. Little is known about primary care physicians' use of pre-screening discussions to promote informed decision making for prostate cancer screening. The aim of this study is to explore physicians' use of pre-screening discussions and reasons why physicians would or would not try to persuade patients to be screened if they initially refuse testing.

Methods

Primary care physicians completed a self-administered survey about prostate cancer screening practices for informed decision making.

Results

Sixty-six physicians (75.9%) completed the survey, and 63 were used in the analysis. Thirteen physicians (20.6%) reported not using prescreening discussions, 45 (71.4%) reported the use of prescreening discussions, and 3 (4.8%) reported neither ordering the PSA test nor discussing it with patients. Sixty-nine percent of physicians who reported not having discussions indicated they were more likely to screen African American patients for prostate cancer, compared to 50% of physicians who reported the use of discussions (Chi-square(1) = 1.62, p = .20). Similarly, 91% of physicians who reported not having discussions indicated they are more likely to screen patients with a family history of prostate cancer, compared to 46% of those who reported the use of discussion (Chi-square(1) = 13.27, p < .001). Beliefs about the scientific evidence and efficacy of screening, ethical concerns regarding patient autonomy, and concerns about time constraints differed between physicians who would and would not try to persuade a patient to be tested.

Conclusion

Although guidelines recommend discussing the risks and benefits of prostate cancer screening, physicians report varying practice styles. Future research needs to consider the nature of discussions and the degree to which informed decision making is being achieved in clinical practice.

The relationship between prostate cancer knowledge and beliefs and intentions to attend PSA screening among at-risk men

OBJECTIVE

To examine the level of knowledge regarding prostate cancer and screening, to investigate prostate cancer illness perceptions, and to test the efficacy of the theory of planned behaviour (TPB) for understanding intentions to attend prostate-specific antigen (PSA) screening, when offered by a doctor or self-initiated.

METHODS

Two hundred and twenty three men completed the PROCASE knowledge scale, the Revised Illness Perceptions Questionnaire and a questionnaire developed to assess attitudes, subjective norms and perceived control over intentions to attend for PSA testing.

RESULTS

Participants had a high level of knowledge and accurate perceptions of prostate cancer. Controlling for knowledge and experience with prostate cancer, the TPB accounted for 49% (p<0.001) of the variation in intentions to attend if recommended by a doctor.

CONCLUSION

The sample of at-risk men were characterised by good knowledge, accurate mental representation of prostate cancer, and positive beliefs towards the PSA test. Components of the TPB accounted for statistically significant amounts of variation in intentions to attend for testing.

PRACTICE IMPLICATIONS

Beliefs about prostate cancer do not appear to influence PSA testing intentions; healthcare providers' recommendations may have the strongest influence on decisions to attend for PSA testing.

Factors prompting PSA-testing of asymptomatic men in a country with no guidelines: a national survey of general practitioners

Background

Increased use of prostate specific antigen (PSA) has been associated with increased prostate cancer incidence. Ireland is estimated to have one of the highest prostate cancer incidences in Europe and has no national guidelines for prostate cancer screening. GPs have a pivotal role in influencing PSA testing, therefore, our aim was to describe GP testing practices and to identify factors influencing these.

Methods

A postal survey, including questions on clinical practice and experience, knowledge and demographics was distributed to all GPs (n = 3,683). The main outcomes were (i) PSA testing asymptomatic men and (ii) "inappropriate" PSA testing, defined as testing asymptomatic men aged < 50 or > 75 years. Factors associated with these outcomes were identified using logistic regression.

Results

1,625 GPs responded (response rate corrected for eligibility = 53%). Most respondents (79%) would PSA test asymptomatic men. Of these, 34% and 51% would test asymptomatic men < 50 and > 75 years, respectively. In multivariate analyses, GPs were more likely to test asymptomatic men if they were ≥ 50 years, in practice ≥ 10 years, female or less knowledgeable about PSA efficacy. Male GPs who would have a PSA test themselves were > 8-times more likely to PSA test asymptomatic men than GPs who would not have a test. GPs who had an asymptomatic patient diagnosed with prostate cancer following PSA testing, were > 3-times more likely to test asymptomatic men. Practice-related factors positively associated with testing included: running 'well man' clinics, performing occupational health checks and performing other tests routinely with PSA. Factors positively associated with 'inappropriate' testing included; being male and willing to have a PSA test, having worked/trained in the UK and supporting annual PSA testing. 91% of respondents supported the development of national PSA testing guidelines.

Conclusion

Our findings suggest that widespread PSA testing of asymptomatic men in primary care is primarily due to a combination of clinical experience, poor knowledge and the support of doctors for PSA testing, as evidenced by the willingness of male doctors to have a PSA test. There is an urgent need for education and support for GPs concerning prostate cancer screening, starting with the implementation of national guidelines.

Evaluation of an internet-based disease trajectory decision tool for prostate cancer screening

OBJECTIVE

To evaluate the application of a chronic disease model (CDM) for prostate cancer to visual analog scale (VAS) and time trade-off (TTO) decision tools.

METHODS

A total of 138 men (mean age 58 years) viewed a CDM module for prostate cancer with and without prostate specific antigen (PSA) screening. Participants rated their hypothetical quality of life with potential prostate cancer treatment complications using a CDM-based VAS decision tool. They were then asked to estimate how many years they would be willing to trade to be free of treatment complications using a CDM-based TTO decision tool. The consistency between VAS and TTO scores and the relationship between scores and preferences for PSA screening test and hypothetical treatment choice for prostate cancer were then evaluated.

RESULTS

There was a significant relationship between the VAS and TTO ratings (regression P < 0.001). The TTO tool was sensitive to age. Mean scores with standard deviations for those less than 58 years compared to those 58 years and more were 7.78 (1.75) and 8.41 (1.52), respectively (P = 0.04). Using the VAS tool, men who chose PSA screening had higher quality of life ratings compared to men who did not choose PSA screening: 7.73 (1.78) and 6.59 (2.39), respectively (P = 0.01). Similar results were found with the TTO decision tool: 8.33 (1.45) and 7.04 (2.00), respectively (P = 0.005). Men who would hypothetically prefer treatment for moderately differentiated prostate cancer also had higher TTO scores compared to men who preferred watchful waiting: 8.54 (1.39) and 7.85 (1.73), respectively (P = 0.04).

CONCLUSION

CDM-based for prostate cancer, VAS and TTO ratings were consistent and were concordant with patient preferences for screening; TTO ratings were also concordant with treatment choice. The use of the CDM-based TTO ratings to adjust for quality of life in decision analytic modeling needs to be explored.